Fig. 7. The epithesis allows both prompt inspection of the resection site and makes daily care easier
Fig. 7. The epithesis allows both prompt inspection of the resection site and makes daily care easier
Fig. 6. Frontal view of the patient after superior overdenture and nasal prosthesis delivery
Fig. 6. Frontal view of the patient after superior overdenture and nasal prosthesis delivery
Fig. 5. The intraoral bar crossing the palatal defect arising the nasal understructure
Fig. 5. The intraoral bar crossing the palatal defect arising the nasal understructure
Fig. 4. A front view of the bar with the intraoral portion and the metal extension for epithesis attachment
Fig. 4. A front view of the bar with the intraoral portion and the metal extension for epithesis attachment
Fig. 3. Postoperative panorex showing the symmetric distribution of the fixtures
Fig. 3. Postoperative panorex showing the symmetric distribution of the fixtures
Fig. 2. The healing abutments positioned onto fixtures and the oronasal communication
Fig. 2. The healing abutments positioned onto fixtures and the oronasal communication
Fig. 1. Intraoperative view of the zygoma implants placed in the residual maxilla
Fig. 1. Intraoperative view of the zygoma implants placed in the residual maxilla
Trevisiol, L., Procacci, P., D’Agostino, A. et al. Rehabilitation of a complex midfacial defect by means of a zygoma-implant-supported prosthesis and nasal epithesis: a novel technique.
Int J Implant Dent 2, 7 (2016). https://doi.org/10.1186/s40729-016-0043-5
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Received: 22 July 2015
Accepted: 23 March 2016
Published: 01 April 2016
DOI: https://doi.org/1...
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were...
Francesca Ferrari, Pasquale Procacci, Lorenzo Trevisiol, Pier Francesco Nocini, Daniele De Santis and Antonio D’Agostino declare that they have no competing interests.
FF was involved in revising the manuscript critically. PP was involved in drafting the manuscript. LT is another surgeon that belongs to surgery equipment. PFN, head professor and surgeon, operated the patient. DDeS was involved ...
Department of Surgery, Section of Oral and Maxillofacial Surgery, University of Verona, Policlinico “Giovanni Battista Rossi”, Piazzale Ludovico Antonio Scuro, 10, 37134, Verona, Italy
Lorenzo Trevisiol, Pasquale Procacci, Antonio D’Agostino, Francesca Ferrari, Daniele De Santis & Pier Francesco Nocini
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Karakoca S, Aydin C, Handan Y, Bal BT. Retrospective study of treatment outcomes with implant- retained extraoral prostheses: survival rates and prosthetic complications. J Prosthet Dent. 2010;103:118–26.
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Parel SM, Branemark PI, Ohrnell LO, Svensson B. Remote implant anchorage for the rehabilitation of maxillary defects. J Prosthet Dent. 2001;86:377–81.
Bowden JR, Flood TR, Downie IP. Zygomaticus implants for retention of nasal prostheses after rhinectomy. Br J Oral Maxillofac Surg. 2006;44:54–6.
D’Agostino A, Procacci P, Ferrari F, Trevisiol L, Nocini PF. Zygoma implant-supported prostheti...
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Implant-supported prosthesis is a valid method to restore resected oral and head cancer patients and offers a good chance to social reintegration. The aesthetic result and facial camouflage are more achievable by means of dentures and epithesis than with several reconstructive interventions. Furthermore, due to the high risk of recurrences, it is sometime mandatory to keep the defect inspectionabl...
Rethinking globally of the possible indications to the adoption of this technique and its advantages compared to reconstructive microsurgery, the use of zygoma-implant-supported prosthesis may be suitable for patients whose systemic conditions are poor. The duration of surgery and of the postoperative recovery would be remarkably shortened avoiding the complications related to the harvesting of a ...
As far as prosthetic design is concerned, it is mandatory to avoid or, if not possible, limit as much as possible distal cantilever: given the absence of the premaxilla, an anterior cantilever is already present. Implant splintage is recommended [1, 8], and the bar design must respect technical data (implant-to-implant distance, cross-arch stabilization avoiding to cover oronasal communication and...
