Reconstruction Of Maxilla

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. 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.

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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