Reconstruction of Maxilla

by Dr.Anjum Iqbal Trainee Medical Officer Oral & Maxillofacial Surgery Khyber College of Dentistry.

Layout

Anatomy of Maxilla Goals of Maxillary Reconstruction Classification of Maxillectomy Defects Planning and evaluation for reconstruction Reconstruction options Defect Specific Reconstruction

Anatomy of Maxilla

Goals of Maxillary Reconstruction

1. 2. 3. 4. 5.

6.
7.

Obtain a healed wound. Restore palatal competence and function. Restore normal mastication and deglutition. Support the eye. Maintain a patent nasal airway. Support and suspend facial soft tissues. Restore the midfacial contour.

Classification Of Maxillectomy Defects

Classification (Santamaria & Cordeiro or MSKCC)

Type I (Limited maxillectomy)

One or two walls, preservation of palate

Type II (Subtotal maxillectomy)

Lower 5 walls, preservation of orbital floor

Classification (Santamaria & Cordeiro or MSKCC)

Type III (Total maxillectomy)

Resection of all six walls Orbital preservation (IIIa) Exenteration of orbital contents (IIIb)

Classification (Santamaria & Cordeiro or MSKCC)

Type IV (Orbitomaxillectomy)

Upper 5 walls, preservation of palate

Classification (Brown)

Planning For Reconstruction

Planning For Reconstruction

Clinical assessment Plain Radiograph

OPG PNS View

CT scan 3-D CT scan Stereolithographic Models

Reconstruction Options

Reconstruction Options

PROSTHETIC OBTURATION AUTOGENOUS FLAPS

Pedicled flaps

Local Regional

Vascularized free flaps Non vascularized autogenous bone grafts Combination procedure

Reconstruction Options

ALLOGENIC GRAFTS

ALLOPLASTIC MATERIALS

Titanium mesh Dental implant

Prosthetic Obturation

Obturators

Advantages

Shortens operative time Shortens post op hospital stay Better visualization for surveillance Helps in speech and swallowing Restores aesthetics

Obturators

Disadvantages

Hypernasal speech Regurgitation of food and fluids into nasal cavity Difficulty maintaining hygiene Need for repeated adjustments

Staging of Obturators

Surgical Obturator

Placed at surgery Restores palatal contour Retains surgical pack Reduces wound contamination Removed in 10-14 days
(By Dr.Muslim Khan)

Staging of Obturators

Interim Obturator

Used until healing completed Addresses both functional and aesthetic needs

Definitive Obturator

Final prosthesis 6-12 months after surgery Problems corrected

Obturators

Surgical Reconstruction

Local Flaps

Surgical Reconstruction Local Flaps

Buccal Fat Pad Flap Palatal Island Flap Nasolabial Flap Tongue Flap Uvula Flap

Surgical Reconstruction Local Flaps

Buccal Fat Pad Flap

Rich vascular supply Commonly used for defects of posterior maxilla and soft palate Adequate for defects up to 4cm Epithelialized in about 2-3 weeks

Surgical Reconstruction Local Flaps

Palatal Island Flap

versatile and reliable local flap greater palatine artery can be rotated 180 degree on pedicle can cover up to 15cm defects
(By Dr.Muslim Khan)

Surgical Reconstruction Local Flaps

Nasolabial Flap

closure of oroantral fistulae and defects of anterior floor of mouth facial and angular arteries up to 5cm width flap limited donor tissue, facial scarring and second surgery

(By Dr.Muslim Khan)

Surgical Reconstruction Local Flaps

Tongue Flap

closure of residual cleft and fistulae of hard palate lingual artery donor site morbidity, limited arc of rotation, and small size
(By Dr.Muslim Khan)

Surgical Reconstruction

Regional Flaps

Surgical Reconstruction Regional Flaps

Submental Flap Temoproparietal-galea Flap Temporalis Flap Platysma Flap Masseter Flap Sternocleidomastoid Mastoid Trapezius Flap

Surgical Reconstruction Regional Flaps

Submental Flap

fasciocutaneous or faciosubcutaneous submental branch of facial artery provides 7-15cm tissue reconstruction of anterior defects hidden donor site scar

Surgical Reconstruction Regional Flaps

Temporoparietal-galea Flap

Temporoparietal fascia and subcutaneous musculoaponeurotic system(SMAS) superficial temporal artery used for less bulky reconstruction such as coverage of plates and bone thin, lack of hair, well camouflaged donor site

Surgical Reconstruction Regional Flaps

Temporalis Flap

fan shaped deep temporal arteries and middle temporal artery direct access through defect (high maxillectomies) access via infratemporal fossa(low maxillectomies)

(By Johan Fagan)

Surgical Reconstruction Regional Flaps

Temporalis Flap

outer table of temporal bone can be taken ease, proximity,hidden incision,reliable blood supply potential facial nerve injury and temporal hollowing

