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Eur J Oral Implantol 2011;4(3):269275

CLINICAL ARTICLE
Carlos Aparicio, MD,
DDS, MSc, MSc, DLT
Clnica Aparicio,
Rda General Mitre 72-74,
08017 Barcelona, Spain
Email: carlos.aparicio@
clinicaaparicio.com
Carlos Aparicio
A proposed classication for zygomatic implant
patients based on the zygoma anatomy guided
approach (ZAGA): a cross-sectional survey
Key words atrophic maxilla, dental implants, extra-sinus pathway, zygomatic implants
This classication, on the Zygoma Anatomy Guided Approach (ZAGA), was rst introduced at the
3-I Spanish Annual Symposium held in Madrid January 2010.
Purpose: The aim of the present cross-sectional study was to propose a classication system based
on a cross-sectional survey of zygomatic implant cases.
Materials and methods: Cone beam computerised tomography (CBCT) postoperative images and
clinical intra-surgery photographs of 200 sites corresponding to 100 patients, treated with a total
of 198 zygomatic implants in the maxilla according to an anatomy-driven prosthetic approach,
were reviewed with regard to anatomy and pathway of the zygomatic implant body. The patients
were consecutively selected independently of the type of surgery performed, with the unique
requirement of a post-surgical CBCT performed at the moment of selection. Of special interest
was the morphology of the lateral sinus wall, residual alveolar crest and the zygomatic buttress.
An attempt was made to divide the patients into groups, describing typical anatomies and implant
pathways.
Results: Five basic skeletal forms of the zygomatic buttressalveolar crest complex and subsequent
implant pathways could be identied in a sample of 100 patients. Out of them, 62% were female
and 38% male, with ages varying between 36 and 83 years (mean age 59.6, SD: 9.67). The ve
groups were classied as ZAGA 0 to 4 representing 15%, 49%, 20.5%, 9% and 6.5% of the studied
sites, respectively. Intra-individual anatomical differences affecting the zygomatic buttressalveolar
crest complex was also found in 58% of the patients.
Conclusions: Five typical anatomical and implant pathway situations could be identied. A classi-
cation system comprising ve groups named ZAGA 0 to 4 is proposed. Anatomical intra-individual
differences were also found in the 58% of the studied population. It is believed that the proposed
classication system is useful for categorising zygomatic implant cases for therapy planning and for
scientic follow-up purposes.
Conict-of-interest statement: There is no nancial conict of interest.
Aparicio Classification for zygomatic implant patients 270
Eur J Oral Implantol 2011;4(3):269275
Introduction
Zygomatic implants ad modum Brnemark are used
for prosthetic rehabilitation of the severely resorbed
maxilla
1-4
. The original technique prescribed an
intra-sinus pathway of the implant and preparation
of a window in the anterior wall of the maxillary
sinus to allow visualisation of the zygomatic bone
during insertion of the implant
1,2
. Different morph-
ologies of the edentulous maxilla can be identied
and in many cases the original procedure results in
a marked palatal position of the implant head. This
in turn results in bulky prosthetic constructions and
impaired hygiene.
In order to use an anatomically and prosthet-
ically driven approach, the original technique has
been modied by also allowing an extra-sinus
path for zygomatic implants
5-12
. With this novel
approach, no initial window or slot is opened at the
lateral wall of the maxillary sinus. The preparation
of the implant site is guided by the anatomy of the
area instead. Firstly, the coronal entrance point at
the level of the alveolar process, for an optimal
prosthetic outcome, is determined according to
prosthetics, biomechanics and anatomical param-
eters. Secondly, the apical zygomatic entrance
point is identied based on the desired number and
length of the implant(s) and the anatomy. Thirdly,
the implant trajectory is planned by joining the
two points, which will determine the preparation
and pathway of the implant body. Thus, depend-
ing on the relation between the zygomatic buttress
and the intraoral starting point of the zygomatic
implant, the path of the implant body will vary from
a total intra-sinus to a total extra-sinus one.
Despite the fact that zygomatic implants have
been used for more than two decades, there are
no randomised controlled trials evaluating their
clinical effectiveness in relation to alternative means
for rehabilitating patients with atrophic edentulous
maxillae
13
. At the same time, there is no classica-
tion system describing the various anatomy-guided
zygomatic implant pathways at present. The aim of
the present cross-sectional survey was to propose a
classication system based on a retrospective review
of zygomatic implant cases. This report is presented
following the STROBE guidelines for observational
studies (http://www.strobe-statement.org/).
