Prevalence of Zygomatic Air Cell defects in a sample of 6-18-year-old patients in Saudi Arabia and Yemen: a retrospective study.

OBJECTIVES: This study aimed to comprehensively analyze the prevalence and influencing factors of Zygomatic Air Cell Defects (ZACD) among pediatric and adolescent populations in Saudi Arabia and Yemen. MATERIALS AND METHODS: A cross-sectional retrospective study was conducted, utilizing digital panoramic radiographs of dental outpatients aged 6 to 18 years. The data were collected from registered digital databases of dental clinics in Al-Qassim, Saudi Arabia, and an oral and maxillofacial radiology center in Sana'a, Yemen, covering the period from July 2018 to September 2022. The radiographs were evaluated based on inclusion and exclusion criteria, and ZACD was assessed using standardized descriptions. Statistical analysis, including logistic regression, was employed to examine the impact of the associated factors. RESULTS: The study encompassed a total of 3,169 participants, revealing an overall ZACD prevalence of 28.5%. Age emerged as a significant predictor (p ≤ 0.0001), with the likelihood of ZACD increasing as the age of the individual advances. Gender and geographic region did not exhibit statistically significant differences in ZACD prevalence. CONCLUSION: This study provides crucial insights into the prevalence of Zygomatic Air Cell Defects among pediatric and adolescent populations in Saudi Arabia and Yemen. It underscores the prevalence of ZACD and the notable influence of age on its occurrence. Additionally, the research challenges prior notions of gender and regional variations in ZACD prevalence, emphasizing the complexity of the factors involved. Early detection is essential to avoid unwanted complications during any surgical intervention in this area.

Assessing the frequency and variability of accessory zygomatic sutures in dry skulls: clinical insights and potential implications.

PURPOSE: This study aimed to determine the presence and incidence of accessory sutures and bipartite zygomatic bone types, and their effects on population affinity and clinical significance. METHODS: We examined 120 dry skulls and 50 zygomatic bones to evaluate the presence, frequency, and location of accessory zygomatic sutures as well as subtypes of bipartite zygomatic bones. Morphometric analysis included measuring the total width and length of the zygomatic bone with accessory sutures (ASs), the total length of the AS, and the shortest distance between the AS and various anatomical landmarks. RESULTS: Bipartite zygomatic bone was observed in 14 of 120 dry skulls (11.6%) and 1 of 50 zygomatic bones (2%), indicating an overall incidence of 16 occurrences (8.82%). The ASs were predominantly located posterolaterally in 11 cases (six males, five females), anteromedially in two cases (one male, one female), superiorly in one case (male), and superolaterally in one case (male). Significant differences were noted in the distribution of the ASs (p < 0.001). Notably, a vertical inferior bipartite zygomatic type, which has not been reported in the literature, was identified. Correlations were observed between the various anatomical landmarks. Among females, the length of AS was significantly different (p = 0.038). Significant differences were also noted in the shortest distance between the AS and the zygomaticofacial foramen (ZFF) based on the body side (p = 0.034). CONCLUSIONS: Our study suggests that the bipartite zygomatic bone is not a common occurrence, indicating its significance as a morphological variation present in certain individuals. The type VII bipartite zygomatic bone exhibited the highest incidence rate, suggesting potential ethnic-specific differences in the prevalence of certain subtypes. The consistent pattern of suture distribution, along with the asymmetry and variability in suture patterns, emphasizes its potential clinical relevance.

Dental Versus Zygomatic Implants in the Treatment of Maxillectomy: A Finite Element Analysis.

