a modified classification for the maxillectomy defect_brown

A MODIFIED CLASSIFICATION FOR THEMAXILLECTOMY DEFECT

James S. Brown, MD, FRCS, FDS, 1 Simon N. Rogers, FRCS, FDS, 1

Deborah N. McNally, BSc (Hons), 2 Mark Boyle, FRCS, FDS 1

1 Regional Centre for Maxillofacial Surgery, University Hospital Aintree, Longmoor Lane, Liverpool L7 4AL UK.E-mail: [email protected] University of Liverpool, Department of Clinical Psychology, Brownlow Hill, Liverpool L69 3GB

Accepted 13 April 1999

Abstract: Background. At present no widely accepted classi-fication exists for the maxillectomy defect suitable for surgeonsand prosthodontists. An acceptable classification that describesthe defect and indicates the likely functional and aesthetic out-come is needed.

Methods. The classification is made on the basis of the as-sessment of 45 consecutive maxillectomy patients derived pro-spectively from the database (September 1992) and retrospec-tively from 1989.

Results. The classification of the vertical component is asfollows: Class 1, maxillectomy without an oro-antral fistula; Class2, low maxillectomy (not including orbital floor or contents); Class3, high maxillectomy (involving orbital contents); and Class 4,radical maxillectomy (includes orbital exenteration); Classes 2 to4 are qualified by adding the letter a, b, or c. The horizontal orpalatal component is classified as follows: a, unilateral alveolarmaxillectomy; b, bilateral alveolar maxillectomy; and c, total al-veolar maxillary resection.

Conclusion. This practical classification attempts to relate thelikely aesthetic and functional outcomes of a maxillectomy to themethod of rehabilitation. © 2000 John Wiley & Sons, Inc. HeadNeck 22: 17–26, 2000.

Keywords: maxillectomy; classification; reconstruction; obtura-tion; rehabilitation

The term “maxillectomy” is widely used in headand neck surgery but often without qualification.This is one of the few defects created in the treat-ment of head and neck cancer that may result inboth facial disfigurement and compromised oralfunction. A limited maxillectomy involving theposterior alveolus unilaterally can be effectivelyobturated and may cause the patient little func-tional or cosmetic embarrassment. A maxillec-tomy associated with exenteration of the orbitwill result in a major cosmetic change for the pa-tient and potential difficulties with obturation. Ifthe posterior edge of the soft palate is included ina maxillectomy defect, the functional conse-quences become the main concern for the clinicianand the patient. In each of these defects the ef-fects on the patient and the approach to the re-construction and rehabilitation are widely differ-ent. The need exists for a classification of thisdefect that takes into account the aesthetic andfunctional outcome and indicates the most appro-priate form of management in terms of obturationor reconstruction.

Classification of the maxillectomy defect hasbeen attempted both from the surgeon’s view andthat of the prosthodontist.1–4 The group at The

Correspondence to: J. S. Brown

CCC 1043-3074/00/010017-10© 2000 John Wiley & Sons, Inc.

Maxillectomy Classification HEAD & NECK January 2000 17

Sloan Kettering Memorial Hospital1 have sug-gested what seems a simple classification but con-clude, “the surgeon should indicate whether themaxillectomy has been extended to include adja-cent structures.” Included as a low maxillectomyare cases in which the orbital floor and peri-orbitamay have been resected. This will imply consid-erably more risk to the appearance and functionof the eye than a resection that has left the orbitalfloor intact. MacGregor and MacGregor2 havesuggested a classification that depends on thevertical component of the defect, but neither ofthese address the issue more pertinent to theprosthodontist, of the bilateral defect involvingthe nasal septum or the contralateral dental-bearing part of the maxilla or antral wall.

Obturation has been the traditional method ofrehabilitation for the maxillectomy patient, but inrecent years the wide variety of reconstructive op-tions that are now available is challenging thetraditional view. The need to examine the maxil-lectomy defect to detect early recurrence has to beconsidered against the considerable functionaland aesthetic advantages of reconstructive sur-gery. The availability of endoscopic techniquesand computerized imaging systems can be used todetect recurrent disease in reconstructed cases,5,6

and there is no evidence that a patients’ survivalmay be compromised by filing the defect.1,6 Localflaps7 can be useful for small defects, and the tem-poralis flap8,9 with vascularized cranial bone canprovide sufficient bone for implants.10,11 Free tis-sue transfer techniques make it possible to closelarge alveolectomy defects and provide sufficientbone for an implant-retained prosthesis.6,12–17

Therefore, a need exists to classify the maxillec-tomy defect so that the results of obturation andreconstruction can be compared between unitsand across the world literature. This is especiallyimportant as functional and quality of life out-comes are becoming as important as cure rates inthe assessment of the outcome in head and neckcancer.

