The aim of the ITI Consensus Workshop on zygomatic implants was to provide Consensus Statements and Clinical Recommendations for the use of zygomatic implants.
Three systematic reviews and one narrative review were written to address focused questions on (1) the indications for the use of zygomatic implants; (2) the survival rates and complications associated with surgery in zygomatic implant placement; (3) long-term survival rates of zygomatic implants and (4) the biomechanical principles involved when zygoma implants are placed under functional loads. Based on the reviews, three working groups then developed Consensus Statements and Clinical Recommendations. These were discussed in a plenary and finalized in Delphi rounds.
A total of 21 Consensus Statements were developed from the systematic reviews. Additionally, the group developed 17 Clinical Recommendations based on the Consensus Statements and the combined expertise of the participants.
Zygomatic implants are mainly indicated in cases with maxillary bone atrophy or deficiency. Long-term mean zygomatic implant survival was 96.2% [95% CI 93.8; 97.7] over a mean follow-up of 75.4 months (6.3 years) with a follow-up range of 36-141.6 months (3-11.8 years). Immediate loading showed a statistically significant increase in survival over delayed loading. Sinusitis presented with a total prevalence of 14.2% [95% CI 8.8; 22.0] over a mean 65.4 months follow-up, representing the most common complication which may lead to zygomatic implant loss. The international experts suggested clinical recommendations regarding planning, surgery, restoration, outcomes, and the patient\'s perspective.

OBJECTIVE: The main purpose of this retrospective study was to assess the difference in the incidence of peri-zygomatic complications (PZCs) when zygomatic implants (ZIs) penetrate or do not penetrate the external surface of zygoma.
METHODS: This study included 32 patients with edentulous maxillae or potentially edentulous maxillae undergo zygomatic implantation. The patients were divided into the penetration group (P-group) and the non-penetration group (N-group) according to whether the apex of implants penetrated the external surface of zygoma in postoperative CBCT. The extension length, the penetration section of the implants, and the skin thickness at the corresponding position were simultaneously measured. Clinical follow-up was conducted regularly until 2 years after surgery. The occurrence of PZCs (including peri-zygomatic infection, skin numbness, non-infectious pain, and foreign body sensation) was recorded. A mixed effect logistic model was used to compare the difference of complication rate between the P-group and the N-group, and odds ratio (OR) was calculated. Then identify the impact of the extension length, penetration section and skin thickness in P-group with the same model.
RESULTS: A total of 71 ZIs were implanted in 32 patients, including 37 implants in the P-group and 34 implants in the N-group. During the 2-year follow-up, a total of 13 implants occurred PZCs, with an overall complication rate of 18.3%. Thereinto, the incidence rate was 29.7% in the P-group, and 5.9% in the N-group (OR = 6.77). In P-group, there was a significant difference in complication rate of different extension lengths, while the penetration section and skin thickness had no statistical significance on the complication rate.
CONCLUSIONS: Under the limitation of this study, to minimize the risk of PZCs, ZI should be placed in a manner that avoids the apex penetrating the external surface of the zygoma.

To assess the feasibility and accuracy of a semi-autonomous two-stage dental robotic technique for zygomatic implants.
Twenty-six zygomatic implants were designed and randomly divided into two groups using 10 three-dimensionally printed resin models with severe maxillary atrophy. In one group, the conventional drilling technique was used, in the other group, the drilling process for the alveolar ridge section (first stage) was completed, after which drilling for the zygoma section (second stage) was done. Based on preoperative planning combined with postoperative cone-beam computed tomography (CBCT), coronal, apical, depth, and angle deviations were measured. Zygomatic implant placement technique-related deviations (sinus slot, intrasinus, and extrasinus) were also recorded and analyzed.
The two-stage technical group\'s coronal, apical, depth, and angle deviations were 0.57 ± 0.19 mm, 1.07 ± 0.48 mm, 0.30 ± 0.38 mm, and 0.91 ± 0.51°, respectively. The accuracy of the two-stage technique was significantly higher than that of the conventional one-stage technique (p < 0.05). The apical deviation in the intrasinus group was 1.12 ± 0.56 mm, which was significantly better than that in the other two groups (p < 0.05). The angle deviation in the sinus slot group was 1.96 ± 0.83°, which was significantly worse than that in the other two groups (p < 0.05).
Using the semi-autonomous two-stage dental robotic technique for zygomatic implants is feasible and is more accurate than using the conventional one-stage technique.
The two-stage technique enabled the semi-autonomous robot to overcome the mouth-opening restriction for zygomatic implants and improved accuracy.

