CLINICAL

Treatment of a Maxillary Dento-Alveolar

Defect Using an Immediately Loaded
Definitive Zygoma Implant-Retained
Prosthesis With 11-Month Follow-Up:
A Clinical Report
Mirza Rustum Baig, MDS, MRD1*
Gunaseelan Rajan, FDS, RCS2

This article describes the dental implant-based rehabilitation of a partially edentulous patient
with a unilateral maxillary dento-alveolar defect. A screw-retained prosthesis with a modified
design was fabricated on zygomatic and regular dental implants. One section of the implant
prosthesis has cemented crowns and the other section is conventional screw-retained. The
design of the prosthesis overcame the hard and soft tissue deficit and provided the desired
esthetics.

INTRODUCTION retained fixed implant prostheses have the

advantages of passively fitting frameworks

I
mplant-based fixed rehabilitation of
partially edentulous maxillae can be
achieved by providing a conventional
screw-retained or cement-retained im-
plant FPD (fixed partial denture), a
hybrid screw-retained or cement-retained
implant FPD, and a cement and screw-
retained implant FPD.1–5
Screw-retained implant fixed prostheses
provide the ease of retrievability, benefit of
splinting, and low profile retention. Howev-
er, the labial or buccal emergence of the
access screw channel due to off axial implant
positioning in cases of severe ridge resorp-
tion compromises esthetics and prevents
creation of ideal morphology.1,6 Cement-
1
Department of Prosthetic Dentistry, Faculty of Den-
tistry, University Malaya, Kuala Lumpur, Malasia; Ragas
Dental College and Hospital, Chennai, India.
2
Rajan Dental Institute, Chennai, India.
* Corresponding author, e-mail: drmrbaig@yahoo.com
DOI: 10.1563/AAID-JOI-D-09-00062
and better esthetics. Custom abutment
options can compensate for misaligned
implants thus improving esthetics.7–9 How-
ever, retrievability, repair and maintenance,
choice of cement, and excess cement in the
sulcus still remain areas of concern. A
combination of a screw-retained prosthesis
with cement-retained crowns combines the
advantages of both approaches.10
This article presents the rehabilitation of
a partially edentulous patient with zygomat-
ic implant using a technique employing
simultaneous cement and screw retention
in the same prosthesis.
CLINICAL REPORT
A 27-year-old partially edentulous female
reported to the clinic seeking a fixed
prosthesis. Four teeth (maxillary right lateral

Journal of Oral Implantology 31

Zygoma Implant-Retained Fixed Partial Denture
FIGURES 1–3. FIGURE 1. Panoramic view of the maxillae and mandible pretreatment. FIGURE 2. Framework
fitted; shown prior to cementation of anterior crowns. FIGURE 3. Screw-retained implant prosthesis with
cemented crowns. (a) Frontal view. (b) Occlusal view.
incisor, canine, first premolar, second pre-
molar) had been extracted along with the
removal of a large periapical cyst 10 years
earlier. An acrylic removable partial denture
had been worn since then, as an interim
measure. On clinical and radiological exam-
ination, there was severe localized resorption
of the maxillary alveolar ridge in the region
of the extracted teeth (Figure 1). A conven-
tional fixed partial denture was considered,
and deemed inappropriate due to the long
span of the partially edentulous space and
the poor periodontal condition of the
anterior abutment tooth. Implant-retained
fixed prosthesis was then planned as a better
alternative.
The patient was presented options of
grafting techniques, but declined them
citing time constraints. Hence, a single
zygomatic implant was planned in conjunc-
tion with 2 root form implants to restore the
partially edentulous segment. A decision was
taken regarding the prognosis of maxillary
right central incisor. Since there was exces-
sive bone loss around this abutment, with
32 Vol. XXXVI/No. One/2010
gingival recession, it was planned for extrac-
tion and immediate implant placement. The
left maxillary central incisor was also elec-
tively planned for extraction and immediate
implant placement to increase the anterior
support for the implant prosthesis and
create favorable biomechanics.
Two dental implants (Nobel Biocare
Replace Select Tapered TiU 5.0 mm 3
16 mm; Nobel Biocare AB, Gothenburg,
Sweden) were placed immediate postextrac-
tion of the maxillary central incisors along
with a single zygoma implant (Branemark
Zygoma TiUnite 45 mm; Nobel Biocare AB).
An insertion torque of 35 Ncm was achieved
for all implants. A 17u zygoma multiunit
abutment was torqued to the zygoma
implant at 15 Ncm torque. Two straight
multiunit abutments were also torqued to
similar levels onto the anterior implants. The
patient’s old dentures were relined with soft
liner (GC Reline soft; GC Corp, Tokyo, Japan),
and issued for interim use. Subsequently,
open-tray impressions were made of the
maxillary arch by using multiunit impression