This study analyzed the stress distributions on zygomatic and dental implants placed in the zygomatic bone, supporting bones, and superstructures under occlusal loads after maxillary reconstruction with obturator prostheses. A total of 12 scenarios of 3-dimensional finite element models were constructed based on computerized tomography scans of a hemimaxillectomy patient. Two obturator prostheses were analyzed for each model. A total force of 600 N was applied from the palatal to buccal bones at an angle of 45°. The maximum and minimum principal stress values for bone and von Mises stress values for dental implants and prostheses were calculated. When zygomatic implants were applied to the defect area, the maximum principal stresses were similar in intensity to the other models; however, the minimum principal stress values were higher than in scenarios without zygomatic implants. In models that used zygomatic implants in the defect area, von Mises stress levels were significantly higher in zygomatic implants than in dental implants. In scenarios where the prosthesis was supported by tissue in the nondefect area, the maximum and minimum principal stress values on cortical bone were higher than in scenarios where implants were applied to defect and nondefect areas. In patients who lack an alveolar crest after maxillectomy, a custom bar-retained prosthesis placed on the dental implant should reduce stress on the zygomatic bone. The stress was higher on zygomatic implants without alveolar crest support than on dental implants.

Orthodontic maxillary molar movement-induced zygomatic pillar remodeling and its consequences on occlusal characteristics and stress distribution.

OBJECTIVE: We aimed to evaluate changes in the zygomatic pillar during orthodontic treatment involving premolar extraction, analyze the effects of maxillary first molar movement on zygomatic pillar remodeling, and examine occlusal characteristics and stress distribution after remodeling. METHODS: Twenty-five patients who underwent premolar extraction were included in the study. The zygomatic pillar measurement range was defined, and cross-sectional areas, surface landmark coordinates, alveolar and cortical bone thicknesses, and density changes were assessed using Mimics software based on the cone-beam computed tomography scans taken before (T0) and after the treatment (T1). Multiple linear regression analysis was performed to determine the correlation between changes in the zygomatic pillar and maxillary first molar three-dimensional (3D) movement and rotation. Additionally, the correlation between pillar remodeling and occlusal characteristics was analyzed by Teetester. Pre- and post-reconstruction 3D finite element models were constructed and loaded with an average occlusal force of two periods. RESULTS: The morphological and structural remodeling of the zygomatic pillar after orthodontic treatment involving premolar extraction showed a decreased cross-sectional area of the lower segment of the zygomatic pillar. The zygomatic process point moved inward and backward, whereas the zygomatico-maxillary suture point moved backward. The thicknesses of the zygomatic pillar alveolar and cortical bones were thinner, and reduced alveolar bone density was observed. Simultaneously, the movement and angle change of the maxillary first molar could predict zygomatic pillar reconstruction to a certain extent. With decreasing the total occlusal force and the occlusal force of the first molar, occlusal force distribution was more uniform. With zygomatic pillar remodeling, occlusal stress distribution in the zygomatic alveolar ridge decreased, and occlusal stress was concentrated at the junction of the vertical and horizontal parts of the zygomatic bone and the posterior part of the zygomatic arch. CONCLUSIONS: Orthodontic treatment involving premolar extraction led to zygomatic pillar remodeling, making it more fragile than before and reducing the occlusal force of the maxillary first molar and the entire dentition with stress concentrated in weak areas. CLINICAL RELEVANCE: No other study has focused on the effects of orthodontics on pillar structures. The present study indicates that the mesial movement of the maxillary first molar weakened the zygomatic pillar and reduced occlusal function, thereby providing insights for inserting anchorage screws and facial esthetics.

Temporary Anchorage Device Misplaced into Infratemporal Space - A Case Report.

INTRODUCTION: During orthodontic treatment, temporary anchoring devices (TADs) are used to restrain tooth movement. They are a relatively recent addition to the dental toolkit. AIM: As TADs have limitations, Dr. Eric Lieu of Taiwan developed Infra Zygomatic Crest (IZC) screws which are placed between the maxillary second premolar at the bony crest. TREATMENT PLANNING: The goal of this case study is to emphasize the value of anatomy, site selection, and IZC retrieval in the event of an accident. Cone beam computed tomography was used as a diagnostic tool for the precise location of the displaced IZC and immediate surgical retrieval was done under local anesthesia from the infratemporal space to prevent further complications. TAKEAWAY LESSONS: Orthodontists knowledge of soft tissue and hard tissue anatomy and precise positioning is crucial for successful TAD implantation.

Prosthetic rehabilitation of patients with maxillary oncology defects using zygomatic implants.

