CASE REPORT Open Access

Rehabilitation of a complex midfacialdefect by means of a zygoma-implant-supported prosthesis and nasal epithesis:a novel techniqueLorenzo Trevisiol, Pasquale Procacci, Antonio D’Agostino*, Francesca Ferrari, Daniele De Santisand Pier Francesco Nocini

Abstract

Purpose: Several authors have described zygoma implants as a reliable surgical option to rehabilitate severemaxillary defects in case of extreme atrophy or oncological resections. The aim of this study is to report a newtechnical approach to the rehabilitation of a complex oronasal defect by means of a zygoma-implant-supportedfull-arch dental prosthesis combined with a nasal epithesis.

Patients and methods: The patient presented with a subtotal bilateral maxillectomy and total rhinectomy defectbecause of a squamous cell carcinoma of the nose. No reconstructive surgery was performed because of the highrisk of recurrence; moreover, the patient refused any secondary procedure. After surgery, the patient presented awide palatal defect associated to the absence of the nasal pyramid. Zygoma-retained prostheses are welldocumented, and they offer good anchorage in rehabilitating wide defects after oncological surgery and a goodchance for patients to improve their quality of life. We hereby describe two prosthetic devices rehabilitating twoiatrogenic defects by means of a single intraoral implant-supported bar extending throughout the oronasalcommunication, thus offering nasal epithesis anchorage.

Results: At 1-year follow-up after functional prosthetic loading, no implant failure has been reported. Clinical andradiological follow-up showed no sign of nasal infection or peri-implantitis. The patient reported a sensitiveimprovement of his quality of life.

Conclusions: Simultaneous oral and nasal rehabilitation of complex oronasal defects with zygoma-implant-supported dental prosthesis and nasal epithesis represents a reliable surgical technique. According to this clinicalreport, the above-mentioned technique seems to be a valuable treatment option as it is safe, reliable and easy tohandle for both surgeon and patient.

Keywords: Extraoral rehabilitation, Obturator prosthesis, Rhinectomy, Zygoma implants, Maxillectomy

* Correspondence: antonio.dagostino@univr.itDepartment of Surgery, Section of Oral and Maxillofacial Surgery, Universityof Verona, Policlinico “Giovanni Battista Rossi”, Piazzale Ludovico AntonioScuro, 10, 37134 Verona, Italy

International Journal ofImplant Dentistry

© 2016 Trevisiol et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made.

Trevisiol et al. International Journal of Implant Dentistry (2016) 2:7 DOI 10.1186/s40729-016-0043-5

BackgroundThe use of zygoma implants in the rehabilitation of pa-tients who underwent surgical resection for oral cancerhas been widely described [1–3]. There are several possi-bilities that can be considered when evaluating the possi-bility of surgical reconstruction after the first cancerresection, such as microvascular free flaps or rotationflaps, but it is sometimes necessary to monitor the healingprocess and the defect site in order to readily detect recur-rences that may occur in high-risk patients [4, 5]. Whiledealing with facial defects, it is mandatory to consider thatthis kind of defect has a big impact on the patient’s qualityof life [6, 7]. For this reason, medical science made astrong effort in developing rehabilitation solutions that en-able operated patients to re-achieve a normal life as soonas possible. According to this objective, zygoma implantsallow to reconstruct full arch even in case of conspicu-ous bone defects with no indication to grafting proce-dures [6, 8]. Furthermore, in case of wide midfacialresections with oronasal communication, zygoma implantsmay be used through the communication to support anextraoral nasal prosthesis. This article describes the re-habilitation of two defects, one intraoral and one extraoral,resulting from a single surgical act. Both intra- and extra-oral prosthetic rehabilitation are supported by four zygomaimplants positioned in the resected maxilla in order to cre-ate an artificial nose and a prosthetic denture.

