We report three patients who underwent alveolo-maxillary resection for cancer and had the resulting oroantral communication directly closed with loco-regional flaps. Simultaneous zygomatic implant insertion was added, in view of granting the optimal dental rehabilitation.
All surgical procedures were successful in terms of oroantral separation and implant survival. One patient had the fixed dental restoration just after 3 months, and the others had to receive postoperative radiotherapy; thus, rehabilitation timing was longer, as expected. We think this approach could improve the outcome in selected patients.
Maxillectomy Zygomatic implant Tumor resection Maxillofacial Carcinoma Maxillary reconstruction.
Major defects following maxillectomy for cancer include oronasal/antral communication, loss of teeth and/or tooth-supporting bone, and facial contour deformity. As a result, speaking, chewing, swallowing, and appearance are variably affected. A priority of restoration is focused on rebuilding the oronasal wall, by means either of flaps (local or free), or prosthetic obturator. Dental rehabilitation might follow by means of regular prosthesis, tooth-bearing obturator, and endosseous implants (in native and/or transplanted bone). Zygomatic implantology (ZI) has been first mentioned by Aparicio et al. in 1993 , then proposed by Brånemark  in order to overcome bone availability after maxillectomy. Commonly, this option is offered as a delayed procedure after tumor resection. Later, ZI has been employed in non-neoplastic, severely atrophic maxilla [3, 4, 5, 6, 7, 8, 9, 10, 11]. The present paper is an early report of a relatively new, one-stage approach providing for tumor resection, palatal repair with loco-regional flaps, and zygomatic implant insertion in three patients. The advantages are the concentration of surgical procedures, reduced time of rehabilitation, and patient discomfort.
Three patients have been operated on for malignant neoplasms affecting the maxilla at the Legnano Hospital, Italy, and at the Humanitas San Pio X, Italy. Written informed consent was obtained from each patient, and the study protocol conformed to the ethical guidelines of the World Medical Association Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects. The surgical plan was based on tumor resection, palatal repair, and zygomatic implant insertion in view of fixed dental rehabilitation. CT scan for zygomatic bone evaluation was part of the presurgical workup. No virtual planning of resection or of implant insertion was considered, and fixture placement was performed under direct vision, enhanced by simple resin guide simulating the resected dental arch. All patients were dentate (natively or after fixed restoration) and resulted partially dentate after tumor resections, thus fitting class IIA defect classification, according to Pellegrino et al. . Osteotomies were achieved with surgical saw, burs, and piezosurgery. Frozen sections were obtained in order to demonstrate clean margins.
The zygomatic bone was adequately exposed. Implants from Noris Medical Ltd. (Nesher, Israel) were chosen. The working threaded part of the implant is 13 mm long, while the remaining, fully smooth shaft has 4-mm diameter and variable lengths. In all, length ranges from 35 to 57.5 mm. Implant drilling was performed using both straight and angled handpieces. The fixtures were placed at 35 rpm for the 2/3 of the apical and manually for the most coronal 1/3 working part. The palatal-alveolar repair was attained with soft tissue, local flaps: these were also wrapped around the implants. In order to obtain a durable watertight seal between oral and nasal/antral cavities, implant uncovering and loading were planned to be deferred by 3 months.
CT scans and/or panoramic radiographs were taken to monitor implant healing.
The screw-retained fixed prosthesis was considered for teeth replacement.
Patient no. 1
Patient no. 2
Patient no. 3
Neoplasms of the maxilla often require extensive surgery and adjuvant treatments: as a consequence, quality of life might result as heavily impaired.
Reconstructive surgery (immediate or delayed) allows anatomic and basic functionality restoration following maxillary tumor resection. Actually, the most important goal has to be achieved—as earlier as possible— is the repair of the natural barrier between oral and nasal/antral cavities: options include free or local flaps and obturator.
Free flaps may either be harvested as single component, or as soft tissue and bone complex. Among the latter, fibula, iliac crest, and scapula are the most popular, with personal preference for the fibula flap. These composite auto-transplants allow both restoration of the oronasal/antral barrier and bone support for implants. Disease-related indications for composite free flaps include repair of large defects (2/3 of the palato-alveolar complex) and 3-D maxillary reconstruction. Their use implies large consumption of resources, yet patients’ survival is quite rewarding .
In contrast, local and regional flaps are less demanding, but their use is restricted to more limited palato-alveolar defects (up to the midline). The temporalis muscle is the workhorse for repairing such defects, while buccal fat pad has room in case of minor oronasal/antral communications . When needed, adequate bone support may be set by secondary bone grafting.
Finally, prosthetic obturator is recommended when the above solutions cannot be available or are contraindicated: it requires adequate anchoring (residual dentition, standard implants, deep vestibular sulcus) and continuous servicing.
In our opinion, primary closure by flaps should be preferred over prosthetic obturator, as this approach makes the patients more comfortable and prosthesis-free, immediately and during his/her daily activity. Indeed, in all three patients, local flaps have performed well and led to successful immediate closure of the oroantral communication following tumor ablation. Seok et al.  advocate the application of 4-hexylresorcinol in order to accelerate and improve re-epithelialization.
Common belief stresses that follow-up in patients wearing obturator would be easier and safer than that in patients having surgical closure of the palate. In fact, possible local recurrence of the tumor could be detected early, yet benefit in survival of such a policy has not definitively proved. Moreover, modern imaging techniques could be at least as effective as inspection in revealing possible relapse at an early stage.
