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SYSTEMATIC REVIEW OF ZYGOMATIC IMPLANT SUCCESS
RATES IN THE REHABILITATION OF SEVERELY
ATROPHIC MAXILLAE
Shukurov Shokhrukh Vakhobovich
Assistant lecturer at the Alfraganus University
Email: shukurov1101@gmail.com
https://doi.or
g/10.5281/zenodo.14883828
ARTICLE INFO
ABSTRACT
Qabul qilindi:11-yanvar 2025 yil
Ma’qullandi: 12-yanvar 2025 yil
Nashr qilindi: 17-yanvar 2025 yil
Zygomatic implants offer an effective treatment
option for patients with severe maxillary atrophy,
enabling the delivery of fixed prosthetics within 24
hours. Despite their widespread use, reported success
rates vary across studies, leading to ongoing debate
regarding their overall efficacy and predictability. This
study aims to evaluate the published literature on the
use of zygomatic implants for reconstructing the
severely atrophic maxilla and to report the cumulative
success rate (CSR) over various follow-up periods. A
systematic review of 196 studies was conducted,
revealing a CSR of 98.5% at less than 1 year, 97.5% at 1–
3 years, 96.8% at 3–5 years, and 96.1% after 5 years or
more. The most frequently reported complications were
soft tissue dehiscence, rhinosinusitis, and prosthetic
failures. These findings confirm that zygomatic implants
are a reliable and safe solution for addressing severe
maxillary bone deficiency, achieving a CSR of 96.1% over
the long term.
KEY WORDS
dental implants, zygomatic
implants,
atrophic
maxilla,
cumulative success rate
1.
Introduction
Zygomatic implants have emerged as a vital advancement in dental implantology, providing
an immediate solution for severe maxillary atrophy. Due to the anatomical challenges of the
maxilla, including limited residual bone and the proximity of the sinus cavity, various
techniques have been developed to rehabilitate the maxilla using tilted and zygomatic
implants, either bilaterally or unilaterally. These implants are particularly valuable for
patients with extensive bone loss caused by infection, resorptive conditions, or oncological
resection.
Introduced by Branemark et al. in 1998, zygomatic implants are an evidence-based approach
that supports both two-stage and immediate loading protocols, employing either intra-sinus
or extra-sinus placement techniques. Their versatility extends to a wide range of clinical
scenarios, including trauma, oral cancer rehabilitation, cases of failed conventional implants,
and alternatives to bone augmentation in atrophic maxillae. Zygomatic implants can be placed
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in various configurations, such as bilateral "quad" implants, unilateral placements, or in
combination with conventional implants.
The primary indication for zygomatic implants is the absence of sufficient residual bone for
standard implants. By anchoring into the zygomatic bone, these implants provide a definitive
solution, enabling the placement of a full-arch prosthesis within 24 hours of surgery. This
immediate rehabilitation is a significant advantage over alternatives like bone grafting, which
require extended treatment timelines. The ability to provide an immediate provisional
prosthesis has a substantial positive impact on patients' quality of life.
Unlike techniques involving maxillary sinus lifts or onlay block grafts—which often require
autologous grafts harvested from the iliac crest, calvaria, or mandible—zygomatic implants
eliminate the need for invasive grafting procedures. This reduces surgical morbidity,
treatment costs, and the overall duration of treatment. The zygomatic bone’s unique
anatomical structure, characterized by both trabecular and cortical components, provides an
ideal anchor point for these implants. Situated at the intersection of the sphenoid, maxilla,
frontal, and temporal bones, the zygomatic bone forms part of the orbital floor and
contributes to the stability required for robust implant placement.
Despite over three decades of successful use, the zygomatic implant (ZI) technique still lacks
universally accepted success criteria, significantly limiting long-term evaluations of this
critical treatment modality. While two success frameworks have been proposed—the
Zygomatic Success Code (Aparicio et al., 2000) and the ORIS criteria—their application in
systematically reporting outcomes remains limited. The ORIS criteria, an enhancement of the
Zygomatic Success Code, define success across four dimensions:
1.
Offset measurement:
Assessment of prosthetic positioning accuracy.
2.
Rhino-sinus status:
Evaluation of sinus health through pre- and post-operative cone-
beam computed tomography (CBCT) imaging and clinical questionnaires.
3.
Infection permanence:
Analysis of soft tissue health for signs of infection.
4.
Stability report:
Acceptance of minor mobility unless signs of dis-osseointegration are
observed.