Materials and methods
After a prospective report
4
of 131 zygomatic implants
placed between 1998 and February 2004, the origin al
technique was progressively modied using a
zygoma anatomy guided approach (ZAGA)
8-10
. Cone
beam computerised tomography (CBCT) postopera-
tive images and clinical intra-surgery photographs
of 200 sites corresponding to 100 of the 177 total
patients treated between April 2005 and Decem-
ber 2010 with zygomatic implants according to the
referred anatomy-driven prosthetic approach, were
reviewed by an independent investigator with regard
to anatomy and pathway of the zygomatic implant
body. Of special interest was the morphology of
the lateral sinus wall, residual alveolar crest and
the zygomatic buttress. An attempt was made to
classify the patients into groups, describing typical
anatomies and implant pathways. Since the results
were intended to be given in percentages, a sample
of 100 consecutive zygoma patients was chosen
from the total pool of 177 patients treated with
zygoma implants between April 2005 and Decem-
ber 2010. April 2005 was chosen as landmark date
to consider ZAGA fully implemented in the authors
centre. The patients were consecutively selected
independently of the type of surgery performed,
with the unique requirement of a post-surgical
CBCT performed at the moment of the selection.
A total of 198 zygomatic implants were installed: 73
patients had 2 zygomatic implants each, 2 patients
had 3 zygomatic implants each, 7 were treated with
4 zygomatic implants and 18 patients received 1
zygomatic implant. Additional regular implants
were used when needed.
All of the implants were placed by the same surg-
eon in a single centre: Clinica Aparicio, Barcelona,
Spain. The main inclusion criteria for treating patients
with zygomatic implants was the presence of a resid-
ual alveolar crest less than 4 mm in width and height,
immediately distal to the canine pillar. When treating
partial edentulism, the possibility of establishing a
tripodisation by placing a minimum of three implants
per quadrant, one zygomatic plus two regular, was
required. CBCT post-surgical images were required
to be included in this study. The exclusion criteria
were acute sinus infection and lack of permeability
of the osteomeatal complex.
Aparicio Classification for zygomatic implant patients 271
Eur J Oral Implantol 2011;4(3):269275
Results
Five basic skeletal forms of the zygomatic buttress
alveolar crest complex and subsequent implant path-
ways could be identied in a sample of 100 patients.
A total of 62% were female and 38% male, with
ages varying between 36 and 83 years (mean age
59.6, SD 9.67). The ve groups were named from
ZAGA 0 to 4 representing 15%, 49%, 20.5%, 9%
and 6.5% of the studied sites, respectively.
Group 0 (ZAGA 0)
The anterior maxillary wall is very at.
The implant head is located on the alveolar crest.
The implant body has an intra-sinus path.
The implant comes in contact with bone at the
alveolar crest and zygomatic bone, and some-
times at the lateral sinus wall (Fig 1).
This group represented 15% of the reviewed
implants.
Group 1 (ZAGA 1)
The anterior maxillary wall is slightly concave.
The implant head is located on the alveolar crest.
b
Fig 1 ZAGA 0 case:
a) schematic and
b) clinical example.
ZAGA 0 is character-
ised by the following:
anterior maxillary wall is
very at; implant head
is located on the alveo-
lar crest and implant
body has an intra-sinus
path.
a
Type 0
The drill has performed the osteotomy slightly
through the wall.
Although the implant can be seen through the
wall, most of the implant body has an intra-sinus
path.
The implant comes into contact with bone at the
alveolar crest, lateral sinus wall and zygomatic
bone (Fig 2).
This group represented 49% of the reviewed
implants.
Group 2 (ZAGA 2)
The anterior maxillary wall is concave.
The implant head is located on the alveolar crest.
The drill has performed the osteotomy through
the wall.
The implant can be seen through the wall and
most of the body has an extra-sinus path.
The implant comes into contact with bone at the
alveolar crest, lateral sinus wall and zygomatic
bone (Fig 3).
This group represented 20.5% of the reviewed
implants.
Aparicio Classification for zygomatic implant patients 272
Eur J Oral Implantol 2011;4(3):269275
Fig 3 ZAGA 2 case:
a) schematic and
b) clinical example.
ZAGA 2 is character-
ised by the following:
anterior maxillary wall is
concave; implant head is
located on the alveolar
crest; drill has per-
formed the osteotomy
through the wall and
most of the implant
body has an extra-sinus
path.
a b
Fig 2 ZAGA 1 case:
a) schematic and
b) clinical example.
ZAGA 1 is character-
ised by the following:
anterior maxillary wall is
slightly concave; implant
head is located on the
alveolar crest; drill has
performed the oste-
otomy slightly through
the wall and most of
the implant body has an
intra-sinus path.
Type 1
a b
Type 2
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Eur J Oral Implantol 2011;4(3):269275
Group 3 (ZAGA 3)
The anterior maxillary wall is very concave.
The implant head is located on the alveolar
crest.
The drill has performed the osteotomy follow-
ing a trajectory that goes from the palatal to the
upper buccal alveolar bone, then the implant
body leaves the concave part of the anterior sinus
wall to penetrate into the zygomatic bone.
Most of the implant body has an anterior extra-
sinus path.
The middle part of the implant body is not touch-
ing the most concave part of wall.
The implant comes in contact with bone in the
coronal alveolar and apical zygomatic bone (Fig 4).
This group represented 9% of the reviewed implants.