Patients with advanced orofacial cancer may require extensive surgical resection; the wider and more evident is the amputated region, the more this condition is generating inability for patients [6]. Visible head site mutilation and functional impairment in speech prevent social reintegration, and abnormal self-perception leads patients to depression [6].
Even if modern surgery offers many techni...
Cortical steroids were administered for the first two postoperative days. A postoperative 10-day cycle of antibiotic therapy (amoxicillin 1000 mg TID) was administered. Analgesics were administered as required. Sutures were removed 15 days after surgery. A soft diet was recommended for the first 2 weeks.
Three months afterwards, healing abutments were connected (Fig. 2) [4].
Approximately 4...
The patient, a male 46 years old at the time of our visit, underwent surgical resection of nasal pyramid and premaxilla including the whole upper jaw teeth sparing nasal bones. When the patient came to our clinic, apart from the defect resulting from the resection, he presented with a retraction scar crossing the upper lip from the floor of the nasal defect through the filtrum. The surgical resec...
The use of zygoma implants in the rehabilitation of patients who underwent surgical resection for oral cancer has been widely described [1–3]. There are several possibilities that can be considered when evaluating the possibility of surgical reconstruction after the first cancer resection, such as microvascular free flaps or rotation flaps, but it is sometimes necessary to monitor the healing pr...
Several authors have described zygoma implants as a reliable surgical option to rehabilitate severe maxillary defects in case of extreme atrophy or oncological resections. The aim of this study is to report a new technical approach to the rehabilitation of a complex oronasal defect by means of a zygoma-implant-supported full-arch dental prosthesis combined with a nasal epithesis.
The patient pres...
Fig. 12. Facial photograph views at 22-month follow-up
Fig. 12. Facial photograph views at 22-month follow-up
Fig. 11. Facial radiograph at 22-month follow-up
Fig. 11. Facial radiograph at 22-month follow-up
Fig. 10. Full facial view of definitive implant-retained obturator at initial fitting (April 2014)
Fig. 10. Full facial view of definitive implant-retained obturator at initial fitting (April 2014)
Fig. 9. Palatal view of definitive implant-retained obturator at initial fitting (April 2014)
Fig. 9. Palatal view of definitive implant-retained obturator at initial fitting (April 2014)
Fig. 8. Anterior view of definitive obturator prosthesis in occlusion
Fig. 8. Anterior view of definitive obturator prosthesis in occlusion
Fig. 7. Smile view of definitive implant-retained obturator at initial fitting (April 2014)
Fig. 7. Smile view of definitive implant-retained obturator at initial fitting (April 2014)
Fig. 6. Intaglio surface of definitive acrylic obturator with bar attachments in place. Note the absence of any other retaining clasps and the simple nature of this prosthesis
Fig. 6. Intaglio surface of definitive acrylic obturator with bar attachments in place. Note the absence of any other retaining clasps and the simple nature of this prosthesis
Fig. 5. Zygomatic implant bar utilising Rhein attachments for retention
Fig. 5. Zygomatic implant bar utilising Rhein attachments for retention
Fig. 4. Twelve-week review post-surgery prior to definitive impressions for the implant-supported prosthesis
Fig. 4. Twelve-week review post-surgery prior to definitive impressions for the implant-supported prosthesis
Fig. 3. Low-level right-sided maxillectomy with the insertion of two zygomatic oncology implants at time of surgery
Fig. 3. Low-level right-sided maxillectomy with the insertion of two zygomatic oncology implants at time of surgery
Fig. 2. Palatal swelling (post-biopsy) between upper right first and second premolar teeth
Fig. 2. Palatal swelling (post-biopsy) between upper right first and second premolar teeth
Fig. 1. Zygomatic oncology implant with cleansable polished surface for intra-oral component
Fig. 1. Zygomatic oncology implant with cleansable polished surface for intra-oral component
Dattani, A., Richardson, D. & Butterworth, C.J. A novel report on the use of an oncology zygomatic implant-retained maxillary obturator in a paediatric patient. Int J Implant Dent 3, 9 (2017). https://doi.org/10.1186/s40729-017-0073-7
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Received: 24 November 2016
Accepted: 26 February 2017
Published: 28 March 2017
DOI: https://doi.org/10.1186/s40729-017-0073-7
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were m...
