Challenges in maxillary reconstruction: beyond the free flap

The reconstruction of extensive maxillary defects represents a complex challenge, heavily impacting mastication, speech and facial projection. Although free tissue transfer (FTT) is considered the gold standard, revascularisation failure or systemic contraindications can preclude this approach. This case report documents the management of a 23-year-old patient presenting with severe maxillary bone loss following a paediatric hemimaxillectomy for fibrous dysplasia. Following the consecutive failure of two free fibula flaps, haematological analysis revealed an elevation of IgG anti-cardiolipin antibodies, suggesting an underlying haemostatic disorder limiting autologous graft options.

The objective of this study is to demonstrate the viability of a customised titanium subperiosteal implant (IPS Implants® Preprosthetic system, KLS Martin) as a therapeutic alternative. The hypothesis tested here is that a digital CAD/CAM (Computer-Aided Design and Computer-Aided Manufacturing) design can provide stable structural support and reliable dental rehabilitation, even after the failure of multiple conventional reconstructive procedures. This case evaluates the integration of a custom-made implant in a single surgical step to restore bone architecture and enable functional prosthetic rehabilitation.

Clinical case methodology

This report details the management of a 23-year-old man presenting with massive maxillary bone loss secondary to infantile fibrous dysplasia. After the failure of two free fibula flaps and a radial flap, the surgeons identified a complex biological profile marked by elevated IgG anticardiolipin antibodies, suggesting a coagulation disorder.

The clinical team implements a customised reconstruction protocol via the IPS Implants® Preprosthetic (KLS Martin) system. The methodology is structured around three key phases:

• Digital design: Practitioners use virtual surgical planning (VSP) and computer-aided design/computer-aided manufacturing (CAD/CAM) to model a custom-made titanium subperiosteal implant.
• Surgical procedure: The procedure is performed in a single stage via an upper gingivobuccal incision. After exposure of the zygomas and the nasomaxillary region, the surgeons position the implant using a specific drill guide.
• Stabilisation and prosthesis: The team stabilises the titanium structure with 6 mm and 7 mm screws. The design includes support abutments passing through the mucosa for prosthetic rehabilitation.

Postoperative follow-up extends from January to October 2025, including clinical adjustments for soft tissue management and the final placement of a screw-retained prosthesis with a titanium framework and zirconia superstructure.

Outcomes of surgical management

The preoperative assessment of a 23-year-old patient, marked by repeated failures of free flap reconstruction (two fibula flap failures and one radial flap), led to a thorough aetiological analysis. Laboratory tests revealed an elevation of anti-cardiolipin IgG antibodies, directing the diagnosis towards a blood dyscrasia. This clinical condition justified the abandonment of soft and bone tissue transfer techniques in favour of a customised subperiosteal implant solution.

Digital planning (Virtual Surgical Planning) enabled the design of an IPS Implants® Preprosthetic implant tailored to the residual anatomy of the facial skeleton. The surgical procedure involved an approach via an upper gingivobuccal incision, exposing the zygomatic buttresses and the nasomaxillary region. The use of a specific drill guide enabled the preparation of the fixation sites in perfect accordance with the digital design.

Protocol component	Study data
Patient age	23 years
History of reconstruction	2 free fibula flaps (failures)
Implant material	Titanium (IPS system)
Mechanical fixation	6 mm and 7 mm screws
Prosthetic abutments	5 planned anchor points

The implantation was successfully performed in a single surgical stage. Primary stability was achieved through the placement of 6 mm and 7 mm fixation screws. Palatal closure was performed using Vicryl sutures, and caps were placed on the 5 abutments without technical difficulty. The patient was discharged on the first postoperative day (D1), marking an initial recovery phase without immediate surgical incident.

A robust alternative for extreme reconstruction cases

This clinical case report highlights a technological turning point in the management of major maxillary defects. For this 23-year-old patient, the successive failure of two free fibula flaps revealed a significant biological challenge: an underlying blood dyscrasia (elevated anti-cardiolipin IgG). When vascular microsurgery reaches its limits due to systemic reasons, the customised subperiosteal implant (PSI) offers a mechanically stable salvage solution without relying on complex bone revascularisation.

The clinical interest here lies in "backward" planning. Unlike traditional bone grafts where the prosthesis adapts to the bone volume obtained, the IPS Implants® system allows the titanium infrastructure to be designed according to the final prosthetic objective. The single-stage procedure allowed the implant to be anchored to the zygomatic and nasomaxillary buttresses, providing immediate structural support where conventional methods had failed over seven years.

However, the practitioner must remain vigilant: soft tissue management remains the critical point. Despite the precision of the CAD/CAM milled titanium, this case reports the occurrence of a post-operative oro-nasal fistula and the need for revision surgeries for abutment exposure. These complications highlight that while the PSI resolves the issue of skeletal support, the mucosal seal and the quality of abutment coverage remain the main challenges of this approach.

Study summary

This clinical case illustrates the success of a custom titanium subperiosteal implant (IPS Implants®) in a 23-year-old patient presenting with major maxillary loss following the failure of two free fibula flaps. Despite a retrospectively discovered thrombophilia (IgG anticardiolipin antibodies), this CAD/CAM approach enabled a functional fixed prosthetic rehabilitation in a single surgical phase.

In practical terms, for the practitioner:

• Alternative to free flaps: The custom-made subperiosteal implant constitutes a reliable salvage solution for patients with failed microsurgical reconstructions or vascular contraindications.
• Systematic haematological assessment: In cases of unexplained flap necrosis, suspect occult thrombophilia; laboratory screening can prevent extensive procedures doomed to failure.
• Workflow optimisation: Virtual surgical planning (VSP) provides structural support and prosthetic abutments in a single step, significantly shortening the rehabilitation time compared to conventional bone grafting.

The reconstruction of major maxillary defects, whether tumoural or traumatic in origin, remains one of the most complex challenges in oral and maxillofacial surgery. Although free tissue transfer (FTT) is currently the gold standard, flap failures and specific contraindications require the consideration of alternatives. This case study describes the management of a 23-year-old patient presenting with severe maxillary bone loss following the treatment of infantile fibrous dysplasia by hemimaxillectomy.

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