copings and master casts were poured with
implant replicas (NobRpl; Nobel Biocare AB).
Full contour wax pattern was fabricated on
multiunit castable copings (Gold coping
multiunit; Nobel Biocare AB), cut back done
to accommodate the ceramic and then it
was cast into a metal (Degudent U; Degu-
dent GmbH, Hanau-Wolfgang, Germany)
framework.
The framework try-in was done in the
patient to check for passivity of fit. Following
this, ceramic veneer (IPS d.SIGN; Ivoclar
vivadent, Schann, Leichtenstein) was fired
on one part of the screw-retained frame and
metal-ceramic splinted crowns were fabri-
cated on the other. Gingiva-colored porce-
lain was also fired onto the screw-retained
infrastructure to replace the soft tissue in
deficit areas. Three weeks postimplant place-
ment, the screw-retained framework was
secured to the multiunit abutments at
10 Ncm torque (Figure 2). The crowns were
cemented over the framework in the central
incisor region using provisional (TempBond;
Kerr Corp, Romulus, Mich) cement (Figure 3a
and b). The patient was then placed on a
follow-up protocol. Eight months postdeliv-
ery of the prosthesis, the cemented crowns
were retrieved and the multiunit abutments
were torqued to 35 Ncm (Figures 4 and 5a
and b). The screw-retained frame was then
secured to the multiunit abutments at
25 Ncm and the screw-access openings filled
with gutta percha and sealed with light-cure
composite (Filtek Z350; 3M ESPE, St Paul,
Minn). The crowns were luted back using
provisional cement (TempBond; Kerr Corp)
(Figure 6).
DISCUSSION
Zygomatic implants have been predictably
used in the last few years for the rehabilita-
tion of completely edentulous atrophic
maxillae.11,12 These implants serve as an
excellent treatment alternative to conven-
Baig and Rajan
tional dental implants for restoring severely
resorbed posterior maxillae by overcoming
the need to perform onlay bone grafting
and/or sinus lift procedures associated with
conventional placements. However, the zy-
goma implants have been sparsely used for
the rehabilitation of partially edentulous
arches. This report describes the rehabilita-
tion of a partially edentulous patient with a
single zygoma implant in conjunction with
conventional implants. Zygoma implant was
considered for this patient as bone grafting
was not an option due to patient consider-
ations (delayed protocols) and decision was
made against extraction of molar teeth with
placement of conventional implants in the
posterior region for supporting the prosthe-
sis. The immediate loading protocol adopted
in this patient is supported by the success
rates recorded for zygomatic implants with
immediate loading.11,13 However, the report-
ed success rates were applicable for bilateral
zygoma implants in conjunction with con-
ventional implants in the premaxillary re-
gion.
The technique employed in this article
significantly negated the effect of fixture
position or angulation on the esthetic
outcome of the implant prosthesis. In areas
(anterior central incisor region) where the
screw-access openings were bound to inter-
fere with the reproduction of desirable
esthetics and morphology, the crowns were
individually cemented on to the cast frame-
work. The remaining part of implant pros-
thesis (where the implant fixture position/
screw-access openings were ideal) had
ceramic veneer material bonded to the cast
framework through a conventional tech-
nique. The crowns on the cemented part of
the prosthesis had only been luted with
provisional cement, thereby enabling easy
retrievability, repair, and maintenance with-
out jeopardizing the entire framework.
Hence, the advantages of both cement and
screw retention were extracted in the
Journal of Oral Implantology 33
Zygoma Implant-Retained Fixed Partial Denture

FIGURES 4–6. FIGURE 4. Panoramic view of the maxillae and mandible (8 months post-treatment). FIGURE 5.
Periapical radiographs (8 months post-treatment). (a) Maxillary right central incisor region. (b) Maxillary
right first molar region. FIGURE 6. Post-treatment smile.

34 Vol. XXXVI/No. One/2010


prosthesis. The cemented crowns were
splinted to increase the retention and offset
the relatively shorter height of the abut-
ments. The customized screw-retained metal
framework was layered with gingiva-colored
porcelain to resemble hard and soft tissue in
the maxillary defect zone.3
SUMMARY
This report describes the use of cemented
crowns in combination with a screw-retained
implant prosthesis. A graftless solution for
fixed rehabilitation of a partially edentulous
patient is presented. The indication for such
treatment is specific and dictated by several
factors. This method provides an alternative
treatment option to conventional tech-
niques.
ABBREVIATION
FPD: fixed partial denture
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