Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I’m Bill Klaproth, and with me is Dr. Waldemar Polido, who is here to discuss full-arch rehabilitation, zygomatic implants versus traditional techniques. Dr. Polido, thank you for being here. 

Dr. Waldemar Polido: Hi, Bill. My pleasure. It’s going to be great to discuss this topic with you today. 

Bill Klaproth (host): Absolutely. So, let me ask you this first. What are dental implants and zygomatic implants? What are the similarities and what are the differences? 

Dr. Waldemar Polido: That’s a really good question. So, both are implants, or dental implants, made to rehabilitate patients that have one, two or more missing teeth. The main difference is that the zygomatic implants, they are longer implants, and they are meant to go through what we call the upper jawbone, inside out through what we call the cheekbone, also the zygomatic bone. So, they are meant to be used in patients that do not have upper jawbone available for traditional dental implants. Traditional implants usually range from 8 millimeters long to maybe 12, 14. Whereas, zygomatic implants start at 32, 34 millimeters long. So, basically, they also integrate the same. The way we drill into bone and put the implants in is basically the same. Some biomechanical restorative concepts are the same, but they are just a different technique meant to anchor the tip of a zygomatic bone into the zygomatic or cheek bone, from inside out, so at the end we have that holding teeth where they need to go. And the other main difference is that we do not place just one zygomatic implant. We need at least one zygomatic implant and one additional implant. Usually, it’s two zygomatic implants, one on each side, plus a traditional implant in the middle. Or even four zygomatic implants. So we can splint or unite a zygomatic implant with a traditional implant. 

Bill Klaproth (host): So depending on the person then, Dr. Polido, traditional dental implants are smaller and those get screwed into the jawbone where the zygomatic implants are longer. If a person doesn’t have much of a jawbone, those then get drilled into the cheekbone. Is that right? 

Dr. Waldemar Polido: That is correct. So they go through the very thin or even nonexistent, sometimes, upper jawbone. And then they get anchored on the cheekbone. 

Bill Klaproth (host): So are there advantages to the zygomatic implants compared to traditional dental implants and bone grafts, obviously you have to use one if someone doesn’t have much of a jawbone, but are there other benefits outside of that? 

Dr. Waldemar Polido: Yeah, the main benefits are actually timing and invasiveness. So, imagine someone that does not have all the teeth in the upper jaw. And they do not have a lot of bone. To be able to put a normal implant, sometimes we have to go to traditional bone grafting reconstruction that requires one procedure just to reconstruct bone, let it heal from four to six months, then go in and put a traditional dental implant, or several of those, like four to six dental implants. Whereas a zygomatic implant, it’s called a graftless procedure, so we do not have to graft. So, we just go through the very thin or minimal maxillary bone, through or out just next to it, or sometimes through the maxillary sinuses. And then we anchor those implants in a very dense, strong zygomatic bone. 

Bill Klaproth (host): So, that’s really interesting. So, let me ask you this, is one of the benefits that this is quicker, a faster procedure? Is it less invasive? Is there less time as well? 

Dr. Waldemar Polido: Yes, it is a bit more invasive than a traditional implant. But when you compare, if you have enough bone, you would just do a normal traditional implant. But when you compare the major grafting procedures, plus waiting the time, plus the invasions of harvesting sometimes bone to graft with a zygomatic implant, you just can go right away and just put the zygomatic implants in. And the other advantage, because the cheekbone is so thick and dense, we get really good stability, what we call anchorage or primary stability. And we can sometimes do what we call immediate loading. So we get a temporary denture and screw retain that onto the zygomatic implants that are placed combined between them or with two conventional dental implants. So it’s the immediacy concept or the chance we’re immediately delivering in a couple of days a temporary denture is a lot higher than when you’re doing a bone graft, of course.

Bill Klaproth (host): Yeah, that makes a lot of sense. So, check me if I have this correct. With the zygomatic implants, it sounds like bone grafting can be avoided then if you use zygomatic implants. Is that right? 

Dr. Waldemar Polido: That is correct. It is considered a graftless technique. In some instances, when even bone may be so destroyed or nonexistent, that even when we do zygomatic, we have to do minor bone grafting at the same time, just to kind of protect the neck of the implant. But even so, it does not compare with a staged grafting technique, which is reconstructing bone first, letting that heal and then going into the traditional implant. So, it is an advantage from that perspective, no question. 

