Quality of life assessment of patients rehabilitated with zygomatic implants in central India: a questionnaire-based cross-sectional study

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Arch Craniofac Surg. 2025;26(5):183-189

Publication date (electronic) : 2025 October 20

doi : https://doi.org/10.7181/acfs.2025.0014

Anshul Rai¹, Jubin Thacker², Zenish Bhatti^,1, Babu Lal³, Jitendra Kumar⁴, Vikas Vijayan¹

¹Department of Dentistry, All India Institute of Medical Sciences, Bhopal, India

²Department of Periodontology, Karnavati School of Dentistry, Gandhinagar, India

³Department of Trauma and Emergency Medicine, All India Institute of Medical Sciences, Bhopal, India

⁴Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Ahmedabad, India

Correspondence: Zenish Bhatti Department of Dentistry, All India Institute of Medical Sciences, Saket Nagar, Habib Ganj, Bhopal 462026, India E-mail: bhattizenish.sr23@aiimsbhopal.edu.in

Received 2025 April 16; Revised 2025 July 19; Accepted 2025 September 29.

Abstract

INTRODUCTION

Maxillary defects may result from diverse etiologies, including genetic predisposition, bone resorption after tooth extraction, sinus pneumatization, trauma, malignancies, or odontogenic infections. In recent years, particularly in the Indian population, post-COVID-19 mucormycosis has emerged as an important cause of maxillary necrosis, frequently necessitating extensive surgical resection [1]. Such defects, whether due to atrophy, oncologic resection, or trauma, profoundly disrupt oral functions— speech, swallowing, and chewing—and impose social, physical, and psychological burdens that diminish patients’ quality of life (QoL). Nevertheless, with effective treatment and prosthetic rehabilitation, many patients undergo a remarkable transformation, progressing from mere survival toward improved health-related QoL [2].

The use of endosseous implants has become an established and clinically validated strategy for oral rehabilitation, offering long-term success. These implants provide predictable outcomes provided that adequate bone volume exists to support them. Although well-documented, success depends on meeting several fundamental criteria, foremost of which is sufficient bone availability [3].

A variety of treatment modalities have been employed to address the challenges of prosthetic rehabilitation in such cases. These include sinus floor augmentation, bone grafting, and Le Fort I surgery. Their goals extend beyond restoring function and esthetics to improving patient-related outcomes and QoL. Despite their effectiveness, these approaches present significant limitations. They often involve multiple surgical interventions, including the use of extraoral donor sites such as the iliac crest, which carry substantial morbidity. Moreover, such procedures prolong treatment duration, requiring graft consolidation and extended healing before implant loading and prosthetic rehabilitation can be completed [4].

Advanced surgical protocols such as zygomatic implants have been widely adopted for rehabilitating the atrophic maxilla. Owing to their distinctive anatomical placement and ability to eliminate the need for extensive grafting, zygomatic implants have become a preferred treatment option for upper arch rehabilitation in cases of severe bone deficiency. Originally developed by Brånemark for reconstructing resected maxillae—particularly those following oncologic resections—the technique involved placing two implants in each zygomatic arch to support prostheses. Since then, multiple modified protocols have been introduced to expand efficacy and versatility, including the extra-sinus technique, sinus slot technique, zygomatic anatomy-guided approach, and the restoratively aimed zygomatic implant routine workflow [5]. These approaches address diverse anatomical and clinical challenges while optimizing patient outcomes [6].

Patient perception and acceptance of treatment modalities are shaped by multiple factors, with QoL being central in cases of severe defects and complex interventions. Oral rehabilitation enhances both function and esthetics, but functionality—evaluated through dietary habits, speech, and psychological well-being— remains the principal measure of success. The Liverpool Oral Rehabilitation Questionnaire version 3 (LORQ-v3), an updated version of the 2004 LORQ, incorporates more comprehensive questions on oral function and patients’ dental and prosthetic conditions [7]. The Oral Health Impact Profile (OHIP) evaluates individuals’ perceptions of the social impact of oral health problems on overall well-being [8]. This index assesses self-reported impairment, discomfort, and disability due to oral conditions. OHIP-14 serves as a shorter version of OHIP-49 that maintains the conceptual framework of the longer scale.

