About maxillofacial reconstruction
The maxillary bone (upper jaw) is important for both aesthetics and oral cavity function. Maxillary reconstruction is considered "state of the art reconstruction" due to its complexity to restore form and function. Patients with a maxillary tumour typically require surgery, which results in an upper jaw defect. The defect of the maxilla, apart from affecting the functions of speech, swallowing, and mastication, also causes cosmetic disfigurement. Traditionally, these defects were prosthetically rehabilitated with an obturator, but, in the last two decades, several publications have demonstrated the advantages of surgically reconstructing these defects.
The impact of Squamous Cell Carcinoma on a young man's life
In 2019, a young man was diagnosed with squamous cell carcinoma, a malignant tumour over his right hard palate. He underwent a subtotal maxillectomy (surgical removal of parts of the upper jaw) and bilateral neck dissection, followed by radiation therapy. He has been in remission for more than two years. The surgery left him with a defect on his right midface region, which affected his appearance, speech, and mastication. An obturator made for him failed to improve his speech and masticatory function due to poor retention and a lack of tissue support. As a result, he has been avoiding socialising with other people due to low self-esteem. The first surgery really had a detrimental impact on his quality of life.
Navigating the challenges of secondary maxillary reconstruction
In 2022, he was referred to Dr. Adzwin, an oral and maxillofacial surgeon at Hospital Kuala Lumpur, Malaysia, a tertiary and national referral center. Dr. Adzwin’s clinical expertise focuses on functional reconstruction of oral and maxillofacial defects post-ablative surgery. Looking at the case, it poses a major challenge for secondary reconstruction. He had lost bony and soft tissue support in his right cheek area, plus the area had been radiated.
Ideally, a fibula or iliac free flap could address his problem. However, because of previous surgery on the neck, it raised concerns about the quality and length of the recipient vessels for microsurgery. Dr. Adzwin came up with the idea of the ZIP Flap (Zygomatic Implant Perforated Flap), a new technique that simplifies maxillary reconstruction. He proposed to incorporate titanium mesh on the anterior wall of the maxilla, place two zygomatic implants on the zygoma for dental prostheses, and close the oral and nasal communications using a radial forearm free flap. The radial forearm has a longer pedicle than the fibula or the iliac free flap. The flap is also thin and pliable, perfect for oral mucosa reconstruction.
Because there was a limited amount of zygomatic bone left, Dr. Adzwin was concerned about placing two zygomatic implants and titanium mesh without collision between the implants and the mesh screws. The case was brought into discussion with Meticuly’s team. With a group of experts in virtual surgical planning, the team had no doubt that it can be done. Within ten days, Meticuly supplied Dr. Adzwin’s customized implant system, which comprises Mid-Face mesh and a surgical stent for accurate placement of the zygomatic implants.
In June 2022, Dr. Adzwin and his team performed the first-ever ZIP Flap (Zygomatic Implant Perforated) in Malaysia. The 8-hour surgery was a success.
Six months have passed since the surgery. Healing was uneventful. The implants have fully osseointegrated, with an Ostell ISQ of 70, indicating good stability. He is now scheduled for dental rehabilitation.
Comments