Surgical Reconstruction Regional Flaps

Platysma Flap

Myocutaneous submental and facial arteries thin, pliable and easily harvested less reliability

(By Dr.Muslim Khan)

Surgical Reconstruction Regional Flaps

Masseter Flap

masseteric artery useful for reconstruction of palatal defects limited volume, trismus

Surgical Reconstruction Regional Flaps

Sternocleidomastoid Flap

myocutaneous or myo-osseus occipital, superior thyroid and supra scapular arteries proximity to defect site, lack of requirement for another incision

Surgical Reconstruction Regional Flaps

Trapezius Flap

Myocutaneous may be used as composite flap with a portion of clavicle or scapula transverse cervical artery, occipital, posterior intercostal and dorsal scapular arteries adequate volume of well vascularized tissue

Surgical Reconstruction

Microvascular Free Flaps

Surgical Reconstruction Microvascular Free Flaps

Radial Forearm Free Flap Radial Forearm Osteo-fascio-cutaneous Flap Rectus Abdominus Flap Fibula Osteo-cutaneous Flap Scapular Osteo-myocutaneous Flap Vascularized Iliac Crest

Surgical Reconstruction Microvascular Free Flaps

Radial Forearm Free Flap

faciocutaneous or osteofasciocutaneous radial artery up to 16cm of vascularized bone segment long pedicle and reliable good size vessels fracture of remaining radius

( by Brian Dickson M.D)

Surgical Reconstruction Microvascular Free Flaps

Rectus Adominus Flap

Large skin surface Large volume of soft tissue Can be divided into 2-3 flaps Upto 18-20cm pedicle length Best for type 3 and 4 defects

Surgical Reconstruction Microvascular Free Flaps

Fibula Osteo-cutaneous Flap

peroneal artery and vein provides greatest length of available bone usual pedicle length about 6-7cm provides sufficient bone for implant placement

Surgical Reconstruction Microvascular Free Flaps

Scapular Osteo-myocutaneous Flap

circumflex scapular artery pedicle length up to 20cm average thickness of bone about 3cm sufficient for implant placement inferior quality bone can be oriented vertically as well as horizontally

Surgical Reconstruction Microvascular Free Flaps

Vascularized Iliac Crest

most successful deep circumflex iliac artery(DCIA) accompanying internal oblique muscle provides excellent soft tissue less donor site morbidity

Surgical Reconstruction

Avascularized Bone Grafts

Surgical Reconstruction Avascularized Bone Grafts

Requirements Of Ideal Bone Grafts

Stability Potential for graft integration Available in large quantities Moldable No such ideal graft is available

Surgical Reconstruction Avascularized Bone Grafts

Commonly used bone grafts

Calvarial bone graft Iliac crest bone graft Rib graft Fibula bone graft Scapula bone graft

Surgical Reconstruction

Titanium Mesh

Surgical reconstruction Titanium Mesh

Alternative in patients where bone grafts are not available or disallowed Can also be used in combination with bone grafts or hydroxyapatite cement Biocompatible Readily available No donor site morbidity

Surgical reconstruction Titanium Mesh

(By Dr.Atta-ur-Rehman)

Defect Specific Reconstruction

Defect Specific Reconstruction

Palate and Alveolar Arch Defects (Brown class1)

greater functional than aesthetic consequence may be allowed to heal by secondary intention palatal island flap best suited

Defect Specific Reconstruction

Inferior Maxillectomy (Brown Class 2,MSKCC Type II)

Obturators Temporalis flap with or without calvarial bone Fasciocutaneous Radial Forearm Flap Osteocutaneous Radial Forearm Flap Fibula Osteocutaneous Flap Scapula Osteocutaneous Flap Vasculariced iliac crest

Defect Specific Reconstruction

Bilateral Inferior Maxillectomy

only orbital supporting bone and zygomatic arch remain Scapular osteocutaneous free flap and osseointegrated implants(min 4) Prosthesis

Defect Specific Reconstruction

Total Maxillectomy with Orbital Preservation (Brown class 3, MSKCC Type IIIa)

reconstructive challenge Obturator Temporalis muscle flap Vascularized Osteocutaneous free flaps are best followed by implants and prosthesis

Defect Specific Reconstruction

Total Maxillectomy with Orbital Exenteration (Brown Class 4, MSKCC Type IIIb)

Prosthesis prosthesis with myocutaneous flap e.g. rectus abdominus iliac crest myo-osseous flap Scapular osteocutaneous free flap dental implants

Defect Specific Reconstruction

Orbitomaxillctomy (MSKCC Type IV)

simpler to reconstruct no horizontal bone must be reconstructed myocutaneous rectus abdominus suitable to fill the defect

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