Oral and Maxillofacial Surgery, Regional Maxillofacial Unit, University Hospital Aintree, Liverpool, UK
Amit Dattani
Maxillofacial Surgery, Regional Craniofacial Unit, Alder Hey Children’s Hospital, Liverpool, UK
David Richardson
Maxillofacial Prosthodontics, Regional Maxillofacial Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
Chris J. Butterworth
You can also sea...
Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol. 2010;11(10):1001–8.
Breeze J, Rennie A, Morrison A, Dawson D, Tipper J, Rehman K, et al. Health-related quality of life after maxillectomy: obturator rehabilitation compared with flap reconstruction. Br J Oral Maxillofac Surg. 2016;54(8):857–62.
Kim SM, Park MW, Cho YA, Myoung H, Lee...
The use of zygomatic implants to supplement the stability and retention of the maxillary obturator in this case has improved the function of the prosthesis and provided for a very high-quality rehabilitation for the patient reported with no evidence of disruption to facial growth in the 22 months following surgery.
The use of modified zygomatic implants (Fig. 1) allows improved hygiene by the patient of the implants within the maxillary defect. The threaded portion of the implants is fully engaged into the bone with only the smooth portion protruding into the defect. Clearly this ongoing hygiene by the patient is of utmost importance in preventing peri-implant soft and hard tissue changes, but the implant d...
The difficulty of restoration with a maxillary obturator prosthesis depends on the extent of the surgical resection, with the acceptance that resections with an increasing horizontal component provide a much greater prosthodontic challenge. The number of remaining teeth is a key component in conventional obturator design [9] with the remaining dentition being used exclusively to retain the prosthe...
The paediatric population rarely suffer malignant disease of the oral cavity requiring any form of maxillectomy, and there is little published evidence around the rehabilitation and restorative management of children undergoing such procedures. The seemingly most common approach for a limited low-level maxillary resection in a child would be to consider resection and simple prosthetic obturation a...
Four weeks later, the patient was returned to the operating room for removal and modification of the obturator. The cavity was healing well, and both implants were firm with no evidence of infection. The initial obturator was modified with the application of a soft lining material and the patient subsequently discharged with instructions on the insertion and removal of the obturator.
At the 12-we...
A medically fit and well 13-year 11-month-old male was referred to the oral and maxillofacial surgery department at Alder Hey Children’s Hospital in Liverpool in regard to an intra-oral swelling of the right palatal region (Fig. 2). An incisional biopsy was initially reported as a pleomorphic adenoma of the premolar region. Subsequently, a CT scan showed no significant bony abnormality, and a w...
The characteristics of a good obturator will improve swallowing, speech function, minimise nasal fluid leakage from the antrum and nasal spaces, restore facial aesthetics including the teeth and facilitate masticatory function and speech. A surgical obturator can be provided at the time of surgery to facilitate function and haemostasis in the immediate post-operative period, and this can subsequen...
Maxillary defects of acquired [1] or congenital origin produce a communication between the oral and nasal cavities sometimes via an opening into the maxillary antrum and by direct communication into the nose. This in turn can result in masticatory compromise, swallowing and speech impairment, nasal fluid regurgitation and aesthetic concerns. The management of the maxillectomy patient is a complex ...
This report details the use of zygomatic oncology osseointegrated implants to support and retain a maxillary obturator in a 13-year-old male patient who underwent a right-sided hemi-maxillectomy (Brown Class 2b) (Brown and Shaw, Lancet Oncol 11:1001–8, 2010) for a myxoid spindle cell carcinoma. At the time of maxillary resection, two zygomatic oncology implants were inserted into the right zygom...