Bill Klaproth (host): Absolutely. So, let me ask you this, are there situations where both dental implants and bone grafting are still preferable to zygomatic implants? 

Dr. Waldemar Polido: I would say yes. Let’s say if bone loss is moderate to minimal, where we can still put narrower normal implants or even shorter bone implants and grafting can be done simultaneously with the implant placement, that is a preferable modality in some instances, but it depends on bone loss and sometimes it’s actually a clinician preference. But yeah, traditional implants have been around for a long, long time. So have zygomatic implants. It’s not a new technique. It’s actually a relatively old technique that is just now improved due to new technology. And obviously if you have enough bone, you will not even think about a zygomatic implant. You just go with traditional implants. 

Bill Klaproth (host): Right, that’s a good distinction and good to know on that. So, how does immediate placement of dental implants compare between zygomatic implants and traditional implants with bone grafts? 

Dr. Waldemar Polido: Yeah, that’s a really good question, too, because immediate implant is considered when you have a tooth that cannot be restored anymore because of whatever cause. And then you have to extract that tooth and put an implant at the same time, on the same surgical procedure. That is considered an immediate implant. Immediate loading is when you put an implant in and you attach the tooth to that implant on that same day or within three to five days. So, a zygomatic implant, when you take the tooth out and there’s no bone and you can plan that nowadays on three-dimensional radiographs and you can plan okay, I’ll remove that tooth there’s no bone around the alveolar bone, which is the bone that holds the tooth in place there’s no bone because bone is lost then you go through that area and use the zygomatic implant and anchor that on the cheekbone. So yes, you can do immediate placement with zygomatic implants, whereas to do immediate placement on a normal implant, you need to have more bone, superior or posterior to that socket that is left. 

Bill Klaproth (host): So, when you say immediate loading, is that where the person has a lower recovery time and can actually chew sooner? I mean in layman’s terms, is that what that means? 

Dr. Waldemar Polido: Yeah, well, if you think the traditional way to do implants is you take the tooth out, let it heal for a couple months, then you drill, you open the gums again, put another anesthesia, put a pin in, which is the implant, the screw implant. You let it osseointegrate, which is form bone around it, for anywhere from two to four months, and then you go in and you attach the teeth. That is the conventional way. Now, nowadays, because of knowledge and experience and technology and all that thing, some instances we can do immediate placement, which is extracting the tooth, put it in the implant at the same time, and immediate placement of a restoration. So imagine someone with no teeth, you put the implant in, the zygomatic implant, you have very good anchorage on the cheekbone. It’s so stable, you can get a denture and screw retain it on the implants. Basically, the patients leave with a denture on the same day or within two or three days instead of waiting three to four months for that bone to heal and then put a denture in. 

Bill Klaproth (host): Definitely an advantage. So, thank you for explaining that to us. So, are there scenarios though where traditional dental implants with bone grafting are still the preferred method? 

Dr. Waldemar Polido: I want to say in the lower jaw, yes. Again, zygomatic implants are only for the upper jaw. Then, for partial teeth loss. Patients have some teeth, but not all. Some teeth can be kept. So, then for partial missing teeth, partial areas of missing teeth, then traditional implants are still the best. Bone graft reconstruction and traditional implants are still the best. And obviously it depends on the anatomy. So, what we try to look at is an anatomically driven type of thing. If patients have some bone on the anterior, let’s say below the nose area, we can put traditional implants instead of going to zygomatic implants. But if they have no bone, then we can add more, you know, up to four zygomatic implants on the same patient. So, some partial instances, of course, a simple tooth, a single tooth that is lost, that is for a traditional implant and for the mandible. For the upper jaw, if they have all missing teeth or will have all the teeth extracted, then the zygoma becomes an interesting idea. 

Bill Klaproth (host): Is there a scenario, and maybe you answered this earlier, where you use both the traditional implants and zygomatic implants at the same time? 

Dr. Waldemar Polido: Yes, so that is based on the available bone that the patient has. If they have bone on the anterior teeth, we call like the canine to canine region, let’s say, right, just below the nose. And for normal implants, then we just do normal implants in the front. And on the back, where they do not have bone, then we go through the sinuses or lateral to it and anchor the tip of the zygomatic implant on the cheekbone. So we combine both techniques. 