OBJECTIVE: To investigate the effects of zygomatic implant placement on the maxillary sinus using radiographic and clinical indicators.
METHODS: Patients with an atrophic maxilla who underwent zygomatic implant placement were included. The thickness and morphology of the Schneiderian membrane (SM), infundibular obstruction, and posterior bone wall of the maxillary sinus were analyzed. The generalized estimating equation and chi-square tests were performed to compare the measurements.
RESULTS: Fifty patients with 100 maxillary sinuses were included. In total, 148 zygomatic implants and 105 regular implants were placed in the maxilla. Overall, the mean pre- and postoperative SM thickness was 2.79 ± 3.26 mm and 3.97 ± 5.45 mm, respectively (p = 0.063). In sinuses with two zygomatic implants, the SM thickness increased significantly from 2.12 ± 2.14 mm preoperatively to 4.07 ± 6.14 mm postoperatively (p = 0.026). The number of sinuses with type IV morphology (fully radiopaque) increased from zero preoperatively to six (13%) postoperatively. Sinuses with a single zygomatic implant showed no difference in the pre- and postoperative SM thickness. Postoperatively, six sinuses had infundibulum obstructions. Postoperative osteitis of the bilateral sinuses was found in two patients.
CONCLUSIONS: We have proposed a new imaging evaluation method and system for evaluating the maxillary sinus response. Preoperative infundibulum obstruction combined with mucosal thickening and double zygomatic implant placement are more likely to induce postoperative maxillary sinus mucositis and osteitis.

The unique anatomical structure of the atrophic edentulous maxilla limits the placement of endosteal root form dental implants without bone grafting and augmentation. Surgical placement of zygomatic implants in an optimal position remains challenging. This technique report illustrates a novel digital guide technology, including the design workflow, application method, and indications for assisting with the placement of zygomatic implants using a bone-supported titanium double-sleeve guide. In addition, when the implant body reaches the zygomatic bone following an intra-sinus path, including ZAGA type 0 and ZAGA type 1 cases, a matching window osteotomy surgical guide is used to locate the lateral window boundary and protect the sinus membrane. With this technique, the surgical procedure is simplified, and the precision of guided zygomatic implant placement is improved.

UNASSIGNED: The purpose of this study is to establish a novel, reproducible technique to obtain the BIC area (BICA) between zygomatic implants and zygomatic bone based on post-operative cone-beam computed tomography (CBCT) images. Three-dimensional (3D) image registration and segmentation were used to eliminate the effect of metal-induced artifacts of zygomatic implants.
UNASSIGNED: An ex-vivo study was included to verify the feasibility of the new method. Then, the radiographic bone-to-implant contact (rBIC) of 143 implants was measured in a total of 50 patients. To obtain the BICA of zygomatic implants and the zygomatic bone, several steps were necessary, including image preprocessing of CBCT scans, identification of the position of zygomatic implants, registration, and segmentation of pre- and post-operative CBCT images, and 3D reconstruction of models. The conventional two-dimensional (2D) linear rBIC (rBICc) measurement method with post-operative CBCT images was chosen as a comparison.
UNASSIGNED: The mean values of rBIC and rBICc were 15.08 ± 5.92 mm and 14.77 ± 5.14 mm, respectively. A statistically significant correlation was observed between rBIC and rBICc values ([Formula: see text]=0.86, p < 0.0001).
UNASSIGNED: This study proposed a standardized, repeatable, noninvasive technique to quantify the rBIC of post-operative zygomatic implants in 3D terms. This technique is comparable to conventional 2D linear measurements and seems to be more reliable than these conventional measurements; thus, this method could serve as a valuable tool in the performance of clinical research protocols.

BACKGROUND: Cone-beam computed tomography (CBCT) and conventional multislice CT (MSCT) are both used in zygomatic implant navigation surgery but the superiority of one technique versus the other remains unclear.
OBJECTIVE: This study compared the accuracy of CBCT and MSCT in zygomatic implant navigation surgery by calculating the deviations of implants.
METHODS: Patients with severely atrophic maxillae were classified into two groups according to the use of CBCT- or MSCT-guided navigation system. The entry and apical distance deviation, and the angle deviation of zygomatic implants were measured on fused operation images. A linear effect model was used for analysis, with statistical significance set at P < .05.
RESULTS: A total of 72 zygomatic implants were inserted as planned in 23 patients. The comparison of deviations in CBCT and MSCT groups showed a mean (± SD) entry deviation of 1.69 ± 0.59 mm vs 2.04 ± 0.78 mm (P = .146), apical deviation of 2 ± 0.68 mm vs 2.55 ± 0.85 (P < .001), and angle deviation of 2.32 ± 1.02° vs 3.23 ± 1.21° (P = .038).
CONCLUSIONS: Real-time zygomatic implant navigation surgery with CBCT may result in higher values for accuracy than MSCT.