The classification suggested in this article isdesigned to predict both the functional and aes-thetic outcome likely to result from this surgeryand relate that to the method of obturation orreconstruction suitable for each maxillectomy de-fect.

METHODS

Forty-five Maxillectomy Cases. Of a total of 487patients entered onto the database for head andneck malignancy (mucosal and salivary gland) be-

tween September 1992–August 1997, 52 patientsunderwent resection of part of the maxilla. A pro-portion of this group (19 of 52) had small posteriormaxillectomies as part of wider oral cavity resec-tions for tumors arising in the buccal mucosa, softpalate, and retromolar region. The method of re-construction for this patient group (19 patients)did not relate to the extent of the maxillectomydefect, which was classified as Class 1 (Figure 1)in 16 patients, with only 3 patients’ resectionsresulting in a low oro-antral fistula (Class 2a).The method of reconstruction related to the man-dibular defect, and therefore these patients wereexcluded from the maxillectomy analysis. The re-maining 33 patients had tumors arising in thepalate, alveolus, and antrum requiring a maxil-lectomy, which was the main defect as far as re-habilitation was concerned (Table 1). In additionto this sample of 33 patients prospectively en-tered onto the database, it was possible to includea retrospective group of 12 patients from 1989,who had sufficient records for an accurate assess-ment of the size of the defect and the method ofrehabilitation.

Two pilot classifications, which included theextent of the soft palate resection and the locationof the palatal defect (anterior or posterior), weretested with this group of 45 patients before decid-ing on the suggested classification in this article.

Of the initial group of 45 maxillectomy pa-tients 30 were available to complete the Univer-sity of Washington (UoW) questionnaire.18 This isa 9-point questionnaire completed by the patientwithout assistance, which has global quality oflife measures and head and neck–specific ques-tions. Each of the questions is scored from 1–100,with a score of 100 indicating an optimum out-come. These scores can then be averaged for thegroup concerned and comparisons made. Thefunctional and quality of life outcomes for smallermaxillectomy defects (Class 1 and 2a) were com-pared with the larger defects (Class 2b plus).

RESULTS

Classification for the Maxillectomy Defect. Thesurgical defect is classified according to the verti-cal dimension of the maxillectomy (Class 1–4),which relates to the involvement of the orbit andskull base and the resultant mainly aesthetic de-formity (Figure 1). Class 2–4 is qualified by theaddition of a letter (a–c), which refers to the hori-zontal or palatal aspect of the maxillectomy, in-cluding the nasal septum, contralateral sinuses,and alveolus that have been excised. This hori-

18 Maxillectomy Classification HEAD & NECK January 2000

zontal or palatal component of the defect moreclosely relates to the likely functional and dentaloutcome for these patients.

Vertical Component.

Class 1 Maxillectomy with no oro-antral fistulaClass 2 Low maxillectomyClass 3 High maxillectomyClass 4 Radical maxillectomy

Horizontal Component.

a Unilateral alveolar maxilla and hard palate re-sected. Less than or equal to half the alveolarand hard palate resection not involving the na-sal septum or crossing the midline

b Bilateral alveolar maxilla and hard palate re-sected. Includes a smaller resection thatcrosses the midline of the alveolar bone includ-ing the nasal septum

c The removal of the entire alveolar maxilla andhard palate

Explanation of terms

Class 1 The removal of alveolar bone not resultingin an oro-nasal or oro-antral fistula. Resec-tions of the ethmoid and frontal sinus cavitydefects or removal of the lateral nasal wallwould fit into this part of the classification.Included in this group is the removal of onlypalatal bone, which will inevitably result in an

Table 1. Site of tumors.

Site No.

Junction of hard and soft palate 7Hard palate 5Tuberosity 4Alveolus 12Antrum 16Nasal 1Total 45Buccal* 7Retromolar* 9Soft palate* 3Total 19

*Excluded from the analysis.

FIGURE 1. Diagram demonstrating the modified classification in relation to obturation and choice ofreconstruction. Abbreviations: FF, free flap.


oro-nasal fistula but leaves the dental-bearingpart of the maxilla intact.

