Journal of Prosthetic Dentistry
Research and Education|Articles in Press

Three-dimensional finite element analysis of zygomatic implants for rehabilitation of patients with a severely atrophic maxilla

Published:February 10, 2023DOI:


      Statement of problem

      Stresses applied to zygomatic implants have been determined to be transferred mainly to the zygomatic bone; however, consensus regarding the stress distribution pattern in the bone surrounding zygomatic implants has not yet been reached.


      The purpose of this 3-dimensional (3D) finite element analysis (FEA) study was to visually compare the stress distribution pattern in 2 different zygomatic implant treatment modalities and evaluate the effect of masseter musculature involvement.

      Material and methods

      A 3D FEA craniofacial model was constructed from the computed tomography (CT) data of a selected patient with a severely atrophic edentulous maxilla. Modeled zygomatic and conventional implants were inserted into the craniofacial model supporting a prosthesis superstructure. Two types of treatment were considered in the study: 2 zygomatic implants placed bilaterally or 2 zygomatic implants placed in conjunction with at least 2 conventional implants at the anterior maxilla. The models were loaded with a vertical force of 150 N, a lateral force of 50 N, and a distributed occlusal force of 300 N applied to the insertion area of the masseter muscle. The stresses on and deformations of the bones and implants were then observed and compared with and without the involvement of the musculature component.


      The stresses were distributed efficiently along the vertical and horizontal facial buttresses, as in the dentate skull; however, a difference in distribution pattern was observed when the models were loaded without applying the muscle component. The maximum deformation of bones surrounding the implants occurred in the abutment connection of the conventional anterior implant in the model with an additional conventional anterior implant.