Case presentationMaterials and methodsThe patient, a male 46 years old at the time of our visit,underwent surgical resection of nasal pyramid and pre-maxilla including the whole upper jaw teeth sparingnasal bones. When the patient came to our clinic, apartfrom the defect resulting from the resection, he pre-sented with a retraction scar crossing the upper lip fromthe floor of the nasal defect through the filtrum. Thesurgical resection was performed in another clinic theprevious year, and since then, the patient experienced asevere decrease in the quality of social life including theloss of job and falling into reactive depression. Thehistological aspect of the neoplasia was characterized byhigh malignancy and contraindicated a microvascularflap reconstruction in order to allow the inspection ofthe nasal cavity and the facial skin nearby the nasal de-fect during follow-up appointments.Furthermore, the conspicuous defect and the different

kind of tissues needed would have required multipledonor sites, making the achievement of a good aestheticand functional result quite challenging. Insofar, due tothe entity of the defect, the uncertain outcome of thesurgical reconstruction, time-costing evaluation andfollow-up need, the patient was proposed to undergozygoma-implant-supported prosthetic restorations.

Surgical treatmentRadiographic examination was carried out by means ofCT scans of the maxillofacial complex. After the evalu-ation of the residual maxillary bone, insertion of fourzygoma implants was planned.The surgical intervention was performed under gen-

eral anaesthesia. Our surgical treatment started with anincision extended from the palatal aspect of the secondmolar site to the crestal aspect of the canine site bilat-erally, with two posterior release incisions. A full-thickness flap was then elevated, and the anterolateralwall of the maxilla was exposed. An oval-shaped win-dow was first drawn and was then opened trough theupper aspect of the maxillary buttress using a largeround diamond bur. These windows are used to checkthe right direction of the zygomatic fixtures during theirinsertion trough the zygomatic bone. Once the maxil-lary buttress has been prepared bilaterally, the zygomaimplant insertion could start. The preoperative planningprovided the insertion of four zygomatic fixtures(Branemark System Zygoma, Zygoma TiUnite® Implant,Nobel Biocare, Goteborg, Sweden), one through the firstmolar area and one through the lateral canine area onboth sides (Fig. 1). The reflected mucoperiosteal flapwas then sutured with resorbable suture (Polysorb 4.0,Covidien, Mansfield, MA, USA).Cortical steroids were administered for the first two

postoperative days. A postoperative 10-day cycle of anti-biotic therapy (amoxicillin 1000 mg TID) was adminis-tered. Analgesics were administered as required. Sutureswere removed 15 days after surgery. A soft diet was rec-ommended for the first 2 weeks.Three months afterwards, healing abutments were

connected (Fig. 2) [4].

Fig. 1 Intraoperative view of the zygoma implants placed in theresidual maxilla

Trevisiol et al. International Journal of Implant Dentistry (2016) 2:7 Page 2 of 6

Prosthodontic treatmentApproximately 4 weeks after healing abutment connec-tion, intraoral defect including implant abutment andextraoral paranasal defect impressions were taken. Thetechnician managed two different casts: one cast fornasal wax up and one cast for dental wax up. Superiorimplant bar supported by [4] zygoma implants wasdesigned crossing the palatal defect in order to manufac-ture palatal obturator at a second time. Furthermore,two metal abutments were lodged and fused on thecranial surface of the bar in order to receive epithesisattachments. The abutments acted as primary crowns andsecondary crowns, press-fitted on abutments and wereused to take an extraoral position impression of theabutments using the nasal wax up as an individual. In thisway, the technician could connect OTK (Ball abutment)attachments on the internal surface of the epithesis andthanks to secondary crowns, the nasal prosthesis can beremoved for prosthetic aftercare and follow-up inspec-tions. OTK attachments are commonly used because oftheir retention in overdenture prosthetic rehabilitation.The female part of this peculiar type of ball attachment ismade out of Teflon™ (politetrafluoroetilene) while the malepart consisted of a titanium structure. A completeimplant-supported bar with two bolt prosthesis was madein order to provide superior arch rehabilitation. At thetime of delivery, the palatal defect was closed by a soft basematerial. The nasal epithesis was made of silicone with anacrylic resin internal plate hosting female OTK attach-ments, whereas male parts were on the secondary crowns.