PURPOSE: Prosthetics for patients after oncological resection of the upper jaw is a complex problem associated with the physiological and anatomical separation of the oral cavity and the nasal/paranasal region. This study reports the clinical results of the use of the zygomatic implants for prosthetic rehabilitation in patients with maxillectomy due to upper jaw tumors. MATERIALS AND METHODS: The study included 16 patients who underwent prosthetic rehabilitation using a zygomatic implant after maxillectomy period from 2021 to 2023. After the tumor was removed, immediate surgical obturators were placed. Main prosthetic rehabilitation was performed 6-12 months after tumor removal, but before that, a temporary obturator was made and used. Six-twelve months after tumor resection, 1-4 zygomatic implants were inserted into the zygomatic bone unilaterally or bilaterally. A total of 42 zygomatic implants were installed, 2 of which were unsuccessful and were removed in 1 patient. The implants were placed using the surgical guide, which was planned and prepared digitally. RESULTS: No postsurgical complications were seen, and the patients were discharged from the hospital after 7-10 days. The patients were able to return to a normal diet (hard food) after just 7 days following surgery, with no further complaints regarding function or pain, apart from the residual edema caused by the intervention. CONCLUSIONS: The use of prostheses fixed on zygomatic implants in patients with maxillary defects is an effective method of prosthodontic rehabilitation in complex clinical cases after maxillectomy.

Round and flat zygomatic implants: effectiveness after a 3­year follow­up non­interventional study.

PURPOSE: This non-interventional study investigates variations in the type and frequency of late complications linked to novel zygomatic implant designs, installed adhering to the Zygoma Anatomy-Guided Approach (ZAGA) concept, over an extended follow-up period of at least 3 years. METHODS: Consecutive patients presenting indications for treatment with ZIs were treated according to ZAGA recommendations. Implants were immediately loaded. The ORIS success criteria for prosthetic offset, stability, sinus changes and soft-tissue status were used to evaluate the outcome. RESULTS: Twenty patients were treated. Ten patients received two ZIs and regular implants; one received three ZIs plus regular implants, and nine received four ZIs. Fifty-nine ZIs were placed: thirty-six (61%) Straumann ZAGA-Flat implants and twenty-three (39%) Straumann ZAGA-Round implants. Four patients (20%) presented earlier sinus floor discontinuities. Fifteen patients (75%) had prior sinus opacities. Nineteen patients were followed for between 38 and 53 months (mean 46.5 months). One patient dropped out after 20 months. When comparing pre-surgical CBCT with post-surgical CBCT, 84.7% of the sites presented identical or less sinus opacity; nine locations (15%) showed decreased, and another nine increased (15%) post-surgical sinus opacity. Fifty-three ZIs (89.8%) maintained stable soft tissue. Six ZIs had recessions with no signs of infection. ZIs and prosthesis survival rate was 100%. CONCLUSIONS: The study highlights the effectiveness of ZAGA-based zygomatic implant rehabilitations using Round and Flat designs. Despite patient number constraints, minimal changes in the frequency of late complications from the 1-year follow-up were observed. 100% implant and prosthesis survival rate over a mean follow-up of 46.5 months is reported.

Effectiveness of zygomatic-implant fixed rehabilitation for the atrophic edentulous maxilla: protocol for a systematic review and network meta-analysis.