Class 2 The alveolus and antral walls but not in-cluding the orbital floor or rim.

Class 3 Including the floor of the orbit with orwithout peri-orbita and with or without skullbase resection.

Class 4 Plus orbital exenteration with or withoutanterior skull base resection.

For example, a radical maxillectomy (includ-ing orbital exenteration) that includes less thanhalf of the maxillary alveolus would be classifiedas a Class 4a.

In general the Class of the defect (1–4) indi-cates the likely aesthetic effect of the surgery andthe qualifying letter (a, b, or c) the increasing dif-ficulty of full oral and dental rehabilitation, whichindicates the functioning dental outcome. The re-lationship of this classification to the rehabilita-tion options is illustrated in Figure 1. A local orpedicle flap (eg, temporalis) functions well inClass 1 and Class 2a but becomes less reliable asthe horizontal component extends across the mid-line (Class 2b). Although an obturator is possiblefor any defect, its use becomes problematic inmore extensive palatal and dental defects (Classb, c) or resections that include the orbit (Class 4).Similarly soft tissue free tissue transfer will re-sult in less reliable dental rehabilitation in largerdefects, in which bone that can be implantedwould be an advantage. The lines in the figureindicate the usefulness of each choice of recon-struction as they relate to the defect.

This principle is confirmed in the analysis ofthe methods of reconstruction as they relate to

the classification of the surgical defect (Table 2).Important differences exist in the choice of reha-bilitation, depending on the class of the defect.Obturation has been used in 44% of the Class 2adefects but much less frequently as the size of thedefect increases. Although few cases were treatedwith obturation in the larger defects, the prob-lems of successful obturation will mount as thevertical and horizontal components of the resec-tion increase (Figure 2). Composite grafts wereinfrequently used for Class 1 and 2a cases (4 of24, 17%), compared with 15 of 21 cases (71%) ofClass 2b and above.

Of these 45 patients with tumors arising in themaxillary alveolus, palate, and antrum, only 3 pa-tients had the posterior part of the soft palateincluded in the resection. Two of these patientshad tumors arising in the tuberosity of the max-illa. The other patient had an extensive adenoidcystic carcinoma excised from the antrum and ex-tending into the soft palate tissues. In the tuber-osity cases little need exists to reconstruct themaxillary bone because the lesions are posterior,leaving sufficient anterior and contralateral max-illa to support a tissue-borne or implant-retaineddenture. All 3 patients had reconstruction with aradial forearm flap, which reflects the need to re-construct the soft palate.

The average totals from the UoW question-naire, comparing Class 1 and 2a defects (16 cases)with larger resections (Class 2b plus, 14 cases),are presented in Table 3. This table presents theindividual data for the average results in each ofthe UoW domains and the cumulative scores ineach group. The results indicate the usefulness ofthis form of classification, with the larger defects(Class 2b plus) having a significantly lower cumu-

Table 2. Tumors arising in the maxillary alveolus, tuberosity,palate, junction of hard and soft palate, or antrum (46 cases)

Classification

Method of rehabilitation

Obturate Radial CR DCIA Total

Class 1 1 7 — — 8Class 2a 7 5 2 2 16Class 2b 2 2 1 3 8Class 2c — 1 — — 1Class 3a — — 3 — 3Class 3b 1 — — 2 3Class 4a — — 1 4 5Class 4b — — — 1 1Totals 11 14 8 12 45

Abbreviations: CR, composite radial forearm flap; DCIA, vascularized iliaccrest graft with internal oblique muscle.

FIGURE 2. Maxillectomy defect in an edentulous case that iscrossing the midline but not involving the orbit and would beclassified as Class 2b.


lative score (p 4 .02). In addition, the lowerscores for activity and recreation in the largermaxillectomy defects were highly significant.

DISCUSSION

Class 1. The removal of maxillary bone withoutthe creation of an oro-nasal or antral fistula canonly be carried out on patients with a sufficientheight of alveolus. Simple methods of reconstruc-tion may be used, but obturation of the defect isgenerally not required. This form of defect mainlyoccurred in the tuberosity region of the maxillafor patients undergoing surgery for tumors aris-ing in the soft palate or the retromolar trigone.Also denoted as Class 1 are defects that occur inonly the palatal, nonalveolar bone of the maxilla,resulting in a central oro-nasal fistula. This defectcan be closed with soft tissue alone because thedental-bearing bone of the maxilla remains unre-sected. A central palatal defect can also be suc-cessfully obturated or closed with local or distantsoft tissue flaps. Free tissue transfer of soft tissueonly may be preferred for larger resections (Fig-ure 3). In this series of patients, all 8 of the Class1 defects were lesions arising in the junction ofthe hard and soft palate. The use of the radialforearm flap obliterates the oro-nasal fistula andmaintains optimum function of the soft palate.