ResultsThe patient received an implant-supported intra/extra-oral rehabilitation with nasal epithesis and overdentureconnected at the same metal framework due to the pres-ence of an oronasal iatrogenic communication (Fig. 3).The nasal defect was classified into total (soft and hardtissues) rhinectomy. The palatal defect was localized at

the premaxilla and was classified into “good” defect (resec-tion margins into hard palate). Following the delivery ofthe prostheses, the patient showed satisfaction both foraesthetic and functional results and reverted to normal lifeachieving social integration (Fig. 4); he also reduced anxio-lithic and antidepressive drug intake according to psychi-atric counselling, and he is waiting to gradually stop themdefinitively. The patient did not receive radiotherapy andwas non-smoker, two factors that are known to influencethe success of implant therapy. He started an implant andprosthetic aftercare program.

DiscussionPatients with advanced orofacial cancer may requireextensive surgical resection; the wider and more evidentis the amputated region, the more this condition isgenerating inability for patients [6]. Visible head sitemutilation and functional impairment in speech preventsocial reintegration, and abnormal self-perception leadspatients to depression [6].Even if modern surgery offers many techniques for re-

construction such as free flaps and rotation flaps, they arenot indicated in all clinical cases. Because of the hugenumber of surgical sessions often required in reaching thewishing result, the use of local or microvascular flap could

Fig. 2 The healing abutments positioned onto fixtures and theoronasal communication

Fig. 3 Postoperative panorex showing the symmetric distribution ofthe fixtures

Fig. 4 A front view of the bar with the intraoral portion and themetal extension for epithesis attachment

Trevisiol et al. International Journal of Implant Dentistry (2016) 2:7 Page 3 of 6

not be indicated in case of elderly patients or patients af-fected by cardiovascular or metabolic diseases. Moreover, amultistep surgical planning is not advisable in the absenceof a complete sure compliance of the patient to the treat-ment [9]. Furthermore, recipient site complication canoccur before and after harvesting or radiotherapy, when re-quired, shall compromise the healing of the flap [9].Nowadays, prosthetic extraoral rehabilitation is effect-

ive, less invasive because no additional surgical proced-ure is required, cosmetically satisfying and leads patientsto a precocious social reintroduction. Additionally,intraoral restoration such as palatal obturator may allowspeech and swallowing which play a crucial role in theretrieval of social life [8, 10].Nasal defects are classified into partial, total and ex-

tended rhinectomy referred to soft tissue resection, boneand soft tissue amputation and bone and soft tissue as-sociated to the maxilla or orbital excision [10].Extraoral defects are usually restored by means of sili-

con epithesis; intraoral ones necessitate maxillary rehabili-tation. In our case, since the premaxilla was lost, noimplant insertion in the anterior region was possible. Theimportance of anterior implant anchorage is well docu-mented even if a higher failure rate than the ones placedin the posterior maxilla is demonstrated [8, 10, 11].In palatal cleft iatrogenic defects, implants insertion

depends on bone residual amount, alveolar ridgeheight, radiotherapy and peri-implant soft tissue con-ditions [8, 10]. In patients who undergone radical sur-gery, all these requirements are often unfavourable andzygoma implants represent a valid alternative in offer-ing prosthetic anchorage [2, 6, 10].As far as prosthetic design is concerned, it is mandatory

to avoid or, if not possible, limit as much as possible distalcantilever: given the absence of the premaxilla, an anteriorcantilever is already present. Implant splintage is recom-mended [1, 8], and the bar design must respect technicaldata (implant-to-implant distance, cross-arch stabilizationavoiding to cover oronasal communication and shape of-fering nasal epithesis connection) and clinical require-ments (patient’s aftercare, visible inspection for follow-up).One of the most important technical issues is about oro-nasal communication: if the bar crosses, it is close to theupper lip, no obturator can be manufactured and the lackof vestibular seal may cause nasal flow during beverageswallowing (Fig. 5).The combined zygoma-implant-supported prosthesis