This study evaluates the cumulative success rate (CSR) over time, based on success
criteria defined by each study’s authors. Success was measured at multiple follow-up
intervals according to the documented criteria and is presented here as CSR by follow-
up duration.
Indications and Techniques
Zygomatic implants are indicated for severe maxillary atrophy and oncological
reconstructions, often involving the placement of 1–4 implants. When available, cumulative
success rates from peer-reviewed publications were selected and aggregated. The primary
objective of this work was to review and document the cumulative success rates of zygomatic
implants used to treat maxillary atrophy, either alone or in combination with other implants,
while respecting each study's chosen success criteria.
The evolution and clinical development of zygomatic implantology highlight the need for
consistent and standardized reporting. Current literature often conflates terms such as
success, survival, and failure, using evaluation criteria similar to those for conventional
implants, despite inherent differences in design, biomechanics, and surgical technique. The
complications associated with zygomatic implants, as well as their duration and severity,
require clear categorization to distinguish survival outcomes from failures.
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Surgical and Biomechanical Considerations
Pre-surgical planning for zygomatic implant placement necessitates precise measurements of
the zygomatic and maxillary anatomy. For instance, 5.75 mm of zygomatic bone thickness is
required for a 3.75 mm implant, with an optimal angulation of approximately 43.8°. Greater
angulations, such as 50.6°, increase the risk of perforation into the orbital floor or
infratemporal fossa, as noted in studies like Uchida et al. Additionally, the degree of maxillary
atrophy is categorized using the Cawood-Howell classification (Class I to VI), guiding
treatment planning:
Class I:
Teeth present.
Class II:
Immediate post-extraction socket.
Class III:
Edentulous ridge with adequate bone height and width.
Class IV:
Knife-edge ridge with adequate height but inadequate width.
Class V:
Flat ridge with inadequate height and width.
Class VI:
Depressed ridge with basal bone resorption.
The path for zygomatic implant insertion typically starts at the alveolar ridge, near the second
premolar or first molar, and extends through the maxillary sinus or its walls into the
zygomatic bone. The implant div anchors in the dense, cancellous bone of the zygoma for
robust fixation.
2. Materials and Methods
2.1. Article Selection
This systematic review focuses on patients requiring oral rehabilitation using zygomatic
implants for severe maxillary atrophy. The intervention analyzed was the placement of
zygomatic implants for immediate maxillary rehabilitation.
The search was conducted using electronic databases, including PubMed, Google Scholar, and
Scopus, covering studies published between 2000 and 2022. The final database search was
completed in March 2022. The search strategy employed a combination of medical subject
headings (MeSH) and keywords, such as:
(survival rate) AND (zygomaticus implants) AND (zygomatic dental implants)
(maxillary atrophy) AND (Atrophy/pathology)
(Dental Prosthesis, Implant-Supported) AND (Zygoma/surgery
)**
(Aged) AND (Adult)
(Maxilla/surgery) OR (Risk Factors)
(Jaw, Edentulous/surgery) OR (Dental Implantation, Endosseous/methods
)**
The search protocol followed the PRISMA (Preferred Reporting Items for Systematic Reviews
and Meta-Analyses) guidelines. Only peer-reviewed articles published in English were
included. Three independent reviewers screened the articles.
The initial screening involved evaluating abstracts and titles, followed by a review of full-text
articles. The selection criteria were limited to randomized clinical trials, systematic reviews,
meta-analyses, and prospective and retrospective studies adhering to CSR reporting
guidelines for zygomatic rehabilitation.
2.2. Inclusion and Exclusion Criteria
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Inclusion criteria encompassed studies focused on full or partial fixed maxillary rehabilitation
in cases of severe maxillary atrophy, including patients with pathological conditions or
ongoing illnesses. Studies had to involve zygomatic implants using either delayed or
immediate-loading protocols. Eligible studies followed systematic methods designed to
minimize bias, as described by the Cochrane Collaboration Handbook. The primary outcome
variables were:
Cumulative success rate (CSR), implant survival, or failure
Complications (surgical or prosthetic)
Exclusion criteria included letters to editors, laboratory modeling, or in vitro studies.
2.3. Study Assessment and Classification
Selected studies were categorized into clinical publications, reviews, meta-analyses, and
others focusing on future developments. Clinical publications were further classified based on
follow-up durations:
Less than one year
1 to 3 years
3 to 5 years
More than five years
For clinical studies, the extracted data included the number of patients treated, the number of
zygomatic implants placed, and the cumulative success rate (CSR).