Bill Klaproth (host): Okay. Got it. So, then in hearing you talk about this and you mentioned technology earlier, I bet that really has helped you and helped to assist in the placement of both traditional and zygomatic implants. Can you talk about digital technology assisting in the planning and placement of both zygomatic implants and traditional dental implants? 

Dr. Waldemar Polido: Oh yeah, I would love to. That’s one of my passions, actually. One of the things I work a lot is with technology utilized for improving the outcomes for our patients. So one of the biggest, if not the biggest, advantage that we had in recent years in implantology or implant surgery is the addition of three-dimensional images. So, in the past, we could do the zygoma implants with just two-dimensional images. So, we had to rely a lot on clinical experience and changing plans during surgery. Nowadays, a patient comes in, we get a skull scan, a bone scan of the face, and then we have special software where we can actually play with the implant position, decide size, decide the position, even do virtual extractions on the computer. We take teeth out, we see the gap, the defect, and then we discuss. We can actually place the new teeth on the computer and see that relationship. We can 3D print the upper jaw in plastic and practice on a plastic. If we want to, just to check details. And then also the software allows us to construct what we call a guide or a template that we take into surgery and we drill and we place the template exactly where we want with minimal deviation. So, it’s pretty accurate. 

Bill Klaproth (host): That is amazing. Do you share this with the patient? Are they able to see their new smile and say, I like that? Or, give this to me? Can you do this for me? 

Dr. Waldemar Polido: Yeah. No question. We can actually add photography to it and just do some stuff with photography, but we can share and it’s a really good communication tool. Because, like, the listeners to this podcast, they are not looking at anything, right? If I just say, hey, you don’t have bone, they don’t know how much bone am I talking about. But if I show them on the screen their own bone, and I just pick an implant from the implant library, and I just place it, and I say, this is bone, this is your implant, you see, it does not fit, you do not have enough bone. Now, if I do this thing, then you see how bone is inside, how the implant is inside your bone, and this is a preferable technique, or they always have the choice to have a bone graft. Like, I would like to think also, going back to one of your previous questions, that a very young patient that is unfortunate to not to have teeth, let’s say less than 40 years old, maybe bone grafting could be an advantage long-term down the road, because then we rebuild bone and the more bone we have around the implants, the better. That is an option. So, definitely technology helps to discuss all these options with our patients. 

Bill Klaproth (host): Absolutely, a benefit for not only the patient, but for you as well. This has really been fascinating, Dr. Polido. Thank you so much for your time. Before we wrap up, is there anything else you’d like to add? Anything we missed or anything else you want to speak about? 

Dr. Waldemar Polido: I think we covered not in detail, pretty much everything, but you know, the zygomatic implants are a technique that was developed many, many years ago for patients that had cancer and had to have the whole jawbone removed. Still is an indication, but nowadays we use it for patients that just lost their teeth and they lost all the bone with it also. Once you lose a tooth, you lose bone. And then when bone becomes, we call atrophic or with minimal volume, then the zygomatic implants due to all this technology, new designs of implants that we have nowadays, new connections between the denture and the implants, we can provide the patients with a better, safer and faster and less invasive type of treatment. I also would like to highlight that because they go into the cheekbone, just through the sinuses, very close to the eye sockets or the orbits, and into areas where we have a complex anatomy, oral and maxillofacial surgeons are mostly prepared to do those types of techniques. Instead of a clinician that is good with traditional implants but is not used to working in that area of the face. So, I think this is a highly advanced, complex technique that requires surgeons who have very good experience and are used to working in that area of the face because if you do not have that experience, it may lead to complications, and we don’t want that for our patients. 

Bill Klaproth (host): That is such a great point. Choose an oral and maxillofacial surgeon if you’re having this type of dental surgery. Oral and maxillofacial surgeons are the experts in this. You are trained in these types of surgeries. Isn’t that right, Dr. Polido? 

Dr. Waldemar Polido: That is correct. And those surgeries usually require sedation, so the patients are asleep or even in the operating room, so we have everyday access and knowledge and training on those areas as well. 

Bill Klaproth (host): Absolutely. Very well said. This has really been informative and educational. Thank you, Dr. Polido. We appreciate it. 

Dr. Waldemar Polido: Thank you for all the questions and the opportunity. 

Bill Klaproth (host): You bet. Once again, that is Dr. Waldemar Polido, and for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast helpful, please share it on your social channels and don’t forget to subscribe. Thanks for listening.