Fig. 17. The appearance of the case shown in Fig. 16 with the polythene “washer” removed at 2 weeks post-surgery, providing access to the zygomatic oncology implants
Fig. 17. The appearance of the case shown in Fig. 16 with the polythene “washer” removed at 2 weeks post-surgery, providing access to the zygomatic oncology implants
Fig. 16. Another ZIP flap case demonstrating the use of a perforated polythene “washer” to keep the flap from overgrowing the implant abutments during the healing phase
Fig. 16. Another ZIP flap case demonstrating the use of a perforated polythene “washer” to keep the flap from overgrowing the implant abutments during the healing phase
Fig. 15. Facial appearance 18 months following treatment
Fig. 15. Facial appearance 18 months following treatment
Fig. 14. Intra-oral view of perforated flap 3 weeks following radiotherapy
Fig. 14. Intra-oral view of perforated flap 3 weeks following radiotherapy
Fig. 13. Panoramic dental radiograph showing the position of the zygomatic implants and the seating of the initial fixed prosthesis
Fig. 13. Panoramic dental radiograph showing the position of the zygomatic implants and the seating of the initial fixed prosthesis
Fig. 12. Provisional acrylic fixed dental prosthesis fitted at 4 weeks post-surgery
Fig. 12. Provisional acrylic fixed dental prosthesis fitted at 4 weeks post-surgery
Fig. 11. Intra-oral view of the soft tissue flap at 3 weeks post-operatively with overgrowth of flap over the zygomatic oncology implants
Fig. 11. Intra-oral view of the soft tissue flap at 3 weeks post-operatively with overgrowth of flap over the zygomatic oncology implants
Fig. 10. Radial forearm flap inset and sutured into the maxillary defect and perforated by the zygomatic oncology implant abutments
Fig. 10. Radial forearm flap inset and sutured into the maxillary defect and perforated by the zygomatic oncology implant abutments
Fig. 9. Inter-occlusal registration using the pre-fabricated maxillary denture prosthesis relined with silicone putty over the implant abutment protection caps
Fig. 9. Inter-occlusal registration using the pre-fabricated maxillary denture prosthesis relined with silicone putty over the implant abutment protection caps
Fig. 8. Abutment level impression utilising light-cured acrylic tray material
Fig. 8. Abutment level impression utilising light-cured acrylic tray material
Fig. 7. Conventional zygomatic implant insertion on the non-defect side of the maxilla following extraction of the remaining teeth and an alveoloplasty
Fig. 7. Conventional zygomatic implant insertion on the non-defect side of the maxilla following extraction of the remaining teeth and an alveoloplasty
Fig. 6. Zygomatic oncology implants sited in the residual zygomatic bone on the defect side of the maxilla
Fig. 6. Zygomatic oncology implants sited in the residual zygomatic bone on the defect side of the maxilla
Fig. 5. Left-sided maxillary resection (Brown class 2b)
Fig. 5. Left-sided maxillary resection (Brown class 2b)
Fig. 4. Panoramic dental radiograph showing dental status at presentation
Fig. 4. Panoramic dental radiograph showing dental status at presentation
Fig. 3. Staging CT scan confirming maxillary destruction but preservation of the orbital floor
Fig. 3. Staging CT scan confirming maxillary destruction but preservation of the orbital floor
Fig. 2. Staging MRI scan showing destructive lesion left maxilla
Fig. 2. Staging MRI scan showing destructive lesion left maxilla
Fig. 1. Clinical view of left-sided maxillary tumour at presentation
Fig. 1. Clinical view of left-sided maxillary tumour at presentation
Domain
Score
Activity
100 (“I am as active as I have ever been”)
Anxiety
100 (“...
Butterworth, C.J., Rogers, S.N. The zygomatic implant perforated (ZIP) flap: a new technique for combined surgical reconstruction and rapid fixed dental rehabilitation following low-level maxillectomy.
Int J Implant Dent 3, 37 (2017). https://doi.org/10.1186/s40729-017-0100-8
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Received: 14 May 2017
Accepted: 23 July 2017
Published: 29 July 2017
DOI: https...