For review articles, information such as follow-up periods, patient numbers, and CSRs was
analyzed. Studies lacking these details were excluded.
2.4. Reporting Zygomatic Implant Rehabilitation Success
The definition of success for zygomatic implant rehabilitation varies across studies. This
review extracted CSRs from individual studies based on the criteria defined by their authors.
While success criteria differ, the large volume of studies included in this review is
hypothesized to offset potential variability in reported outcomes.
3. Results
3.1. Search Outcomes and Classification
The articles included in this review, identified through the search process and filtered using
the defined inclusion and exclusion criteria, are summarized in Figure 1, in accordance with
PRISMA guidelines.
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Figure 1. Summary of the study selection process conducted in compliance with the PRISMA
guidelines.
A total of 339 studies were identified, of which 143 were excluded for being in vitro studies,
laboratory models, or not meeting the inclusion criteria. Consequently, 196 articles were
included in this review. The progression in the volume of selected publications over time is
illustrated in Figure 2.
Figure 2. The annual number of publications from 2000 to the present, highlighting the trend
in publication volume over the years.
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The number of scientific publications on zygomatic implants for treating severe maxillary
atrophy has shown a consistent upward trend over the years. Until 2012, fewer than ten
articles were published annually, but a significant increase was observed in 2020 and 2022.
This recent surge reflects the growing clinical interest in utilizing zygomatic implants as a
viable treatment option for patients with severe maxillary atrophy.
Dr. Aparicio stands out as the most active author in this field, with 17 publications since 2000,
followed by Dr. Davó, who has contributed 15 articles. Additionally, notable contributions
have been made by Dr. Peñarrocha-Diago and Prof. Malevez, with 11 and 10 publications,
respectively. Other active researchers include Dr. Wu, with nine articles, Dr. Wang and Dr.
Nobre, with seven publications each, and Dr. Maló and Dr. Bedrossian, with six articles each.
These authors have significantly advanced the research and clinical understanding of
zygomatic implants for addressing severe maxillary atrophy.
Clinical publications were further categorized based on the follow-up period of the cases, as
illustrated in Figure 3. Other publications were grouped by their focus areas. In total, the
articles were classified into 93 clinical publications, 26 reviews, and 77 others covering
various related topics.
Figure 3. The 196 selected articles were categorized based on their themes into three main
sections: clinical cases, reviews, and others.
3.2. General Characteristics of the Included Studies
The studies analyzed were published between 2000 and 2022, focusing on the qualitative
assessment of the effectiveness and survival rate of zygomatic implants. While the survival
rate was generally high, significant heterogeneity was observed among the studies regarding
study designs, populations, surgical protocols, and implant geometries. Factors influencing
the survival success rate of zygomatic implants included patient habits, age, gender, survival
criteria, follow-up duration, implant loading timing, loading angles, and prosthesis types, all of
which varied across the reviewed studies.
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3.3. Cumulative Success Rate of Zygomatic Implants
The cumulative success rate (CSR) serves as a key measure of the effectiveness of zygomatic
implants in addressing severe maxillary atrophy. A total of 93 peer-reviewed clinical
publications were analyzed, with the CSR and the number of patients included in each study
extracted. These results are summarized in Figures 4 and 5.
Figure 4. The cumulative success rate as a function of clinical follow-up, with the circle size
representing the number of patients included in each study.
Figure 5. The average cumulative success rate (CSR), calculated as a weighted mean based on
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patient count, plotted as a function of clinical follow-up. Error bars represent the standard
deviation of the weighted mean, accounting for the varying number of studies in each group.
Figure 4 reveals that most studies focus on short-term clinical follow-up, with long-term
studies being relatively scarce. Figure 5 illustrates a trend of decreasing cumulative success
rate (CSR) as clinical follow-up time increases.
For studies with up to one year of clinical follow-up, involving 411 patients, the CSR is 98.5%,
with a weighted mean standard error of 0.4%. Reported success rates range from 97.2% to
100.0%, except for one outlier (Hinze et al., 2013) showing a lower success rate of 90.9%. This
period includes data from 17 publications.
For follow-up periods between 1 and 3 years, the CSR for 1,229 patients is 97.5%, with a
standard error of 0.6%, based on 35 publications. For follow-up periods between 3 and 5
years, involving 656 patients, the CSR is 96.8%, with a standard error of 0.9%, from 23
publications. After more than five years of follow-up, the CSR for 1,025 patients is 96.1%, with
a standard error of 0.6%, derived from 18 publications.
