Fully guided, flapless zygomatic implants for oncological rehabilitation-a technical note

Midface defects following head and neck cancer surgery present significant functional and aesthetic challenges. While free-tissue transfer is a favoured reconstructive approach, it may be contraindicated in the medically comorbid and failure may be catastrophic, resulting in significant morbidity. In such cases, zygomatic implant-retained prosthetic obturators provide an effective alternative. However, traditional zygomatic implant placement often requires the elevation of large full-thickness mucoperiosteal flaps, risking osteoradionecrosis in irradiated bone following postoperative radiotherapy. This technical note describes a novel method for fully guided, flapless zygomatic implant placement that was applied in a 74-year-old with a Brown Class IId maxillary defect following hemi-maxillectomy of a pT4aN0M0 right maxillary squamous cell carcinoma. Using virtual surgical planning, two zygomatic implants were placed utilizing 3D-printed tissue-borne drill guides based on the patient's obturator. These guides were designed with low tolerance flutes to minimize angular deviation and utilized hard and soft tissue undercuts to ensure stability. By using a flapless technique, trauma to the irradiated tissues was minimized, whilst achieving accurate zygomatic implant placement. This case highlights the importance of a multidisciplinary approach between the surgical, prosthetic, and engineering teams. Further studies are needed to validate the accuracy and predictability of this innovative approach.