The implant positions were then accurately registered by utilising light-cured resin tray material (Individo® Lux, Voco Gmbh, Germany) and abutment level impression copings. The resin material was applied in sections around the impression copings and cured incrementally to ensure a rigid splinting of the impression copings (Fig. 8). Abutment protection caps were then placed over all four abutments prior to the jaw registration procedure which was undertaken using the pre-fabricated denture appliance relined with silicone putty material (Provil soft putty, Heraeus Kulzer GmbH) (Fig. 9).

The radial forearm free flap (RFFF) was then disconnected from the arm and inset into the maxillary defect after creating a tunnel down into the left neck for the pedicle. The flap was carefully perforated over the zygomatic implant abutment protection caps using a short incision just through the skin layer followed by blunt dissection to allow the abutment and cap to perforate the flap ensuring a tight adaptation of the flap around the abutment (Fig. 10). The flap anastomosis was then completed utilising the operating microscope and the neck and arm wounds closed. The patient recovered well from the surgery and was subsequently discharged at 8 days post-operatively. The tumour and neck dissection specimens were examined and reported as pT4a NO M0 squamous cell carcinoma of the left maxilla with a 7.2 mm depth of invasion. There was a close anterior mucosal margin of 1.3 mm and the decision was therefore taken for post-operative adjuvant radiotherapy.

Three weeks post-surgery, the patient was seen for review and to try-in the provisional prosthesis. Unfortunately, in the interim, the RFFF had overgrown the zygomatic implants (Fig. 11.) and so, under local anaesthesia, the implants were re-exposed to allow the provisional prosthesis to be tried in. The incisal level of the prosthesis was modified, and the prosthesis was then finalised in the laboratory and fitted 1 week later, 1 month following surgery (Fig. 12). A post-fitting radiograph demonstrated good positioning of the implants and seating of the initial prosthesis (Fig. 13). The patient then completed 6 weeks of radiotherapy (63 Gy in 30 fractions). He subsequently attended with a fracture of the provisional prosthesis 3 weeks after completion of radiotherapy when the bridge was removed for repair. All implants were firmly integrated, the initial oral ulceration was now settling and the flap reconstruction was performing well with no evidence of breakdown or dehiscence (Fig. 14). The bridge was repaired and re-fitted the same day, and arrangements were made for the construction of a new definitive acrylic bridge with a cobalt-chrome framework which was subsequently fitted for the patient. The patient continued to be followed up, and 12 months following surgery completed a quality of life feedback questionnaire [7] where he rated his overall quality of life as “very good” and scored maximally in most domains with the exception of speech and fear of recurrence (Table 1). At 18 months post-surgery, the patient was still disease free with no further incidents of prosthodontic related complications since the definitive bridge was fitted. His facial appearance (Fig. 15) was symmetrical with no significant distortion despite his previous maxillary resective surgery.