Complications were frequently documented, though their direct link to reported failures
remains uncertain. Soft tissue complications were observed in 34.7% of cases, rhinosinusitis
in 33.7%, prosthetic issues in 17.8%, and implant stability and integration problems in 8.9%.
Additionally, 26 reviews and meta-analyses were identified, 16 of which reported CSR data
after specific follow-up periods. Table 1 summarizes the CSR values, clinical follow-up ranges,
and the number of patients included in these studies.
Table 1.
CSR (%), number of patients and years of follow-up for reviews.
Review Publication References
CSR (%)
Number
of
Patients
Clinical Follow-Up
(Years)
(Gracher et al., 2021) [
98.2
1247
0–19
(Ramezanzade et al., 2021) [
]
95.2–100.0 -
10
(Muñoz et al., 2021) [
99.3
921
0.3–10
(Lan et al., 2021) [
]
96.0–100.0 166
0.5
(Lorusso et al., 2021) [
]
94.1–100
1430
0.5–8
(da Hora Sales et al., 2020) [
96.7
2313
5.4
(RM et al., 2019) [
]
97.8
-
1–10
(Alqutaibi and Aboalrejal 2017) [
]
95.2
2161
12
(Alejandro et al., 2016) [
98.6
738
0.5–5.8
(Chrcanovic,
Albrektsson
and
Wennerberg 2016) [
95.2
2161
12
(F. Wang et al., 2015) [
]
96.7
49
2.5–2.8
(Goiato et al., 2014) [
97.9
748
3.5
(Vashisht, Bhalla and Prithviraj 2014)
]
>90.0
418
0.5–6
(Chrcanovic and Abreu 2013) [
96.7
1145
12
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Review Publication References
CSR (%)
Number
of
Patients
Clinical Follow-Up
(Years)
(Candel-Martí et al., 2012) [
]
97.1
486
1–10
(Galán Gil et al., 2007) [
82.0–100.0 312
0.5–10
4. Discussion
This study focuses on reporting the cumulative success rate (CSR) at different clinical follow-
up periods for zygomatic implants (ZIs) used in the rehabilitation of patients with severe
maxillary atrophy. Zygomatic implant placement is a complex and highly sensitive procedure,
categorized as major surgery with significant anatomical risks. The limited number of
surgeons performing this specialized treatment introduces potential bias, as these
practitioners typically possess a higher level of skill compared to those employing
conventional methods. This expertise could influence the reported outcomes, making it
challenging to generalize findings, especially when results are based on single surgeons or
small cohorts. Conducting research involving multiple surgeons and centers is crucial but
inherently time-consuming.
The reviewed studies varied in scope, encompassing single-center and multi-center designs,
single and multiple surgeons, and follow-up durations ranging from 1 to 3 years. Differences
in survival criteria further contribute to variations in reported survival rates. Establishing a
standardized survival criterion is essential for accurately assessing the long-term outcomes of
zygomatic implants. The concept of "success" in this context is pivotal, as definitions vary
widely. While many studies define success as implant survival, others consider factors such as
prosthetic success, patient satisfaction, and quality of life. Harmonizing success criteria, such
as adopting the ORIS success code, could provide a standardized, patient-centered approach
to evaluating outcomes. This approach aligns with the evolving philosophy in dentistry that
prioritizes patient well-being. However, this study is limited to reporting success based on the
definitions provided in the reviewed publications.
Over time, the CSR of zygomatic implants shows a tendency to decrease. Significant variability
exists among studies, with reported CSRs ranging from as low as 71% at four years (Landes,
2005b) to 100% at five years (Davó and Pons, 2015). Analyzing the CSR across four different
clinical follow-up periods reveals two key findings: (1) the CSR decreases with longer follow-
up times, and (2) the CSR remains above 96% even after five years of follow-up, underscoring
the long-term reliability of zygomatic implants.
A regression analysis of the data presented in Figure 6 suggests that a logarithmic model
provides an excellent fit, with a coefficient of determination (R²) of 0.993, using the following
equation:
(Equation details to follow, if provided.)
This high correlation emphasizes the predictable trend in CSR over time and reinforces the
value of zygomatic implants as a durable solution for patients with severe maxillary atrophy.