BACKGROUND: Atrophic edentulous maxilla is a debilitating condition caused by the progressive and irreversible bone resorption following loss of teeth, that results in bone of inadequate volume and density. This makes conventional implant therapy extremely challenging without complex reconstructive procedures. Several techniques such as sinus augmentation, short implants, and tilted implants have been used for the rehabilitation of the atrophic maxilla. In recent years, zygomatic implants have emerged as a graftless rehabilitation technique. However, few studies compare zygomatic-implant fixed rehabilitation with other fixed rehabilitation techniques. The existing body of evidence on zygomatic implants is largely based on clinical and disease-oriented outcomes. METHODS: A network meta-analysis (NMA) will be conducted in order to compare the effectiveness of zygomatic-implant fixed rehabilitation with the other rehabilitation techniques. Experimental and observational studies comparing different implant-assisted fixed rehabilitation in adults with atrophic maxilla will be included. The primary and secondary outcomes will be patient's satisfaction and quality of life respectively. Additional outcomes include the implant's survival/success, and biological and prosthetic complications. An electronic search will be performed through various databases for articles in English and French, without time limits. Risk of bias will be assessed using the Revised Cochrane Risk-of-Bias tool for randomized controlled trials, and ROBINS-I for non-randomized and observational studies. Two independent reviewers will screen the titles and abstracts and extract data. Any discrepancy between reviewers will be discussed and resolved through consensus or with the help of a third reviewer. Pairwise meta-analyses will be performed using a random effects model. I2, τ2, transitivity, subgroup/meta-regression analyses will assess and explain heterogeneity and distribution of effect modifiers. A network plot will be created to connect the different interventions directly and indirectly. Interventions will be ranked using the surface under cumulative ranking curve. Confidence in the results of the NMA will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). DISCUSSION: This study will be the first to assess the effectiveness of zygomatic-implant fixed rehabilitation for the atrophic maxilla using NMA. The evidence obtained will aid clinical decision-making and will advance the knowledge of the rehabilitation techniques for the atrophic maxilla. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023353303.

Image fusion-based low-dose CBCT enhancement method for visualizing miniscrew insertion in the infrazygomatic crest.

Digital dental technology covers oral cone-beam computed tomography (CBCT) image processing and low-dose CBCT dental applications. A low-dose CBCT image enhancement method based on image fusion is proposed to address the need for subzygomatic small screw insertion. Specifically, firstly, a sharpening correction module is proposed, where the CBCT image is sharpened to compensate for the loss of details in the underexposed/over-exposed region. Secondly, a visibility restoration module based on type II fuzzy sets is designed, and a contrast enhancement module using curve transformation is designed. In addition to this, we propose a perceptual fusion module that fuses visibility and contrast of oral CBCT images. As a result, the problems of overexposure/underexposure, low visibility, and low contrast that occur in oral CBCT images can be effectively addressed with consistent interpretability. The proposed algorithm was analyzed in comparison experiments with a variety of algorithms, as well as ablation experiments. After analysis, compared with advanced enhancement algorithms, this algorithm achieved excellent results in low-dose CBCT enhancement and effective observation of subzygomatic small screw implantation. Compared with the best performing method, the evaluation metric is 0.07-2 higher on both datasets. The project can be found at: https://github.com/sunpeipei2024/low-dose-CBCT .

The 'Manchester' method of minimal access fixation of the zygomatic arch in zygomatic complex fractures: a case series.

We have introduced a minimally invasive approach for the fixation of the zygomatic arch during the surgical management of zygomatic complex fractures. Access for this technique is provided by a preauricular approach and eyelid incisions with the addition of transcutaneous stab incisions overlying the arch. These stab incisions allow transcutaneous drilling and screw placement through a size CH 20 (5.0 mm) paediatric nasopharyngeal airway (NPA). We present a case series of seven patients. In all patients the arch component was successfully reduced and fixed, and no intraoperative or postoperative complications were observed. The use of an NPA is novel. It functions as a flexible self-irrigating sleeve and protects the skin from mechanical and thermal damage. The technique uses readily available equipment, is easy to learn, and simplifies surgery to the zygomatic arch.

Consideration of the diameter of superficial temporal arteries related to filler injections in the temporal region.

BACKGROUND: The concavity of the temple due to adipose tissue atrophy from aging accentuates the zygomatic arch and lateral orbital rim, leading to an aged appearance. The use of hyaluronic acid filler in the temporal region has gained popularity due to its procedural simplicity and consistent outcomes. OBJECTIVE: To evaluate the safety of administering hyaluronic acid filler in the temporal region concerning the frontal branch of the superficial temporal artery, which is at risk of injury. METHODS: Empirical observations were conducted on the internal diameter of the frontal branch of the superficial temporal artery, a critical anatomical site for potential injury. RESULTS: A significant proportion of the artery segments exhibited an internal diameter below 1 mm. Given that the outer diameter of an 18-gauge cannula is 1.27 mm, this method can be considered a relatively secure approach for enhancing the temporal region. CONCLUSION: The use of an 18-gauge cannula for hyaluronic acid filler administration in the temporal region appears to be a safe and effective method, with the potential risk to the frontal branch of the superficial temporal artery being minimal.

