Schiroli Guido, Angiero Francesca, Silvestrini-Biavati Armando, Benedicenti Stefano
University of Genoa, Department of Medical, Biophysical, Dental Science and Technologies, DISTIBIMO, Genoa, Italy.
J Oral Maxillofac Surg. 2011 Dec;69(12):2979-89. doi: 10.1016/j.joms.2011.03.050. Epub 2011 Aug 11.
The aim of the present report is to describe a procedure for zygomatic implant placement using image-guided implant surgery. This is an innovative technique and includes a new clinical approach to provide the direction to guide drilling.
The ethical committee of the University of Genoa approved the study. All patients had clinical indications of severe maxillary atrophy (Class 4 Cadwood-Howell). A total of 25 implants were placed, of which 17 were in the premaxilla, 7 in the zygomatic area, and 1 in the pterygoid bone. The treatment was performed in 2 phases. The first phase included cone-beam acquisition to exclude sinus disease and evaluate the anatomy of the residual premaxillary bone in 3 dimensions. The success of osseointegration achieved by the primary implants (PIs) was confirmed after temporary loading and before proceeding with the second phase, in which all patients were scheduled for zygomatic implants. A total of 3 or 4 regular platform MK III implants (17 in all) were placed in the premaxilla using conventional implant surgery. A model within the analogs of the PIs was prepared (master model), taking a conventional impression. Next, a radiologic template was prepared on the same master model and stabilized on the PIs, using dedicated prosthetic components. The guide was screwed onto the PIs during computed tomography acquisition to determine a fixed and repeatable position of the guide. In the second phase, after routine planning, a mucosa-supported stereolithographic SurgiGuide with sleeves for the zygomatic implants and the corresponding stereolithographic model, including the mucosa, were received from the manufacturers. The guide was repositioned on the master model to replace the sleeves for the PIs in the same position. With an original customized surgical kit, including an innovative intrasinus device, we next simulated surgery on the stereolithographic model to determine and control the direction of the osteotomies and the final depth of drilling. The SurgiGuide was anchored onto the PIs before the zygomatic osteotomy, after which flapless surgery was performed to place the zygomatic implants according to the plan.
Two PIs in the premaxillary area failed (and were replaced before the zygomatic step). No zygomatic implants failed. The follow-up examinations at 4 to 39 months showed good esthetic, phonetic, and functional results.
The results of the proposed surgical procedure appear to be encouraging. Although it is difficult to achieve the correct driven angle of osteotomies for zygomatic implants, in all patients we achieved correct zygomatic positioning, in agreement with previous planning. Additional research and randomized clinical trials are needed to assess the predictability of the procedure.
本报告旨在描述一种使用影像引导种植手术进行颧骨种植体植入的方法。这是一种创新技术，包括一种新的临床方法来提供引导钻孔的方向。
热那亚大学伦理委员会批准了该研究。所有患者均有严重上颌骨萎缩的临床指征（卡德伍德 - 豪厄尔4类）。共植入25枚种植体，其中17枚位于前上颌骨，7枚位于颧骨区域，1枚位于翼骨。治疗分两个阶段进行。第一阶段包括锥形束扫描以排除鼻窦疾病并三维评估剩余前上颌骨的解剖结构。在临时加载后且在进行第二阶段之前，确认了初级种植体（PI）实现的骨结合成功，第二阶段所有患者均计划植入颧骨种植体。使用传统种植手术在前上颌骨植入总共3枚或4枚常规平台MK III种植体（共17枚）。取常规印模，在PI的仿制品内制作模型（主模型）。接下来，在同一个主模型上制作放射学模板，并使用专用修复部件固定在PI上。在计算机断层扫描采集期间将导向器拧到PI上，以确定导向器的固定且可重复的位置。在第二阶段，经过常规规划后，从制造商处接收带有颧骨种植体套筒的黏膜支持的立体光刻手术导板以及包括黏膜在内的相应立体光刻模型。将导板重新定位在主模型上，以在相同位置替换PI的套筒。使用包括创新的窦内装置在内的原始定制手术套件，接下来在立体光刻模型上模拟手术，以确定和控制截骨方向及最终钻孔深度。在颧骨截骨术前将手术导板固定在PI上，之后进行无瓣手术，按计划植入颧骨种植体。
前上颌骨区域的2枚PI失败（在颧骨手术步骤之前被替换）。没有颧骨种植体失败。4至39个月的随访检查显示出良好的美学、语音和功能结果。
所提出的手术方法的结果似乎令人鼓舞。尽管难以实现颧骨种植体截骨的正确驱动角度，但在所有患者中我们都实现了与先前规划一致的正确颧骨定位。需要进一步的研究和随机临床试验来评估该方法的可预测性。