OBJECTIVE: Image-guided surgical navigation system (SNS) has proved to be an increasingly important assistance tool for mini-invasive surgery. However, using standard devices such as keyboard and mouse as human-computer interaction (HCI) is a latent vector of infectious medium, causing risks to patients and surgeons. To solve the human-computer interaction problem, we proposed an optimized structure of LSTM based on a depth camera to recognize gestures and applied it to an in-house oral and maxillofacial surgical navigation system (Qin et al. in Int J Comput Assist Radiol Surg 14(2):281-289, 2019).
METHODS: The proposed optimized structure of LSTM named multi-LSTM allows multiple input layers and takes into account the relationships between inputs. To combine the gesture recognition with the SNS, four left-hand signs waving along four directions were designed to correspond to four operations of the mouse, and the motion of right hand was used to control the movement of the cursor. Finally, a phantom study for zygomatic implant placement was conducted to evaluate the feasibility of multi-LSTM as HCI.
 RESULTS: 3D hand trajectories of both wrist and elbow from 10 participants were collected to train the recognition network. Then tenfold cross-validation was performed for judging signs, and the mean accuracy was 96% ± 3%. In the phantom study, four implants were successfully placed, and the average deviations of planned-placed implants were 1.22 mm and 1.70 mm for the entry and end points, respectively, while the angular deviation ranged from 0.4° to 2.9°.
CONCLUSIONS: The results showed that this non-contact user interface based on multi-LSTM could be used as a promising tool to eliminate the disinfection problem in operation room and alleviate manipulation complexity of surgical navigation system.

OBJECTIVE: The purpose of this retrospective study was to evaluate the long-term changes in the thickness of Schneiderian membranes after zygomatic implant placement using cone beam computed tomography (CBCT).
METHODS: Twenty-five consecutive patients were included in this study. All the patients underwent bilateral zygomatic implant placement. Schneiderian membrane thickness (SMT) in 49 maxillary sinuses (one sinus was not included because of early loss of the zygomatic implants) was measured using CBCT before and at least 1 year after zygomatic implant placement. Ostium patency of each sinus was also evaluated and recorded.
RESULTS: In total, 84 zygomatic implants and 30 regular implants were placed in included patients. Two unilateral maxillary zygomatic implants in one patient were removed 2 months after implant placement. The SMT increased from 1.03 mm (inter-quartile range: 1.57 mm) to 1.33 mm (inter-quartile range: 1.98 mm) after a median follow-up time of 23.00 months (inter-quartile range: 14 months), and the difference was statistically significant. Before zygomatic implant insertion, 24.5% (12/49) of sinuses had SMT greater than 2 mm, whereas this value was 28.6% (14/49) after zygomatic implant placement. The percentage of sinuses observed with ostium patency also increased from 2.0% (1/49) to 12.2% (6/49).
CONCLUSIONS: Chronic Schneiderian membrane thickening could result from zygomatic implant insertion. Intensive postoperative care and clinical and radiographic monitoring are recommended after zygomatic implant placement.

BACKGROUND: The zygomatic implant is suggested to be placed in zygomatic areas with the largest thickness, but regions to obtain the largest bone-to-implant contact (BIC) were unknown.
OBJECTIVE: To identify the zygomatic regions for placing quad zygomatic implants that obtain the largest BIC.
METHODS: The zygomatic thicknesses of 300 zygomata were measured at total 12 points on the superior, middle, and inferior areas on the 3-dimensional reconstruction images. In 50 edentulous maxillae, the zygomatic BICs of virtually placed implants were measured and the incidence of the intrusion into the infratemporal fossa calculated at each point.
RESULTS: The largest thickness in the superior, middle, and inferior regions were at Point A1 (8.01 ± 2.10 mm), Point B1 (7.02 ± 1.73 mm), and Point C0 (6.65 ± 1.66 mm), respectively. The virtually placed implants at Point A3 (16.70 ± 4.18 mm) and Point B1 (12.07 ± 3.84 mm) had the highest BICs while retaining the minimum incidence of the intrusion complications.
CONCLUSIONS: To obtain the largest BICs and avoid the intrusion complications, results suggested that the postero-superior region (Point A3 ) and the center of zygoma (Point B1 ) were the optimal places for the placement of quad zygomatic implants.