Learning curve of dynamic navigation-assisted zygomatic implant surgery: An in vitro study.

STATEMENT OF PROBLEM: Dynamic computer-assisted zygomatic implant surgery (dCAZIS) has been reported to provide clinical efficacy with high accuracy and low risk of complications. However, the learning curve before performing dCAZIS effectively is unknown. PURPOSE: The purpose of this in vitro study was to explore the learning curve of dCAZIS in dentists with different levels of experience in implant dentistry and navigation surgery. MATERIAL AND METHODS: Six senior dental students were randomly divided into 3 groups for initial training (FH-CI group: pretraining on freehand conventional implant surgery; FH-ZI group: pretraining on freehand ZI surgery; DN-CI group: pretraining on conventional implant surgery under dynamic navigation). Then, every operator conducted 6 repeated dCAZIS training sessions on edentulous 3-dimensional (3D) printed skull models and was asked to complete a self-report questionnaire after each training session. A total of 36 postoperative cone beam computed tomography (CBCT) scans with 144 ZI osteotomy site preparations were obtained and superimposed over the preoperative design for accuracy measurements. The operation time, 3D deviations, and results of the self-reports were recorded. Comparisons among groups were analyzed with independent-sample Kruskal-Wallis tests (α=.05), and correlations between study outcomes and the number of practices were calculated. RESULTS: Operator experience and increased practice times did not significantly affect the accuracy of dCAZIS (P>.05). However, the operation time varied among groups (P<.001), and significantly shortened with more practice, reaching 11.51 ±1.68 minutes at the fifth attempt in the FH-CI group (P<.001 compared with the first practice), 14.48 ±3.07 minutes at the third attempt in the FH-ZI group (P=.038), and 8.68 ±0.58 minutes at the sixth attempt in the DN-CI group (P<.001). All groups reached their own learning curve plateau stage within 6 practice sessions. As the number of practice sessions increased, the results from the self-report questionnaires gradually improved. CONCLUSIONS: Among dentists with different levels of experience in implant dentistry and navigation surgery, dCAZIS was found to have a learning curve with respect to operation time but not implant accuracy. Experience in ZI surgery had little impact on the learning curve of dCAZIS, but experience in navigation surgery was a key factor.

Displacement of Zygomatic Implant in Infratemporal Region in a Case of COVID-19-Associated Mucormycosis.

Reconstruction of maxillary defects can be carried out using a variety of treatment modalities. The choice of modality depends on numerous factors, including the size and extent of the defect, patient characteristics, and existing comorbidities. One of the various options is reconstruction and rehabilitation using a fixed prosthesis supported over a zygomatic implant. In maxillectomy cases, a zygomatic implant can be used to improve the retention of the obturator prosthesis, as the loss of alveolar bone makes it impossible to use conventional endosseous implants. Although zygomatic implants are reported to have high success rates, they are not free of complication. We hereby present a rare complication associated with the placement of a zygomatic implant in a patient with COVID-19-associated mucormycosis who underwent operation. This rare complication has never been reported before. This case report also highlights on the management of complications involving displacement of a zygomatic implant in the infratemporal region.

Modeling stability post zygomatic fracture reconstruction.

Zygomaticomaxillary complex (ZMC) fracture repair is one of the most common surgical procedures performed in craniomaxillofacial trauma management. Miniplates and screws are used to stabilize the fractured bone using small local incisions, however, these procedures are not infrequently associated with hardware-related post-operative complications. The amount of fixation hardware utilized varies depending on the fracture pattern and surgical judgment, with three-point fixation being the conventionally accepted treatment. However, limited experimental testing and clinical studies have suggested that ZMC stabilization may be achieved with less than three-point fixation. In this study, we utilized a previously developed finite element modeling approach that allows for detailed bone and muscle representation to study the mechanical behavior of the fractured craniomaxillofacial skeleton (CMFS) under one, two, or three-point fixation of the ZMC. Results suggest that using a miniplate along the infraorbital rim in three-point fixation increases the amount of strain and load transfer to this region, rather than offloading the bone. Two-point (zygomaticomaxillary and zygomaticofrontal) fixation yielded strain patterns most similar to the intact CMFS. One-point (zygomaticofrontal) fixation resulted in higher tensile and compressive strains in the zygomaticofrontal region and the zygomatic arch, along with a higher tensile strain on the zygomatic body. These modeling results provide biomechanical evidence for the concept of over-engineering in the stabilization of facial fractures. Furthermore, they support previous suggestions that less than three-point fixation of ZMC fractures may be adequate to achieve uneventful healing.