This 6-year clinical study evaluates the role of zygomatic implants in the prosthetic rehabilitation of edentulous maxillae. Specifically, it focuses on patient-centered outcomes, measuring post-rehabilitation QoL through a structured questionnaire survey. The findings aim to clarify the effectiveness of zygomatic implants in enhancing functional, esthetic, and psychological well-being.

METHODS

RESULTS

A total of 52 patients participated in this study, comprising 34 men and 18 women, aged between 23 and 76 years (mean age: 39.6 years). All participants underwent maxillary rehabilitation with zygomatic implants. Among them, 25 patients received bilateral rehabilitation, while 27 underwent unilateral rehabilitation. No patients were lost to follow-up, and none had a history of prosthetic rehabilitation prior to this study.

The causes of maxillary dentition loss were varied. Of the 52 patients, 53% experienced loss due to COVID-19–associated mucormycosis, 8% due to maxillary malignancy, 15% due to benign tumors, 15% from partial anodontia associated with congenital or other conditions, and 9% due to bone resorption related to aging.

All participants completed both pre- and post-rehabilitation assessments using the LORQv3 and OHIP-14 questionnaires. Assessments were conducted preoperatively and 1 year postoperatively.

Table 1 summarizes responses to LORQv3 items 1–17. Prerehabilitation, patients reported significant challenges across multiple domains, including social interaction (56%), speech (47%), chewing (42%), and orofacial appearance (31%). At 1 year post-rehabilitation, improvements were evident in all oral function domains, with notable gains in chewing (42% improvement), swallowing (25%), salivation (12%), mouth open-ing (8%), and speech (38%). Improvements were also recorded in orofacial appearance (24%) and social interaction (43%). All domains demonstrated statistically significant improvements after rehabilitation (Table 1).

Table 1.

Before and after scores on the LORQv3 questionnaire for 52 study participants

Patients did not report loss of natural mandibular dentition; thus, 100% maintained function in that aspect. Approximately 52% of patients retained natural maxillary teeth and were rehabilitated unilaterally (Questions 18 and 19). Since none had prior prosthetic interventions, questions 20–39 were excluded from the pre-rehabilitation survey (Table 2). After rehabilitation, no major issues were reported with the prostheses, and overall patient satisfaction was high. For question 40, no additional or extraordinary problems were identified beyond those already addressed.

Table 2.

Items 20 to 39 of the LORQv3 questionnaire, dealing with prostheses and patients’ satisfaction after 1 year of prosthodontic rehabilitation

Table 3 presents OHIP-14 findings. Pre-rehabilitation, the most frequently reported concerns were physical pain (76.9%) and psychological discomfort (65.5%). Other notable pretreatment issues included functional limitation (63.5%) and physical disability (42.3%). At 1 year post-rehabilitation, marked reductions were observed, with minimal to no issues reported in psychological disability (2.1%), social disability (5.8%), and handicap (3.8%).

Table 3.

Before and after scores on the OHIP-14 questionnaire for 52 study participants

The internal reliability of both questionnaires, measured using Cronbach’s alpha, was high. Preoperatively, reliability was 0.942 for OHIP-14 and 0.922 for LORQv3. Postoperatively, values remained consistent, at 0.929 for OHIP-14 and 0.910 for LORQv3.

This study demonstrates substantial improvements in OHRQoL achieved through maxillary rehabilitation with zygomatic implants (Figs. 1, 2). These improvements were reflected in reduced patient-reported problems and supported by the high internal reliability of both assessment instruments.

Fig. 1.

Sequential radiographic and clinical images illustrating zygomatic implant rehabilitation in two edentulous patients with atrophic maxillae. (A) Preoperative orthopantomogram (OPG) demonstrating maxillary atrophy and pneumatized sinuses. (B) Postoperative OPG showing placement of four zygomatic implants and two anterior implants. (C) Post-rehabilitation clinical photograph showing patient satisfaction. (D) OPG demonstrating bilateral quad zygomatic and mandibular implants. (E) Final prosthesis in place over zygomatic and mandibular implants. (F) Post-rehabilitation clinical photograph showing patient satisfaction.

Fig. 2.

Radiographic and clinical sequence demonstrating unilateral zygomatic implant placement for posterior maxillary rehabilitation in two female patients with compromised bone conditions. (A) Preoperative orthopantomogram (OPG) showing atrophic posterior maxilla and missing teeth. (B) Postoperative OPG with unilateral zygomatic implant and anterior conventional implants. (C) Post-rehabilitation clinical photograph showing patient satisfaction. (D) Preoperative OPG showing unilateral posterior maxillary edentulism. (E) Postoperative OPG with two zygomatic implants and posterior prosthesis in place. (F) Post-rehabilitation clinical photograph showing patient satisfaction.