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were...
Consent has been obtained from the patient for the use and publication of all images.
Chris Butterworth and Simon Rogers declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Department of Oral & Maxillofacial Surgery, University Hospital Aintree, Lower Lane, Liverpool, L9 7AL, UK
C. J. Butterworth & S. N. Rogers
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CB devised the treatment concept and undertook all implant surgeries and prostho...
Okay DJ, Genden E, Buchbinder D, Urken M. Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent. 2001;86(4):352–63.
Rohner D, Bucher P, Hammer B. Prefabricated fibular flaps for reconstruction of defects of the maxillofacial skeleton: planning, technique, and long-term experience. Int J Oral Maxillofac Implants. 2013;28(5):e221...
The ZIP flap technique represents an innovative approach to the management of patients presenting with low-level malignant maxillary tumours. It provides effective closure of the resulting maxillary defect restoring speech and swallowing functions and also establishing a high-quality fixed dental rehabilitation in a rapid timescale, thus facilitating a more timely return to function and restored f...
Whilst technically, it would be possible to construct and fit the prosthesis on the same day or even a week later, the need for microvascular flap monitoring in the immediate post-operative period, together with the significant recovery period required by the patient following surgery has lead the authors to delay the fitting of the prosthesis at the 4 to 6-week period post-operatively. In terms o...
In contrast, the use of a soft tissue flap such as the RFFF or antero-lateral thigh flap can often be safely employed in elderly patients with peripheral vascular disease without unduly lengthening the operation too significantly with two-team operating. In addition, the predictability of these flaps with their excellent pedicle lengths is ideal for closure of the resulting oro-nasal surgical defe...
In low-level maxillectomy (Brown class II), the need for bony reconstruction is questionable depending on the horizontal component. With the preservation of the orbital floor, zygomatic prominence and some bony support for the nose, facial appearance, in the experience of the authors and, as demonstrated by this case, is not significantly worsened despite low-level removal of the maxilla. The key ...
In order to address some of the issues highlighted in this early case, the technique was modified slightly to try and prevent flap overgrowth and prosthesis fracture in the early stages. In order to prevent flap overgrowth over the zygomatic oncology implant abutments, the use of a polythene washer was instituted on subsequent cases treated in the unit. Once the flap was perforated, a 2-mm thick p...
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 abutment...
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 m...
The surgical management and prosthodontic rehabilitation of the maxillectomy patient is complex with a variety of options available to the head and neck cancer team ranging from simple prosthodontic obturation [1] to reconstruction using pre-fabricated or digitally planned composite flaps [2] with or without the placement of osseointegrated implants [3]. The primary aims of treatment include effec...
This aim of this report is to describe the development and evolution of a new surgical technique for the immediate surgical reconstruction and rapid post-operative prosthodontic rehabilitation with a fixed dental prosthesis following low-level maxillectomy for malignant disease.
The technique involves the use of a zygomatic oncology implant perforated micro-vascular soft tissue flap (ZIP flap) fo...
Dattani, A., Richardson, D. & Butterworth, C.J. A novel report on the use of an oncology zygomatic implant-retained maxillary obturator in a paediatric patient.
Int J Implant Dent 3, 9 (2017). https://doi.org/10.1186/s40729-017-0073-7
Download citation
Received: 24 November 2016
Accepted: 26 February 2017
Published: 28 March 2017
DOI: https://doi.org/10.1186/s40729-017-00...
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were...
Oral and Maxillofacial Surgery, Regional Maxillofacial Unit, University Hospital Aintree, Liverpool, UK
Amit Dattani
Maxillofacial Surgery, Regional Craniofacial Unit, Alder Hey Children’s Hospital, Liverpool, UK
David Richardson
Maxillofacial Prosthodontics, Regional Maxillofacial Unit, University Hospital Aintree, Longmoor Lane, Liverpool, L9 7AL, UK
Chris J. Butterworth
You can also sea...
Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol. 2010;11(10):1001–8.
Breeze J, Rennie A, Morrison A, Dawson D, Tipper J, Rehman K, et al. Health-related quality of life after maxillectomy: obturator rehabilitation compared with flap reconstruction. Br J Oral Maxillofac Surg. 2016;54(8):857–62.
Kim SM, Park MW, Cho YA, Myoung H, Lee...
The use of zygomatic implants to supplement the stability and retention of the maxillary obturator in this case has improved the function of the prosthesis and provided for a very high-quality rehabilitation for the patient reported with no evidence of disruption to facial growth in the 22 months following surgery.
The use of modified zygomatic implants (Fig. 1) allows improved hygiene by the patient of the implants within the maxillary defect. The threaded portion of the implants is fully engaged into the bone with only the smooth portion protruding into the defect. Clearly this ongoing hygiene by the patient is of utmost importance in preventing peri-implant soft and hard tissue changes, but the implant d...
The difficulty of restoration with a maxillary obturator prosthesis depends on the extent of the surgical resection, with the acceptance that resections with an increasing horizontal component provide a much greater prosthodontic challenge. The number of remaining teeth is a key component in conventional obturator design [9] with the remaining dentition being used exclusively to retain the prosthe...
The paediatric population rarely suffer malignant disease of the oral cavity requiring any form of maxillectomy, and there is little published evidence around the rehabilitation and restorative management of children undergoing such procedures. The seemingly most common approach for a limited low-level maxillary resection in a child would be to consider resection and simple prosthetic obturation a...
Four weeks later, the patient was returned to the operating room for removal and modification of the obturator. The cavity was healing well, and both implants were firm with no evidence of infection. The initial obturator was modified with the application of a soft lining material and the patient subsequently discharged with instructions on the insertion and removal of the obturator.
At the 12-we...
A medically fit and well 13-year 11-month-old male was referred to the oral and maxillofacial surgery department at Alder Hey Children’s Hospital in Liverpool in regard to an intra-oral swelling of the right palatal region (Fig. 2). An incisional biopsy was initially reported as a pleomorphic adenoma of the premolar region. Subsequently, a CT scan showed no significant bony abnormality, and a w...
The characteristics of a good obturator will improve swallowing, speech function, minimise nasal fluid leakage from the antrum and nasal spaces, restore facial aesthetics including the teeth and facilitate masticatory function and speech. A surgical obturator can be provided at the time of surgery to facilitate function and haemostasis in the immediate post-operative period, and this can subsequen...
Maxillary defects of acquired [1] or congenital origin produce a communication between the oral and nasal cavities sometimes via an opening into the maxillary antrum and by direct communication into the nose. This in turn can result in masticatory compromise, swallowing and speech impairment, nasal fluid regurgitation and aesthetic concerns. The management of the maxillectomy patient is a complex ...
This report details the use of zygomatic oncology osseointegrated implants to support and retain a maxillary obturator in a 13-year-old male patient who underwent a right-sided hemi-maxillectomy (Brown Class 2b) (Brown and Shaw, Lancet Oncol 11:1001–8, 2010) for a myxoid spindle cell carcinoma. At the time of maxillary resection, two zygomatic oncology implants were inserted into the right zygom...
