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 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.

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).