Patients who undergo limited maxillectomies(eg, resection lateral nasal wall) not resulting inan oro-antral fistula can also be classified asClass 1. These defects generally do not requirereconstruction or obturation and have excellentfunctional and aesthetic outcomes.

Class 2. A Class 2 defect is a defect created atthe level of the maxillary sinuses and the nasalcavity. The main problem for the patient is theadequate provision of an upper dental appliance,either by obturation if no reconstruction isplanned or by adequate retention from anadapted upper denture or an implant-retainedappliance if the defect has been reconstructed. AClass 2a defect can usually be successfully obtu-rated in a dentate maxilla (Figure 4). Obturationcan also successfully rehabilitate an edentulouscase, but retention of the denture can be trouble-some. If a flap reconstruction is chosen to closethe defect, the height of the antrum does not re-quire reconstruction, allowing a wide choice of lo-cal, pedicle, and free flaps. Full-thickness cranialbone can be brought into the oral cavity and vas-cularized on the temporalis or galeo-pericranialflaps.5,8,9 Free scapula, fibula, and composite ra-dial forearm flaps provide sufficient height to re-place the bone in this situation. If an implant-retained prosthesis is planned, considerationmust be given to the quality of bone in the re-sidual maxilla and the choice of composite recon-struction. In this series of patients, a variety ofrehabilitation techniques have been used, indicat-ing the wide choice available to the clinician inthis class of defect (Table 2). In more extensivealveolar defects (b, c) or in edentulous cases, ob-turation will be more difficult to achieve (Figure2). In this situation the same methods of recon-struction as in Class 2a would be adequate to re-store form and function as long as sufficient bonewas made available for implants to be placed in a

Table 3. University of Washington questionnaire results comparing a standard maxillectomy defect (Class 1 and 2a) with largerdefects (Class 2b plus) treated by obturation or reconstruction (30 cases).

Classification Class 1 and 2a (16 cases) Class 2b plus (14 cases)

University of Washington Mean SD % BS Mean SD % BS

Pain 80 25 50 91 19 79Activity* 77 19 31 45 28 7Recreation† 88 13 50 57 23 0Employment 49 29 19 34 12 0Disfigurement 73 23 31 73 21 29Speech 83 15 44 71 24 21Chewing 63 22 25 50 28 14Swallowing 86 15 56 89 21 71Shoulder function 96 10 86 95 13 85Cumulative score‡ 695 90 0 604 111 0

Analyzed on SPSS for windows by analysis of variance (ANOVA).Abbreviations: Class 2b plus, all cases classified as greater than 2a; BS, % best score.*F = 13.47, df = 1, p = .001.†F = 20.75, df = 1, p = .0001.‡F = 6.09, df = 1, p = .02.


favorable position if full dental rehabilitation isplanned. If the defect involves the anterior max-illa (Figure 5), sufficient bone must be placed withany reconstructive technique to give support tothe nose and provide bone in the desired positionto retain implants for a denture.

Class 3. Class 3 is a high maxillectomy, whichcan include the orbital floor or part of the orbitaltissues, but the globe is not resected. Maxillecto-mies that include the skull base may fall into thiscategory, although these usually include an or-bital exenteration. It is more likely that patientswill have aesthetic problems associated with ahigh maxillectomy. Ectropion and enophthalmosmay occur, and in some cases the cheek is notadequately supported, resulting in a poor facialappearance. Obturation can be successful in thisgroup, but more problems occur with fitting aheavier appliance, and insertion may be difficultin the presence of trismus.