Nevertheless, some patients are or have become more demanding about full or maximum recovery of the finest activities linked to chewing, phonation, deglutition, and aesthetics: in these cases, dental rehabilitation through implant-supported prosthesis might greatly help, the fixture(s) being usually inserted in native or grafted bone. Zygomatic implants could overcome the possible problem of lacking or poor-quality bone [2, 5, 12, 15, 16, 17, 18, 19, 20, 21, 22]. In such patients, ZI is usually a delayed, multi-staged procedure, either after having primarily closed the oronasal/antral communication [12, 17, 19], either after left it untreated or amended with obturator [5, 16, 18]: the overall time from tumor treatment and final dental rehabilitation might require 1 year or more. Intuitively, interest has arisen in shortening this gap and we planned to move toward this direction.
The relatively innovative aspect of the present paper deals with the idea of challenging three different tasks in a single-stage procedure: resection of the tumor, closure of the oronasal/antral communication, and insertion of the zygomatic implants finalized to a fixed restoration. In few words, we tried to reach the best cost/benefit ratio.
Indeed, Pellegrino et al.  should be credited for the first reported case, even if not clearly evident from their paper (personal communication from Prof. C. Marchetti). The authors also proposed a new classification of rehabilitation-orientated maxillary defects: in our opinion, it deserves attention because of its clarity and effectiveness in orientating therapeutic options.
We were able to complete the above plan within the expected period of 3 months in patient no. 1, whose outcome is optimal after 1 year.
Supplementary advantage of ZI at the time of tumor resection is to give implants sufficient time to become osseointegrated before prospective radiotherapy course, then avoiding or minimizing its well-known negative impact on healing . Actually, patient nos. 2 and 3 took some benefits from this policy.
In addition, applying a maxillary prosthesis in the early stages minimizes contraction of facial soft tissues .
We performed ZI under direct vision, enhanced by resin guide pointing landmarks. The procedure was somewhat easier than ZI in simply atrophic patients, as the resected bone allowed more room to vision and manipulation. On the other hand, the prepared flaps and the residual dentition could make things a bit more difficult than usual situations. Some authors advocate either general  or specific computer-aided surgery [12, 25], or surgical navigation [15, 26], for accurate, safe zygomatic implant installation. Undoubtedly, these are effective apparatuses, whose limitations are availability and operating costs. The pilot hole technique  and piezosurgery could offer similar advantages—at least in terms of safety—with lower costs.
Zygomatic implants are most suitable for immediate loading due to the high torque usually necessary for their insertion and consequent outstanding primary stability. However, we privileged the delayed loading to achieve and maintain an adequate seal between oral and nasal/antral cavities.
Long-term results of ZI are quite satisfactory. Brånemark  reported a 97% success rate in a series of 184 zygomatic implants inserted in 81 patients. Aparicio et al.  conducted a large review of zygomatic implant survival: success rates ranged 94.4 to 100%. Recently, Chrcanovic et al.  extended the analysis over 4556 zygomatic implants in 2161 patients: they found a noteworthy 12-year cumulative survival rate of 95.21%.
Despite the prosthetic aspects of the proposed technique are somewhat beyond the paper scope, some considerations appear obliged. Screw-retained, metal-core dental prostheses are popular, manageable devices allowing easy removal for fixture inspection and cleaning. An interesting point is that in patient no. 1, the interdental and inter-arch obligations lead to a double-cantilevered dental restoration, entailing a possible overload: to mitigate it prudently, mesial (to canine) and distal (to the second molar) splinting were conceived. Indeed, implant stability was preserved, as checked at regular clinical and X-ray follow-up examinations (Fig. 5).
Within reason, delayed ZI insertion in regard of radiotherapy and/or primary ablative surgery would have been more hazardous and difficult, if not impossible. In turn, fixed dental restoration would have been more demanding, more lasting, suboptimal, even not feasible. Concisely, immediate insertion of ZI at the ablative tumor time could be considered as a biological investment.
In selected cases, maxillary resection, zygomatic implant(s) placement, and palato-alveolar repair through local flaps can be conducted as the same-stage procedure. Advantages would include the following:
• Immediate closure of the oronasal communication
• Quick return to normal or near-normal feeding and phonation
• Wide access to bony segment receiving zygomatic implants
• Unnecessary bone grafting
• Short surgery time
• Reduced number of substantial interventions
• Short time-to-rehabilitation
• Reduced financial impact
• Valid functional results
• Excellent long-term performance of ZI
We intend to propose this approach and wish the results will be confirmed in a large series.
- Pt: Patient
- ZI: Zygomatic implantology
The authors wish to warmly thank Mr Walter Quaglia, a dental technician, for his enthusiastic lab support.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Availability of data and materials
PS ideated the approach, performed the surgery, took care of the patients, collected the data, and wrote the manuscript. FG planned and performed or assisted with the implant surgery. AM, LR, FC, and AB assisted with the surgery and took care of the patients. EG helped in the data collection, documentation, and editorial assistance. UG did the critical review. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
All patients have agreed and signed the consent for publication.
Ethics approval and consent to participate
Written informed consent was obtained from each patient, and the study protocol conformed to the ethical guidelines of the World Medical Association Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects.
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