and nasal epithesis represents a new approach to re-habilitate wide complex midfacial defects. Nasal recon-struction, oroantral communication closure, labialcompetence correction and dental prosthetic rehabili-tation are not commonly corrected by a uniquesurgical intervention or by a unique prostheticrehabilitation. The prosthetic rehabilitation here

presented allows to achieve all the above-mentionedgoals by means of a single prosthesis.Intraoral implants offer good anchorage for palatal ob-

turator prosthesis, and extraoral implants’ use to supportfacial epithesis is well documented. Dawood describes anew implant design to support nasal epithesis and upperjaw prosthesis, but he reports just a single patient treat-ment [12]. Bowden reports zygoma implant placementhorizontally below orbital floors and nasal prosthesis an-chorage, but we managed with combined midfacial andpalatal defects [2].Prosthetic aftercare usually requires patient’s instruction

about bar and implants’ daily hygienic procedures and sili-cone nasal epithesis cleaning [13, 14]. Despite carefulhome care, silicone facial prosthesis lifespan is 1.5/2 yearson average because of discoloration, clip detachment fromacrylic to silicone or acrylic carrier detachment to silicone,bad fit or silicone laceration [13, 14]. Unfavourable eventsfor intraoral prosthesis are screw loosening and bar dis-location or screw fracture, obturator misfitting due to softtissue remodelling, implant failure and prosthetic teethfracture or excessive abrasion due to occlusal loss ofbalance [14].

Fig. 5 The intraoral bar crossing the palatal defect arising thenasal understructure

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Rethinking globally of the possible indications to theadoption of this technique and its advantages comparedto reconstructive microsurgery, the use of zygoma-implant-supported prosthesis may be suitable for pa-tients whose systemic conditions are poor. The durationof surgery and of the postoperative recovery would beremarkably shortened avoiding the complications relatedto the harvesting of a free flap. Closely related to this as-pect, the cost-benefit ratio is definitely more convenient.This technique proves itself to be more easily manage-able also in non-compliant patients or in patients withlimited prognosis or high risk of recurrence, allowingthe clinician a more effective inspection of the resectedsite during follow-up consults.

ConclusionsImplant-supported prosthesis is a valid method to re-store resected oral and head cancer patients and offers agood chance to social reintegration. The aesthetic resultand facial camouflage are more achievable by means ofdentures and epithesis than with several reconstructiveinterventions. Furthermore, due to the high risk of re-currences, it is sometime mandatory to keep the defect

inspectionable. Despite the average poor lifespan ofprosthetic materials and the accurate professional andhome care required by intraoral implants, prosthetic re-habilitation could be considered an effective and suitablemethod for rehabilitation of extensively resected headand neck cancer patients (Figs. 6 and 7).

ConsentWritten informed consent was obtained from the patientfor publication of this case report and any accompanyingimages. A copy of the written consent is available for re-view by the Editor-in-Chief of this journal.

Competing interestsFrancesca Ferrari, Pasquale Procacci, Lorenzo Trevisiol, Pier Francesco Nocini,Daniele De Santis and Antonio D’Agostino declare that they have nocompeting interests.

Authors’ contributionsFF was involved in revising the manuscript critically. PP was involved indrafting the manuscript. LT is another surgeon that belongs to surgeryequipment. PFN, head professor and surgeon, operated the patient. DDeSwas involved in the surgical phase and in intellectual contribution to publishthis manuscript. AD is another surgeon that belongs to the same surgeryequipment. All authors read and approved the final manuscript.

Fig. 6 Frontal view of the patient after superior overdenture andnasal prosthesis delivery

Fig. 7 The epithesis allows both prompt inspection of the resectionsite and makes daily care easier

Trevisiol et al. International Journal of Implant Dentistry (2016) 2:7 Page 5 of 6

Received: 22 July 2015 Accepted: 23 March 2016

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