If reconstruction is the choice of treatment, at-tempts should be made to adequately support theorbital floor and cheek and provide bone for den-ture support. It is therefore more difficult to pro-

vide sufficient height and width of bone with ascapula or fibula flap.19 The vascularized iliaccrest with internal oblique provides a method ofclosing large fistulas and providing sufficientbone to support the orbit and cheek and an im-plant-retained prosthesis if required.6 The com-posite radial forearm flap can be used for this typeof defect, but the support of the cheek and theorbital contents may be less than ideal and pro-vide inadequate bone for intra-oral implants. InClass 3b and c defects, loss of nasal support mayoccur if the whole of the septum has been re-sected, as well as contralateral sinuses and alveo-lus. Successful obturation would probably requireto be implant retained, which could not beachieved for some months after the surgery.

Class 4. In Class 4 defects the main problem forthe patient is the aesthetic change to the face af-ter the loss of the orbit. Function is still impor-tant, but the restoration of a reasonable quality oflife depends more on the aesthetic than functionalresult. Obturation can be difficult to achieve suc-cessfully during and after the inevitable course ofradiotherapy in this patient group. The skin over

FIGURE 3. (A and B) Lesion at the junction of the hard and softpalate reconstructed with a radial forearm because half the softpalate was excised (Class 1).


the orbit may break down, causing considerabledistress for the patient and increased difficultiesfor the prosthodontist .

Reconstruction techniques need to close thefistula, ensure the healing of the eyelid skin, pro-vide adequate bone to support the cheek and al-low the wearing of a dental prosthesis, and seal-ing of the dura if a craniofacial resection has beennecessary. The advantage of the DCIA with inter-nal oblique is the extent of width and depth ofbone from the generous donor site and the reliableand extensive muscle flap large enough to seal thecranium, obturate the orbit, and close the oro-nasal fistula (Figure 6). The epithelialization ofthe muscle in the oral and nasal cavities preventsptosis of a skin flap and provides thin tissue,which facilitates the soft tissue preprosthetic sur-gery required in the placement of implants.

It is unusual for a Class 4 maxillectomy defectto be extended across the midline in the antral orpalatal region. In this series, the initial DCIA re-construction failed in 1 case of a Class 4b defect.Obturation was attempted but was unsatisfactoryfor the patient because the orbital skin was lostand the prosthesis poorly retained. The clinical

situation was considerably improved by the fash-ioning of a bilobed latissimus dorsi flap to closethe orbital and oral defects. Full dental rehabili-tation has not been achieved at the time of writ-ing

The acceptance of any form of classificationdepends on its usefulness, clarity, and simplicity.The method must be logical, easy to remember,and so reduce the chances of ambiguity that maycloud any attempt at the comparison of differentpatient groups. As in most head and neck surgery,after survival the patient’s concerns are func-tional and aesthetic. This classification is the firstattempt to combine both the likely functional andaesthetic outcomes and a relationship with reha-bilitation choices.

Attempts to accurately classify the maxillec-tomy defect would result in an unnecessarily com-plex classification. As well as the level and extentof maxillectomy suggested in this classification,the extent of soft palate resection, nasal resection,skull base involvement, anterior or posteriormaxillectomy, and the presence or absence ofteeth may be incorporated. As part of the inves-tigation and method in this study, each of thesefactors was considered, but the classification be-came extensive and was bound to be unworkable.In addition, various complex classifications weretested, with little improvement in informationthan that reported in this study.

The extent of soft palate resection is importantin terms of functional outcome,4 but in most casesof maxillectomy resection resulting in an oro-antral fistula, the posterior rim of the soft palateis retained, which would maintain reasonable ve-lopharyngeal competence and allow obturationwith a fair functional result. Most patients under-going soft palate resection, which included theposterior rim, had tumors arising in the retromo-lar region or the soft palate itself, resulting in aminimal posterior maxillectomy defect. This formof defect often may not result in a fistula into theantrum, and the oral and dental rehabilitation isoften straightforward. Posterior maxillectomy de-fects have little bearing on the aesthetic outcome,and the need for a reconstruction rather than ob-turation will depend on the extent of the soft pal-ate resection. It is acknowledged that the removalof the posterior rim of the soft palate is importantand should be noted by the surgeon, but its inclu-sion in the main part of this classification wouldhave made a more complex system with little gainin relevant information. By confining the classifi-cation to the maxillary sites (alveolus, palate, and

FIGURE 4. (A and B) Good aesthetic and functional outcome forobturation of a posterior unilateral maxillectomy defect (Class2a).


paranasal sinuses), the extent of the soft palateresection becomes less important. It is essential,therefore, to include the site of origin of the tumorin any attempt to compare functional and aes-thetic outcomes in this patient group.