DISCUSSION

Improvement in OHRQoL following prosthodontic rehabilitation of maxillary defects is essential for patients’ physical, psychological, and social well-being [9,10]. Several studies have evaluated health-related QoL in head and neck cancer patients after oral rehabilitation; however, these studies were often limited by small sample sizes or site-specific cohorts [11,12]. In the present study, we utilized two validated instruments—the LORQv3, originally developed by Pace-Balzan et al. in 2004 [2], and the OHIP-14, introduced by Slade in 1997 [8]—to comprehensively assess changes in OHRQoL before and after zygomatic implant– supported prosthetic rehabilitation.

This study adopts a broader scope by including patients with maxillary defects of diverse etiologies, such as congenital anomalies, mucormycosis, tumors, trauma, and age-related causes. It is important to recognize that variability in defect type, patient age, and overall health status likely contributed to heterogeneity in outcomes. Although all patients received standardized rehabilitation, subgroup analyses based on defect extent or etiology were not feasible due to the limited sample size, which remains a limitation of this study. In contrast to earlier research, which primarily focused on rehabilitation following head and neck cancer treatment, the present study evaluates a more heterogeneous patient cohort to better capture the impact of prosthetic rehabilitation across multiple domains.

Zygomatic implants were selected as the rehabilitation modality due to the complexity of the defects and the need to avoid extensive surgical procedures. These advanced techniques have demonstrated success comparable to conventional methods, particularly in cases where traditional approaches are not feasible. Multiple studies report excellent long-term survival rates for zygomatic implants, ranging from 95.2% to 100% over follow-up periods exceeding 10 years [13]. This makes them a reliable alternative in the rehabilitation of severely atrophic maxillae and other complex defects.

Alternative treatment modalities for maxillary reconstruction include grafting techniques [14], sinus floor elevation [15], and guided bone regeneration. Traditionally, the gold standard has been autogenous bone grafting for alveolar ridge reconstruction. Onlay grafts, for example, are often used in cases requiring substantial augmentation [16]. However, severe defects present significant challenges for these approaches.

Bone grafting procedures require large amounts of donor bone and extend treatment timelines, with 4–6 months typically needed for graft consolidation prior to implant placement [17]. Moreover, implants placed in pristine bone demonstrate superior survival rates compared with those placed in grafted bone [17,18].

The LORQv3 was selected for its ability to provide a detailed evaluation of oral rehabilitation outcomes. At 1 year post-rehabilitation, assessments demonstrated marked improvements across all domains. Patients presented with differing levels of maxillary tooth loss (partial versus complete), which may have influenced results in areas such as speech, salivation, and swallowing. This heterogeneity could not be fully controlled and should be considered when interpreting the findings. Some patients also reported persistent challenges with social interaction, possibly linked to functional or esthetic concerns associated with surgical outcomes or other interventions affecting appearance.

The OHIP-14, a widely applied tool for assessing the social and functional effects of oral health conditions, was also used in this study. It is designed to capture self-reported dysfunction, discomfort, and disability caused by oral disorders. In our cohort, OHIP-14 scores demonstrated significant improvement across all domains—including psychological discomfort, functional limitation, and physical disability—after 1 year of prosthetic rehabilitation.

This study is the first to evaluate OHRQoL in a sample of 52 patients with diverse maxillary defect etiologies using both LORQv3 and OHIP-14. The primary objective was to assess patient adaptation and the benefits of prosthetic rehabilitation with zygomatic implants. The results indicate significant functional and psychosocial improvements, affirming the value of zygomatic implant–supported prostheses in managing severe maxillary defects.

Based on our 1-year survey of maxillary rehabilitation with zygomatic implants and fixed prostheses, it can be concluded that it is essential to understand patients’ problems and needs before initiating treatment. The results of both questionnaires, LORQv3 and OHIP, showed improvement in all domains of oral health and QoL of patients following rehabilitation with zygomatic implant-supported prostheses. These findings underscore the efficacy of this treatment modality for patients with severe maxillary defects. Consistent and long-term followup is crucial for monitoring the quality and prognosis of treatment in patients with extensive and debilitating defects.

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