El reposicionamiento malar. Presentación de una técnica original: punto MM / Malar repositioning. Presentation of an original technique: point MM

El envejecimiento facial es una sinergia compleja de cambios texturales de la piel, hiper- o hipoactividad muscular, reabsorción del tejido graso y resorción ósea. El déficit de volumen resultante, la deflación y la posterior caída del tercio medio facial produce una cara menos atractiva y juvenil. Los procedimientos inyectables en región malar son cada vez más populares y solicitados por los pacientes. El conocimiento de la anatomía de la cara media es fundamental para el inyector. La comprensión de la irrigación facial puede ayudar a disminuir la exposición a la aparición de hematomas y complicaciones vasculares severas. Existen múltiples técnicas de inyección propuestas para el tercio medio, en este artículo presentamos una técnica original, simple, segura y eficaz con resultados satisfactorios y riesgo reducido

Facial aging is a complex synergy of textural skin changes, muscle hyperactivity, fat dysmorphism, bone resorption. The resulting volume deficit and deflation of the mid face produces a less attractive and youthful face. Injectable midface procedures are becoming increasingly popular and requested by patients. Knowledge of the anatomy of the midface is critical for the injector. Understanding the irrigation of the face can help decrease the risk of hematoma and severe vascular complications. There are multiple injection techniques proposed for the middle third, in this article we present a simple, safe and effective technique with satisfactory results and lower risk

1-Piece Versus 2-Piece Fronto-Temporo-Orbito-Zygomatic Craniotomy: A Narrative Overview of Evolution.

BACKGROUND: The fronto-temporo-orbito-zygomatic (FTOZ) craniotomy is a commonly utilized surgical approach for many complex skull base lesions, especially lesions traversing skull base compartments. This craniotomy has evolved over multiple stages, originating from the classic pterional craniotomy and many variations that have emerged over time. METHODS: Few clinical and anatomic studies have both shaped these craniotomies as well as provided immense information about instances in which they are most useful. We review the origin and history of the one-piece and two-piece fronto-temporo-orbito-zygomatic craniotomy and deliberate their advantages and disadvantages. RESULTS: The FTOZ craniotomy provides access to the orbit as well as to multiple compartments in the cranium (anterior, middle and upper third posterior cranial fossae); thus, offering a multi-corridor approach to complex skull base lesions. The one-piece and two-piece fronto-temporo-orbitozygomatic craniotomies are two particularly notable variations that have stood the test of time. Selection between the two variations is mostly surgeon preference and comfort with the technique; however, there are certain indications that specifically suit each approach. Additionally, a pictorial review has been crafted to clearly illustrate the cuts to be made in both methods. CONCLUSION: Understanding the evolution of this craniotomy and surgical approach provides an insight into accessing complex skull base pathologies with minimal brain retraction via safe and viable corridors.

All-on-4 Concept With Use Of Zygoma Implants for Rehabilitation in the Severely Atrophied Maxilla With a Definitive Immediate Restoration.

This case report of a 45-year-old patient at initial presentation shows an illustration of the limitations of periodontal maintenance therapy and subsequent implant prosthetic therapy. In close consultation with the patient, treatment strategies were adopted to maximize the preservation of prognostically questionable teeth. Eight years later, the patient had a highly atrophied maxilla that could be successfully restored with implants. This was achieved with 2 zygoma implants and 2 anterior conventional implants, which were immediately loaded according to the All-on-4 concept and immediately provided with a definitive prosthetic restoration. The case report demonstrates to the general practitioner that using zygoma implants in such constellations may offer a solution to achieve a fixed, rapid, and financially acceptable prosthetic rehabilitation.