reconstruction of maxilla
DESCRIPTION
A Brief presentation on the reconstruction options for Maxillary defects.TRANSCRIPT
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Reconstruction of Maxilla
by
Dr.Anjum Iqbal
Trainee Medical Officer
Oral & Maxillofacial Surgery
Khyber College of Dentistry.
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Layout
Anatomy of Maxilla Goals of Maxillary Reconstruction Classification of Maxillectomy Defects Planning and evaluation for reconstruction Reconstruction options Defect Specific Reconstruction
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Anatomy of Maxilla
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Goals of Maxillary Reconstruction
1. Obtain a healed wound.
2. Restore palatal competence and function.
3. Restore normal mastication and deglutition.
4. Support the eye.
5. Maintain a patent nasal airway.
6. Support and suspend facial soft tissues.
7. Restore the midfacial contour.
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Classification Of Maxillectomy Defects
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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
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Classification (Santamaria & Cordeiro or MSKCC)
Type III (Total maxillectomy)– Resection of all six walls – Orbital preservation (IIIa) – Exenteration of orbital
contents (IIIb)
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Classification (Santamaria & Cordeiro or MSKCC)
Type IV (Orbitomaxillectomy)– Upper 5 walls, preservation of
palate
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Classification (Brown)
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Planning For Reconstruction
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Planning For Reconstruction
Clinical assessment Plain Radiograph
– OPG– PNS View
CT scan 3-D CT scan Stereolithographic
Models
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Reconstruction Options
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Reconstruction Options
PROSTHETIC OBTURATION AUTOGENOUS FLAPS
– Pedicled flaps Local Regional
– Vascularized free flaps– Non vascularized autogenous bone grafts– Combination procedure
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Reconstruction Options
ALLOGENIC GRAFTS
ALLOPLASTIC MATERIALS– Titanium mesh– Dental implant
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Prosthetic Obturation
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Obturators
Advantages– Shortens operative time– Shortens post op hospital stay– Better visualization for surveillance– Helps in speech and swallowing– Restores aesthetics
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Obturators
Disadvantages– Hypernasal speech– Regurgitation of food and fluids into nasal cavity– Difficulty maintaining hygiene– Need for repeated adjustments
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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)
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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
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Obturators
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Surgical Reconstruction
Local Flaps
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Surgical Reconstruction Local Flaps
Buccal Fat Pad Flap Palatal Island Flap Nasolabial Flap Tongue Flap Uvula Flap
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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
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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)
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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)
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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)
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Surgical Reconstruction
Regional Flaps
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Surgical Reconstruction Regional Flaps
Submental Flap Temoproparietal-galea Flap Temporalis Flap Platysma Flap Masseter Flap Sternocleidomastoid Mastoid Trapezius Flap
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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
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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
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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)
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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
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Surgical Reconstruction Regional Flaps
Platysma Flap– Myocutaneous– submental and facial
arteries– thin, pliable and easily
harvested– less reliability (By Dr.Muslim Khan)
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Surgical Reconstruction Regional Flaps
Masseter Flap– masseteric artery– useful for reconstruction of palatal defects– limited volume, trismus
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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
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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
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Surgical Reconstruction
Microvascular Free Flaps
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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
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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)
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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
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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
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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
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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
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Surgical Reconstruction
Avascularized Bone Grafts
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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
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Surgical Reconstruction Avascularized Bone Grafts
Commonly used bone grafts– Calvarial bone graft– Iliac crest bone graft– Rib graft– Fibula bone graft– Scapula bone graft
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Surgical Reconstruction
Titanium Mesh
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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
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Surgical reconstruction Titanium Mesh
(By Dr.Atta-ur-Rehman)
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Defect Specific Reconstruction
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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
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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
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Defect Specific Reconstruction
Bilateral Inferior Maxillectomy– only orbital supporting bone and zygomatic arch
remain– Scapular osteocutaneous free flap and
osseointegrated implants(min 4)– Prosthesis
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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
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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
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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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