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Trans fibula zygomatic implants for maxillary rehabilitation

clinical case
Performed by Dr. Sankalp Mittal, MDS, Oral & Maxillofacial Surgeon
Reporting a case of a 56 year old male patient with post-covid mucormycosis of maxilla. As a part of treatment for maxillary mucormycosis, his infrastructure maxillectomy was done along with palatal mucosa, resulting in maxillary defect with oro-nasal communication.

After 6 months maxillary and palatal defect was reconstructed with free fibula flap by micro vascular surgery. After 6 month of successful Microvascular surgery, patient was referred to us for Dento-alveolar Rehabilitation.
While the Bone volume of fibula was sufficient for placement of endosseous implants, but on careful examination of CBCT it was revealed that there is no bone formation at the junction of fibula and residual Zygomatic bone.

It was apparent that fibula was held to Zygomatic bone only with the help of bone plates. It was a case of non-union of fibula to Zygomatic bone.
If this non-united fibula were to be subjected to prosthetic loading and subsequent masticatory forces, it would have resulted in further bone resorption. After evaluating the quality and quantity of residual zygomatic bone, it was planned to place zygomatic implants through fibula to zygomatic bone. It will serve dual purpose , retention of prosthesis as well as stabilization of fibula bone Surgery was performed under local anesthesia.

As expected surgically after removal of loose bone plates and screws there was non-union of fibula and there was considerable mobility of fibula.
Left side distal zygomatic implant was distal to fibula bone. It started from first molar to zygomatic bone. On the contrary Left mesial zygomatic implants and right mesial and distal zygomatic implants travelled through fibula to zygomatic boneresulting in transfibula zygomatic implant placement . In midline two conventional endosseous implants were placed in fibula.
Immediately after implant placement , Multiunit abutments and healing caps were placed. After three months, a metal ceramic screw retained hybrid prosthesis was delivered to patient.
Post operative opg and cbct were compared with post loading opg and cbct, no bone loss at fibula was noted .
Therefore we can conclude in order to stabilize non-united fibula to zygomatic bone and rehabilitate patients, we can employ the trans-fibula zygomatic implant techniques.

 

FIG-1 –Pre-operative extraoral photograph of the patient after maxillary reconstruction with fibula flap

 

FIG-2 Intraoral photograph- POST RECONSTRUCTION OF FREE FIBULA FLAP BY MICROVASCULAR SURGERY

 

FIG-3 Maxilla (occlusion view) with successful free fibula flap covering oro-nasal communication which was caused by post-mucormycosis
Infrastructure maxillectomy

 

FIG-4 CBCT FACE- Six month Post-operative fibula flap reconstruction

 

Fig-5 CBCT- AXIAL VIEW- fibula flap placed post-maxillectomy

 

FIG-6- Six month postoperative CBCT reveals plates and screw attachment between fibula to zygomatic bone

 

Fig-7 SIX MONTH POST OPERATIVE CBCT showing non-union of zygomatic bone to fibula

 

FIG-8 – PREOPERATIVE Planning for placement of zygomatic implants

 

FIG-9 Preoperative planning – Right side Trans-zygomatic implant Planning passing through fibula and extending to zygomatic bone

 

FIG-10 Preoperative planning – left side Trans-zygomatic implant

 

Planning passing through fibula and extending to zygomatic bone

FIG-11 INTRA-OPERATIVE Photograph showing four hole plate with screws holding fibula flap to zygomatic bone

 

FIG-12- INTRAOPERATIVE PHOTOGRAPH – showing left side zygomatic drill engaging fibula to zygomatic bone

 

. FIG-13- INTRAOPERATIVE PHOTOGRAPH – showing left side zygomatic implant placement engaging fibula to zygomatic bone

 

Fig-14 Intraoperative photograph of right side – implant placement of the mesial followed by drilling for the zygomatic implant placement on the distal

 

FIG-15 Intraoperative photograph of right side – Transzygomatic implant placement

 

FIG-16- POST-OPERATIVE Maxillary view withmultiunit abutment and healing caps placed

 

Fig-17 – After three months – METAL CERAMIC SCREW RETAINED HYBRID prosthesis was delivered to patient

 

FIG-18 INTRAORAL PHOTOGRAPH- METAL CERAMIC SCREW RETAINED HYBRID prosthesis placed

 

FIG-19- OPG view – after three months POST- IMPLANT PLACEMENT AND PROSTHESIS PLACEMENT

 

 

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