      The FEA revealed the stresses were distributed efficiently along the vertical and horizontal facial buttresses, as in the dentate skull. However, the stresses in both models were concentrated in the zygomatic bone when incorporating the muscle component. Therefore, incorporating muscular force into FEA studies could affect the analysis result.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Prosthetic Dentistry
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Jahangiri L.
        • Devlin H.
        • Ting K.
        • Nishimura I.
        Current perspectives in residual ridge remodeling and its clinical implications: a review.
        J Prosthet Dent. 1998; 80: 224-237
        • Klemetti E.
        A review of residual ridge resorption and bone density.
        J Prosthet Dent. 1996; 75: 512-514
        • Malevez C.
        • Daelemans P.
        • Adriaenssens P.
        • Durdu F.
        Use of zygomatic implants to deal with resorbed posterior maxillae.
        Periodontol 2000. 2003; 33: 82-89
        • Ali S.A.
        • Karthigeyan S.
        • Deivanai M.
        • Kumar A.
        Implant rehabilitation for atrophic maxilla: a review.
        J Indian Prosthodont Soc. 2014; 14: 196-207
        • Sharma A.
        • Rahul G.R.
        Zygomatic implants/fixture: a systematic review.
        J Oral Implantol. 2013; 39: 215-224
        • Esposito M.
        • Grusovin M.G.
        • Rees J.
        • et al.
        Effectiveness of sinus lift procedures for dental implant rehabilitation: a Cochrane systematic review.
        Eur J Oral Implantol. 2010; 3: 7-26
        • Nyström E.
        • Ahlqvist J.
        • Gunne J.
        • Kahnberg K.E.
        10-year follow-up of onlay bone grafts and implants in severely resorbed maxillae.
        Int J Oral Maxillofac Surg. 2004; 33: 258-262
        • van Steenberghe D.
        • Naert I.
        • Bossuyt M.
        • et al.
        The rehabilitation of the severely resorbed maxilla by simultaneous placement of autogenous bone grafts and implants: a 10-year evaluation.
        Clin Oral Investig. 1997; 1: 102-108
        • Jensen J.
        • Sindet-Pedersen S.
        • Oliver A.J.
        Varying treatment strategies for reconstruction of maxillary atrophy with implants: results in 98 patients.
        J Oral Maxillofac Surg. 1994; 52: 210-216
        • Aparicio C.
        • Brånemark P.I.
        • Keller E.E.
        • Olivé J.
        Reconstruction of the premaxilla with autogenous iliac bone in combination with osseointegrated implants.
        Int J Oral Maxillofac Implants. 1993; 8: 1-15
        • Nyström E.
        • Nilson H.
        • Gunne J.
        • Lundgren S.
        Reconstruction of the atrophic maxilla with interpositional bone grafting/Le Fort I osteotomy and endosteal implants: a 11-16 year follow-up.
        Int J Oral Maxillofac Surg. 2009; 38: 1-6
        • Branemark P.I.
        The zygomatic fixture: clinical procedures.
        1st ed. Nobel Biocare AB, Gothenburg, Sweden1998: 1
        • Esposito M.
        • Grusovin M.G.
        • Felice P.
        • Karatzopoulos G.
        • Worthington H.V.
        • Coulthard P.
        The efficacy of horizontal and vertical bone augmentation procedures for dental implants - a Cochrane systematic review.
        Eur J Oral Implantol. 2009; 2: 167-184
        • Albrektsson T.
        • Berghlund T.
        • Lindhe J.
        Clinical periodontology and implant dentistry.
        4th ed. Blackwell, Oxford2003: 809-820
        • Brånemark P.I.
        • Gröndahl K.
        • Ohrnell L.O.
        • et al.
        Zygoma fixture in the management of advanced atrophy of the maxilla: technique and long-term results.
        Scand J Plast Reconstr Surg Hand Surg. 2004; 38: 70-85
        • Parel S.M.
        • Brånemark P.I.
        • Ohrnell L.O.
        • Svensson B.
        Remote implant anchorage for the rehabilitation of maxillary defects.
        J Prosthet Dent. 2001; 86: 377-381
        • Landes C.A.
        • Paffrath C.
        • Koehler C.
        • et al.
        Zygoma implants for midfacial prosthetic rehabilitation using telescopes: 9-year follow-up.
        Int J Prosthodont. 2009; 22: 20-32
        • Bedrossian E.
        • Stumpel 3rd, L.J.
        Immediate stabilization at stage II of zygomatic implants: rationale and technique.
        J Prosthet Dent. 2001; 86: 10-14
        • Davo R.
        • Pons O.
        • Rojas J.
        • Carpio E.
        Immediate function of four zygomatic implants: a 1-year report of a prospective study.
        Eur J Oral Implantol. 2010; 3: 323-334
        • Ishak M.I.
        • Abdul Kadir M.R.
        • Sulaiman E.
        • Abu Kasim N.H.
        Finite element analysis of different surgical approaches in various occlusal loading locations for zygomatic implant placement for the treatment of atrophic maxillae.
        Int J Oral Maxillofac Surg. 2012; 41: 1077-1089
        • Tie Y.
        • Wang D.M.
        • Wang C.T.
        • Wu Y.Q.
        • Zhang Z.Y.
        Biomechanical evaluation of unilateral maxillary defect restoration based on modularized finite element model of normal human skull.
        Conf Proc IEEE Eng Med Biol Soc. 2005; 2005: 6184-6187
        • Nkenke E.
        • Hahn M.
        • Lell M.
        • et al.
        Anatomic site evaluation of the zygomatic bone for dental implant placement.
        Clin Oral Implants Res. 2003; 14: 72-79
        • Rossi M.
        • Duarte L.R.
        • Mendonça R.
        • Fernandes A.
        Anatomical bases for the insertion of zygomatic implants.
        Clin Implant Dent Relat Res. 2008; 10: 271-275
        • Varghese K.G.
        • Gandhi N.
        • Kurian N.
        • et al.
        Rehabilitation of the severely resorbed maxilla by using quad zygomatic implant-supported prostheses: a systematic review and meta-analysis.
        J Prosthet Dent. 14 December 2021; ([Epub ahead of print])
        • Ishak M.I.
        • Kadir M.R.
        • Sulaiman E.
        • Kasim N.H.
        Finite element analysis of zygomatic implants in intrasinus and extramaxillary approaches for prosthetic rehabilitation in severely atrophic maxillae.
        Int J Oral Maxillofac Implants. 2013; 28: e151-e160
        • Pesqueira A.A.
        • Goiato M.C.
        • Filho H.G.
        • et al.
        Use of stress analysis methods to evaluate the biomechanics of oral rehabilitation with implants.
        J Oral Implantol. 2014; 40: 217-228
        • Geng J.P.
        • Tan K.B.
        • Liu G.R.
        Application of finite element analysis in implant dentistry: a review of the literature.
        J Prosthet Dent. 2001; 85: 585-598
        • Korioth T.W.
        • Versluis A.
        Modeling the mechanical behavior of the jaws and their related structures by finite element (FE) analysis.
        Crit Rev Oral Biol Med. 1997; 8: 90-104
        • Ujigawa K.
        • Kato Y.
        • Kizu Y.
        • Tonogi M.
        • Yamane G.Y.
        Three-dimensional finite elemental analysis of zygomatic implants in craniofacial structures.
        Int J Oral Maxillofac Surg. 2007; 36: 620-625
        • NobelBiocare
        Branemark System® - zygoma implant placement & prosthetic procedure.
        (Available at:)
        • Migliorança R.M.
        • Coppedê A.
        • Dias Rezende R.C.
        • de Mayo T.
        Restoration of the edentulous maxilla using extrasinus zygomatic implants combined with anterior conventional implants: a retrospective study.
        Int J Oral Maxillofac Implants. 2011; 26: 665-672
        • Wen H.
        • Guo W.
        • Liang R.
        • et al.
        Finite element analysis of three zygomatic implant techniques for the severely atrophic edentulous maxilla.
        J Prosthet Dent. 2014; 111: 203-215
        • Yemineni B.C.
        • Mahendra J.
        • Nasina J.
        • Mahendra L.
        • Shivasubramanian L.
        • Perika S.B.
        Evaluation of maximum principal stress, von mises stress, and deformation on surrounding mandibular bone during insertion of an implant: a three-dimensional finite element study.
        Cureus. 2020; 12e9430
        • Van Oosterwyck H.
        • Duyck J.
        • Vander Sloten J.
        • et al.
        The influence of bone mechanical properties and implant fixation upon bone loading around oral implants.
        Clin Oral Implants Res. 1998; 9: 407-418
        • Strait D.S.
        • Wang Q.
        • Dechow P.C.
        • et al.
        Modeling elastic properties in finite-element analysis: how much precision is needed to produce an accurate model?.
        Anat Rec (Hoboken). 2005; 283: 275-287
        • Miyamoto S.
        • Ujigawa K.
        • Kizu Y.
        • Tonogi M.
        • Yamane G.Y.
        Biomechanical three-dimensional finite-element analysis of maxillary prostheses with implants. Design of number and position of implants for maxillary prostheses after hemimaxillectomy.
        Int J Oral Maxillofac Surg. 2010; 39: 1120-1126
        • Freedman M.
        • Ring M.
        • Stassen L.F.
        Effect of alveolar bone support on zygomatic implants: a finite element analysis study.
        Int J Oral Maxillofac Surg. 2013; 42: 671-676
        • Alexandridis C.
        • Caputo A.A.
        • Thanos C.E.
        Distribution of stresses in the human skull.
        J Oral Rehabil. 1985; 12: 499-507