The dental status of the patient may indicatemore successful obturation in the dentate groupwith improved retention of the prosthesis, butthis depends on the site, number and health of theteeth, and gums left in place. To include thesefactors would have made the classification toocomplex. In some studies the presence of teethmay be an important factor that would need to beincorporated as part of the dental record.

The nasal walls are often included as part ofthe standard hemimaxillectomy (Class 2a). Thelateral nasal wall is most commonly involved, butformal reconstruction of this structure is seldomcarried out. In a similar fashion, the ethmoid andfrontal sinuses do not require formal reconstruc-tion. The inclusion of the nasal walls, ethmoid,and frontal sinus cavity defects without entry intothe oral cavity have, therefore, been classified as

Class 1. This reflects the likely good functionaland aesthetic outcome with this form of minimalmaxillectomy.

The removal of the nasal septum is potentiallya cosmetic and functional problem for the patient,but this is seldom completely removed in a waythat would result in nasal collapse. There is onecase in this series of an anterior alveolar carci-noma, which required the removal of more thanhalf the maxilla bilaterally in the anterior region,with the whole of the nasal septum. This case wasclassified as a Class 2b lesion, although the prob-lems of nasal collapse will result in as much dis-figurement and functional disadvantage as aClass 3 maxillectomy.

The site of the alveolectomy or palatal resec-tion is important to the prosthodontist faced withthe problem of obturation. Bilateral anterior de-fects pose more problems than the classical uni-lateral posterior hemimaxillectomy defect (Figure4). An attempt was made to incorporate these fac-tors into the alveolectomy part of the classifica-tion by use of the scoring system, which also in-

FIGURE 5. (A) A squamous cell carcinoma requiring a bilateral maxillectomy, reconstructed with a vascularized iliac crest graft withinternal oblique. (B) Implants inserted into the grafted bone. (C) Epithelialized muscle that contracts onto the grafted bone and minimizesthe preparatory implant surgery.


cluded the soft palate resection. This again madethe classification complex and did not signifi-cantly alter the classified patient groups.

This classification is designed to predict thelikely aesthetic and functional outcome for the pa-tient and give some indication of the most suit-able form of reconstruction. In Class 2 cases 8 of13 (42%) of the defects reconstructed required acomposite free flap compared with 100% of casesin Classes 3 and 4. In the Class 2 defects thevascularized iliac crest graft with internal obliquewas used in 5 of 8 cases (63%) and in 7 of the 11

(64%) reconstructed cases in Classes 3 and 4. Theother composite grafts were all radial forearmflaps, which reflect the practice of the unit before1996, when this flap was used more commonly.Although a composite fibula or scapula flap pro-vides sufficient bone for Class 2 defects, adequatebone replacement is more difficult to achieve inClass 3 and 4 defects by use of these free flaps.The vascularized iliac crest graft with internaloblique easily provides sufficient height anddepth of bone for the replacement of the fullheight of the maxilla in Class 3 and 4 defects and

FIGURE 6. (A and B) Class 4a defect with a vascularized iliaccrest graft with internal oblique muscle in place before clo-sure. The muscle closes the oral defect and can be seen fillingthe orbital space. (C and D) Successful oral and facial reha-bilitation (full upper denture worn on epithelialized musclewithout implants).


can be adapted to reconstruct the alveolar part ofthe resection and the orbital floor.

The comparison of the quality of life outcomesbetween the Class 1 and 2a and Class 2b plus ina group of 30 patients was found to be significant(Table 3). In the Class 1 and 2a group, 8 patientswere reconstructed and 8 were obturated, and inthe Class 2b plus group 11 patients were recon-structed and only 3 were obturated. Althoughthese are small numbers no significant differ-ences were found between the method of rehabili-tation in each group. It is interesting that boththe activity and recreation questions scored sig-nificantly lower in the more extensive resections.This may reflect the need for more complex recon-structions or obturation in this group. In Class1and 2a, of those patients completing the UoWquestionnaire, only 2 of 6 (33%) reconstructed pa-tients required composite free flaps, comparedwith 9 out of 11 (82%) in the Class 2b plus group.As expected, speech and chewing scored lower av-erages for the larger defects, but the other headand neck–specific questions (disfigurement, swal-lowing, and shoulder function) showed similar re-sults. The similarity of the disfigurement scorebetween the smaller and larger defects was sur-prising, but only 2 patients required orbital exen-teration, and both wore full dentures and had im-plant-retained orbital prostheses. It is likely thatthe method of rehabilitation will require morecomplex treatments, likely to have a bearing onthe quality of life, as the ablative defect becomesmore extensive. Although this is a small compara-tive group, these results support this hypothesisand to some extent justify this suggested maxil-lectomy classification.