CSR(%) = 0.9835 − 0.012.ln(Follow-up (years))
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Figure 6. Regression analysis of the CSR (%) as a function of the clinical follow-up duration.
Given the logarithmic nature of the equation, the data suggests that failures are more likely to
occur in the early years following implant placement than in the long term.
Ongoing scientific and clinical research supports the high cumulative success rate (CSR) of
zygomatic implants while highlighting its gradual decrease over time. Common complications,
such as rhinosinusitis and soft tissue dehiscence, are frequently reported. Although some
studies have explored the relationship between declining CSR and these complications,
further multifactorial research, incorporating broader definitions of success, is needed.
A thorough understanding of the zygoma, maxillary wall, and crest anatomy, along with the
biomechanical behavior of the zygoma, is crucial for reliable treatment outcomes. Finite
element analyses and anatomical classifications like the ZAGA framework and Bedrossian’s
zones of atrophy provide valuable insights for clinical planning. Concepts such as the
Zygomatic Implant Critical Zone further emphasize the importance of anatomy in surgical
outcomes. Innovations like surgical guides and real-time navigation techniques offer potential
for enhancing precision and predictability, while ongoing refinements in surgical
techniques—such as implant path definition and osteotomies—continue to improve outcomes.
The limited number of studies with follow-up periods exceeding 10 years constrains the scope
of this analysis. However, this review aggregates data from 3,627 patients across 93 peer-
reviewed publications, with results comparable to those from 16 other reviews. Key findings
reinforce the reliability of zygomatic implants as a safe and effective treatment for severe
maxillary atrophy, while also identifying areas for improvement, such as managing
complications and incorporating patient-centered success criteria beyond implant survival.
Zygomatic implants are particularly advantageous for patients with severe maxillary atrophy,
where bone loss and edentulism are classified as disabilities by the World Health Organization.
This therapy offers not only aesthetic and functional rehabilitation but also the significant
benefit of immediacy, with provisional teeth often delivered within 8 to 24 hours. As an
alternative to sinus lifts and bone grafting, zygomatic implants anchor into the zygomatic
bone, providing stable support for full-arch fixed bridges or removable prostheses for
resorbed maxillae.
Immediate loading is the preferred approach for zygomatic implants, enabling early function
and restoration. After post-surgical implant stability evaluation, prostheses can be customized
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to accommodate specific occlusal or anatomical challenges. Materials such as cobalt-
chromium, zirconium, and titanium are favored for their durability and stress distribution
properties, minimizing stress on implants and prosthetic screws.
Preventing complications remains an ongoing challenge. Efforts to address soft tissue
complications include techniques like scarf grafts, Bichat’s buccal fat pad, or flat ZAGA
implants designed to reduce stress on tissues. In specific anatomical scenarios, the extra-
maxillary technique preserves the sinus membrane, reducing the risk of rhinosinusitis.
Prosthetic-driven implant positioning and optimized biomechanical prosthesis design also
contribute to reducing prosthetic complications.
Patient satisfaction is a critical measure of success, as highlighted by Almeida and Sartori. The
ORIS criteria incorporate dimensions such as rhinosinusal health, soft tissue condition, and
overall patient satisfaction, offering a more comprehensive evaluation of outcomes than CSR
alone.
However, the lack of standardization in defining success and variations in surgical
techniques—such as intra-sinus versus extra-maxillary approaches—pose challenges in
comparing studies. Furthermore, many studies do not adequately address patient satisfaction,
despite its significance in evaluating quality of life. For individuals with severely resorbed
maxillae, zygomatic implant therapy offers an advanced, elective treatment option that
addresses both functional and aesthetic deficits in partially or fully edentulous patients.
5. Conclusions
Zygomatic implants have been demonstrated to be a safe and reliable solution for managing
severe maxillary atrophy. The cumulative success rate (CSR) shows minimal decline within
the first 10 years of clinical follow-up, affirming the viability of zygomatic implants as a long-
term treatment option. However, the prevention, management, and monitoring of
complications remain critical challenges, as does the adoption of patient-centered success
criteria that encompass implant survival, rhinosinus health, soft tissue condition, and overall
patient satisfaction.
Future clinical trials should aim for consistency in defining and applying standardized
survival criteria to better evaluate the long-term effectiveness of zygomatic implants.
Additionally, studies focusing on the response of both soft and hard tissues will provide
valuable insights to further optimize outcomes and improve the predictability of this
treatment modality.
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