Group 4 (ZAGA 4)
The maxilla and the alveolar bone show extreme
vertical and horizontal atrophy.
The implant head is located buccally of the alveo-
lar crest. There is no or minimal osteotomy at
this level.
The drill has arrived at the apical zygomatic
entrance following a path outside the sinus
wall.
Most of the implant body has an extra-sinus/
extra-maxillary path. Just the apical part of the
implant is surrounded by bone.
The implant comes in contact with bone in the
zygomatic bone and part of the lateral sinus wall
(Fig 5).
This group represented 6.5% of the reviewed
implants.
In addition, 58% of the patients showed anatomical
differences between left and right zygomatic but-
tressalveolar crest complexes. In other words, right
and left sites of 58 patients were classied as differ-
ent ZAGA groups.
Fig 4 ZAGA 3 case:
a) schematic and
b) clinical example.
ZAGA 3 is character-
ised by the follow-
ing: anterior maxillary
wall is very concave;
implant head is located
on the alveolar crest;
drill has performed the
osteotomy following
a trajectory that goes
from the palatal to the
buccal alveolar bone,
then the implant body
leaves the concave part
of the anterior sinus
wall to penetrate into
the zygomatic bone so
that the middle part
of the implant body is
not touching the most
concave part of wall.
a b
Type 3
Aparicio Classification for zygomatic implant patients 274
Eur J Oral Implantol 2011;4(3):269275
Discussion
To the best of the present authors knowledge, no
classication system exists to describe the vari-
ous anatomy-guided zygomatic implant pathways
related to the zygomatic buttressalveolar crest
complex. Based on a cross-sectional study of 200
sites, a classication system comprising ve basic
anatomical groups named from ZAGA 0 to 4 is
proposed. This classication system is based on the
authors clinical experience with the original zygo-
matic implant technique and subsequent develop-
ment in order to reduce the bulkiness of the xed
dental prosthesis
4,8-10
. The latter study
10
reported
on a 3-year period using zygomatic implants placed
with this modied technique in 20 patients with
extreme buccal concavities in the maxillary sinus
areas. In addition, all patients but one received a
xed construction within 24 hours after surgery.
After a mean follow-up of 41 months, no implants
were removed, and no acute sinus infection or
unexpected tissue reactions to the zygomatic
implants were observed. Moreover, the extra-
sinus technique enabled placement of the implant
head at or near the top of the residual crest, which
resulted in a more normal extension of the xed
dental prosthesis framework.
The present proposed classication could help
the clinician to rene the original technique for the
placement of zygomatic implants by understanding
the possibility of nding not only inter-individual
anatomy differences but also intra-individual ones.
Establishment of the intraoral coronal entrance
point at the alveolar process is the key factor for
a successful outcome of the ZAGA procedure. The
implant head should be placed at or near the top
of the alveolar crest, with a mesiodistal entrance at
the level of the second premolar/rst molar regions.
By following specic prosthetic, biomechanical and
anatomical factors, the intraoral entrance point
depends on the vertical and horizontal resorption
of the alveolar/basal process and on the anterior
maxillary wall curvature. Guided by these factors,
the intraoral preparation can start either on the
bone crest (buccally of the crest in the shape of
a lateral canal) or, in cases of severe resorption,
the rst perforation can be performed extraorally,
directly on the zygomatic buttress.
a b
Fig 5 ZAGA 4 case:
a) schematic and
b) clinical example.
ZAGA 4 is characterised
by the following: maxilla
and the alveolar bone
show extreme vertical
and horizontal atrophy;
implant head is located
buccally of the alveolar
crest (there is no or
minimal osteotomy
at this level); drill has
arrived at the apical
zygomatic entrance
following a path outside
the sinus wall and most
of the implant body has
an extra-sinus/extra-
maxillary path.
Type 4
Aparicio Classification for zygomatic implant patients 275
Eur J Oral Implantol 2011;4(3):269275
A tendency to place the zygomatic implants
more and more externally to the maxillary wall
during the last 3 years has been noticed. Clin ical
follow-up studies have shown good outcomes
and no obvious irritation of the overlaying soft tis-
sues
8-12
, though there is a complete lack of valid
comparative trials
13
.
Due to the technical difculty of matching
the CBCT slice with the oblique trajectory of the
implant, especially when two implants are placed
in one zygomatic bone, when needed, the help of
clinical photographs was used to clarify the CBCT
images.
Conclusions
Five basic skeletal forms of the zygomatic buttress
alveolar crest complex and implant pathways have
been identied. A classication system comprising
ve basic anatomical groups named from ZAGA 0
to 4 is proposed. Anatomical intra-individual differ-
ences have also been found in 58% of the studied
population. It is believed that the proposed system
is useful for classifying zygomatic implant cases
for therapy planning and for scientic follow-up
purposes.
Acknowlegements
The work of Dr Karen Francisco in grouping the
sites according to the CBCT images has been highly
appreciated.
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