More surgeons are offering patient’s recon-struction and obturation in the management ofthe maxillectomy defect.1 At present, much con-troversy remains over the most suitable methodof reconstruction and whether obturation willprovide an adequate solution. It is hoped that thewide adoption of this classification will allow afair comparison of maxillectomy defects in thecontinuing debate over the best form of facial andoral rehabilitation for these patients.

Acknowledgments. The authors are grateful toMr David Vaughan, for allowing the use of datafrom his patients, and to Mr John Cawood and Mr

Robert Howell, who provide the oral rehabilita-tion service.

REFERENCES1. Spiro RH, Strong EW, Shah JP. Maxillectomy and its clas-

sification. Head Neck 1997;19:309–314.2. MacGregor IA, MacGregor. Cancer of the face and mouth.

Edinburgh: Churchill Livingstone; pp 552–553.3. Aramany MA. Basic principles of obturator design for par-

tially edentulous patients. Part I: classification. J Pros-thet Dent 1978;40:554–557.

4. Umino S, Masuda G, Ono S, Fujita K. Speech intelligibil-ity following maxillectomy with and without a prosthesis:an analysis of 54 cases. J Oral Rehab 1998;25:153–158.

5. Tideman H, Samman N, Cheung LK. Immediate recon-struction following maxillectomy: a new method. Int JOral Maxillofac Surg 1993;22:221–225.

6. Brown JS. Deep circumflex iliac artery free flap with in-ternal oblique as a new method of immediate reconstruc-tion of maxillectomy defect. Head Neck 1996;18:412–421.

7. Obwegeser HG. Late reconstruction of large maxillary de-fects after tumor-resection. J Maxillofac Surg 1973;1:19–29.

8. Bradley P, Brockbank J. The temporalis muscle flap inoral reconstruction. J Maxillofac Surg 1981;9:139–145.

9. Colmenero C, Martorell V, Colmenero B, Sierra I. Tempo-ralis myofascial flap for maxillofacial reconstruction. JOral Maxillofac Surg 1991;49:1067–1073.

10. Ewers R. Reconstruction of the maxilla with a doublemusculoperiosteal flap in connection with a composite cal-varial bone graft. Plast Reconstr Surg 1988;81:431–436.

11. Choung P, Nam I, Kim K. Vascularised cranial bonegrafts for mandibular and maxillary reconstruction. Theparietal osteofascial flap. J Craniomaxillofac Surg 1991;19:235–242.

12. Hatoko M, Harashina T, Inque T, Tanaka I, Imai K. Re-construction of palate with radial forearm flap; a report of3 cases. Br J Plast Surg 1990;43:350–354.

13. Granick MS, Ramasastry S, Newton ED, Solomon MP,Hanna DC, Kaltman S. Reconstruction of complex maxil-lectomy defects with the scapular-free flap. Head Neck1990;12:377–385.

14. Jortay A, Coessens B, Greant P, Bisschop P. Use of osteo-muscular free flaps after extended maxillectomy and cra-niofacial resection. About 2 cases. Acta Chir Belg 1994;94:236–239.

15. Serafin D, Riejkohl R, Thomas I, Georgiade NG. Vascu-larised rib-periosteal and osteocutaneous reconstructionof the maxilla and mandible: an assessment. Plast Recon-str Surg 1980;66:718–727.

16. Nakayama B, Matsuura H, Hasegawa Y, Ishihara O, Ha-segawa H, Torii S. New reconstruction for total maxillec-tomy defect with a fibula osteocutaneous free flap. Br JPlast Surg 1994;47:247–249.

17. Inque T, Harashina T, Asanami S, Fujino T. Reconstruc-tion of the hard palate using free iliac bone covered witha jejunal flap. Br J Plast Surg 1988;41:143–146.

18. Hassan SJ, Weymuller EA. Assessment of quality of life inhead and neck cancer patients. Head Neck 1993;15:485–496.

19. Frodel JL, Funk GF, Capper DT, et al. Osseointegratedimplants: a comparative study of bone thickness in fourvascularised flaps. Plast Reconstr Surg 1993;115:339–349.


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