Figure 17. The appearance of the case shown in Fig. 16 with the polythene “washer” removed at 2 weeks post-surgery, providing access to the zygomatic oncology implants
Figure 15. Facial appearance 18 months following treatment
Figure 15. Facial appearance 18 months following treatment
Figure 14. Intra-oral view of perforated flap 3 weeks following radiotherapy
Figure 13. Panoramic dental radiograph showing the position of the zygomatic implants and the seating of the initial fixed prosthesis
Figure 12. Provisional acrylic fixed dental prosthesis fitted at 4 weeks post-surgery
Figure 11. Intra-oral view of the soft tissue flap at 3 weeks post-operatively with overgrowth of flap over the zygomatic oncology implants
Figure 10. Radial forearm flap inset and sutured into the maxillary defect and perforated by the zygomatic oncology implant abutments
Figure 10. Radial forearm flap inset and sutured into the maxillary defect and perforated by the zygomatic oncology implant abutments
Figure 9. Inter-occlusal registration using the pre-fabricated maxillary denture prosthesis relined with silicone putty over the implant abutment protection caps
Figure 8. Abutment level impression utilising light-cured acrylic tray material
Figure 7. Conventional zygomatic implant insertion on the non-defect side of the maxilla following extraction of the remaining teeth and an alveoloplasty
Figure 6. Zygomatic oncology implants sited in the residual zygomatic bone on the defect side of the maxilla
Figure 5. Left-sided maxillary resection (Brown class 2b)
Figure 4. Panoramic dental radiograph showing dental status at presentation
Figure 3. Staging CT scan confirming maxillary destruction but preservation of the orbital floor
Figure 2. Staging MRI scan showing destructive lesion left maxilla
Figure 1. Clinical view of left-sided maxillary tumour at presentation
Table 1 Patient-reported quality of life outcomes following ZIP flap procedure
From: The zygomatic implant perforated (ZIP) flap: a new technique for combined surgical reconstruction and rapid fixed dental rehabilitation following low-level maxillectomy
Domain
Score
Activity
100 (“I am as active as I have ever been”)
Anxiety
100 (“I am not anxious about ...
References
Okay DJ, Genden E, Buchbinder D, Urken M. Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent. 2001;86(4):352–63.
Rohner D, Bucher P, Hammer B. Prefabricated fibular flaps for reconstruction of defects of the maxillofacial skeleton: planning, technique, and long-term experience. Int J Oral Maxillofac Impl...
Conclusions
The ZIP flap technique represents an innovative approach to the management of patients presenting with low-level malignant maxillary tumours. It provides effective closure of the resulting maxillary defect restoring speech and swallowing functions and also establishing a high-quality fixed dental rehabilitation in a rapid timescale, thus facilitating a more timely return to function...
Immediate/early loading of zygomatic [8] and dental implants [9] have been well demonstrated already within the literature with very high implant survival rates. In the oncology setting, Boyes-Varley et al. [4] lost no zygomatic/oncology implants in their series of 20 patients restored with implant-retained obturators, 6 of whom received radiotherapy post-operatively. The case reported...
The use of soft tissue flaps to close a typical hemi-maxillectomy defect is an effective way of dealing with the oro-nasal communication, but in isolation, this technique works against dental rehabilitation as the bulk of the flap provides a very poor moveable foundation for a subsequent removable prosthesis. The move towards the use of composite reconstruction (especially the fibula flap) h...
Discussion
In order to reduce intra-operative time, the soft tissue free flap is harvested at the same time as the implant placement and prosthodontic procedures. On raising a skin island, it is appropriate to make it a little over-sized for the required defect to ensure that tension and possible dehiscence at the surgical margins during healing is reduced.
In low-level maxillectomy (Brown...
Procedural modifications to the ZIP flap technique
In order to address some of the issues highlighted in this early case, the technique was modified slightly to try and prevent flap overgrowth and prosthesis fracture in the early stages. In order to prevent flap overgrowth over the zygomatic oncology implant abutments, the use of a polythene washer was instituted on subsequent cases treated in th...
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...
The ZIP flap technique
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...
Case presentation
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 destruc...
Background
The surgical management and prosthodontic rehabilitation of the maxillectomy patient is complex with a variety of options available to the head and neck cancer team ranging from simple prosthodontic obturation [1] to reconstruction using pre-fabricated or digitally planned composite flaps [2] with or without the placement of osseointegrated implants [3]. The primary aims of treatment...
The zygomatic implant perforated (ZIP) flap: a new technique for combined surgical reconstruction and rapid fixed dental rehabilitation following low-level maxillectomy
Abstract
This aim of this report is to describe the development and evolution of a new surgical technique for the immediate surgical reconstruction and rapid post-operative prosthodontic rehabilitation with a fixed dental prost...