A 66-year-old male patient presented with an enlarging mass in the left maxilla (Fig. 1). The mass had been present for a few weeks. An incisional biopsy revealed squamous cell carcinoma. Staging scans were undertaken (Fig. 2) which demonstrated a T4N0M0 maxillary alveolus tumour in close proximity to the left orbital floor with obliteration of the maxillary antrum and destruction of the lateral maxillary wall (Fig. 3). The patient was partially dentate in both jaws with no significant dental pathology (Fig. 4).

The findings were discussed with the patient together with the treatment options for this malignant tumour requiring a low-level Brown class 2b maxillectomy [5]. The patient preference was not to have prosthodontic obturation but rather reconstruction using microvascular free tissue transfer. In view of the unilateral low-level nature of the tumour, a soft tissue reconstruction combined with primary insertion of zygomatic implants to support a subsequent fixed dental prosthesis on a shortened dental arch concept was considered the best option. The remaining molar teeth were planned for extraction based on the potential need for post-operative radiotherapy and likelihood of trismus post-operatively. The remaining maxillary teeth on the non-defect right-hand side were planned for extraction to allow either the placement of immediate dental implants or the placement of conventional zygomatic implants depending on the state of the socket anatomy post-extraction.

Dental impressions were taken to allow construction of a maxillary complete denture template to both aid the placement of the zygomatic implants on the defect side and to act as an occlusal registration device during surgery. The occlusal vertical dimension was also measured between nasal tip and chin point to allow subsequent registration to occur at the correct level during surgery.

The patient underwent tracheostomy, a limited left-sided selective neck dissection for node sampling and vessels preparation. The maxillary tumour was excised in a standard manner via an intra-oral approach with preservation of the left orbital floor (Fig. 5). The resection extended to the maxillary alveolar midline in the incisor region with extension posteriorly just into the soft palate. The defect was measured to allow the harvesting of a slightly oversized left fascio-cutaneous radial forearm flap which was carried out in parallel to the implant procedures. Following resection, the amount of bone remaining in the left zygoma was assessed and deemed satisfactory for the placement of two zygomatic oncology implants [6] (Southern Implants Ltd., South Africa) which were subsequently inserted with excellent primary stability (Fig. 6). The remaining maxillary teeth were then carefully extracted although it was not possible to preserve all the labial socket bone which was fused to several of the teeth. It was therefore decided to proceed with an alveoloplasty and insertion of two conventional zygomatic implants (Southern Implants Ltd., South Africa) on the right side which were inserted into the canine and second premolar sites with high primary stability (Fig. 7). Standard implant bridge abutments (AMCZ abutments, Southern Implants, South Africa) were then torqued into place onto all four zygomatic implants with longer 5 mm versions being used on the defect side to facilitate the later flap perforation. The soft tissues of the right maxilla were then closed with multiple resorbable sutures.