Maxilletomy recocstruction by Dr.Athar khan

FOLLOWING MAXILLECTOMY FOR AN ODONTOGENIC TUMOUR OPTIONS OF RECONSTRUCTION

By Dr.M.Athar khan

PGR OMFS NID,Multan.

PROBLEMS AFTER MAXILLECTOMY

Airway problem

Oronasal communication

Facial disfigurement

Masticatory & feeding problem

Deviation of the mandible

CLASSIFICATION OF DEFECTS AFTER MAXILLECTOMY

A. SURGICAL

COMPONENT(VERTICAL)

B. DENTAL

COMPONENT(HORIZONTAL)

A. SURGICAL COMPONENT(VERTICAL)

CLASS 1

Minimal loss of alveolar bone without

an oroantral fistula

Loss of hard palate only with no breach

of oral cavity or lose of the alveolus.

CLASS 2

It includes the alveolus and

antral walls, but not extending to

the orbital rim and adnexae

CLASS 3

Similar to class 2 but including

the orbital floor or medial wall.

CLASS 4

maxillectomy with orbital

exenteration

B. DENTAL COMPONENT (HORIZONTAL)

CLASS a

less than or equal to half the dental

alveolus.

CLASS b

more than half the dental alveolus or

crossing the mid line.

CLASS c

the entire maxillary alveolus

RECONSTRUCTION OF CLASS 1 (A TO C)

Can be simply treated with obturator or a

soft

tissue flap

Can even be left without obturation to be

healed

by secondary intention

ADVANTAGES

Simple & quick procedure

Donor site is not required

Immediate facial & dental restoration

Inspection of the cavity & check for

recurrence

is available

DISADVANTAGES

Difficult obturator fit & high risk of failure in

class 3 and 4.

Oro nasal reflux can be a problem

Reconstruction remains an option in the

longer

term

Pedicled

Flaps

o Temporalis Flap

o Buccal fat pad

o

Temporoparietal

Fascia Flap

RECONSTRUCTION OF CLASS 2A

o Submental

island flap

o Uvula flap

oTongue flap

oMasseter flap

oNasolabial flap

FREE TISSUE TRANSFER

Composite Fibula Flap

Radial Forearm Flap

TEMPORALIS FLAP

Originates along the lateral skull at the

temporal

line and inserts on the coronoid process of

the

mandible.

It is a powerful elevator of the mandible

Blood supply is from anterior deep temporal

and the

posterior deep temporal arteries.

ADVANTAGES

Ease of Elevation

Reliable blood supply

Proximity to the maxillofacial structures

Camouflage of the incision with in the

hair line

DISADVANTAGES

Sensory Disturbances

Potential facial nerve Injury

Temporal Hollowing

Limited arc of rotation

BUCCAL FAT PAD

First reported to be used in 1977 for closure of

oroantral or oronasal

communication

In 1983 Neder used fat pad as a free graft in the oral

cavity

Buccal fat pad epithelializes within two to three

weeks when used as a

Pedicled flap.

Blood supply is from buccal and deep temporal

branches of maxillary

artery.

ADVANTAGES

Can be used in conjunction with free bone

grafting

Provides increased soft tissue bulk over

reconstruction bars.

Donor site complications are rare.

NASOLABIAL FLAP

Blood supply is from perforators of the facial and

angular arteries

The superiorly based flap is used for the closure of

oroantral

fistula

Limited donor tissue, facial scaring and limited arc

of rotation are

the main disadvantages

`flap is extremely difficult to use in dentate patients

UVULA FLAP

In patients who have a long redundant uvula and have undergone a

resection of

the posterior hard palate or part of the soft palate, the uvula provides an

easily

harvested source of muscle & mucosa

Blood supply is from random perforators from local palatal vessels

Can be used to provide mucosa for the oral and nasal surface of the hard

palate

Flap is not available in total palatal resections

Its dimensions are inadequate for larger defects

TONGUE FLAP

May be based anteriorly, dorsally, posteriorly, or

bipedicled dorsally

Dorsally based flap is used for closure of hard palate

Blood supply is from lingual artery

The mobility of the pedicles caused by normal tongue

movement can

cause the flap to pull away from the defects

Alteration of the natural tongue contour & bulk at the

tip can alter

speech

MASSETER FLAPHas been used for many years in the reanimation of

paralyzed face

Langdon modifies the procedure by resecting the

anterior portion of

the vertical ramus & coronoid process to allow

transfer of the flap to

defects of the palate

Blood supply is from the masseteric artery, a branch of

the transverse

facial artery

Major disadvantage is the potential for trismus and

limited volume of tissue

TEMPOROPARIETAL FASCIA

Provides a rapidly re-epetheliazed coverage

in oral cavity

Can be elevated, grafted with skin or

cartilage, or both

Flap receives its blood supply from the

superficial

temporal artery

ADVANTAGES

Robust Blood Supply

Ease of Elevation

Lack of hair

Well camouflaged donor site

Vascular anatomy is constant & reliable

Surface of the fascia readily accepts grafts

DISADVANTAGES

Numbness of the donor site

Alopecia

Lack of skin paddle for flap

monitoring.

SUBMENTAL ISLAND FLAP

Blood supply is from the submental artery, a branch

of facial artery.

Appropriate for cases in which no prior neck surgery

has obliterated

the vascular pedicles

Provides abundant regional tissue with a reliable

blood supply

Flap may be used without skin as a fascio-

subcutaneous flap for the

augmentation of contour defects

Also used for reconstruction of most anterior oral

cavity defects

ADVANTAGES

Excellent color match

Excellent aesthetics

Transfer of tissues with like

thickness & texture

Reliable vascular anatomy

The only disadvantage is the

incisional scar.

FREE TISSUE TRANSFER

1. COMPOSITE FIBULA FLAP

only long & straight bone that is not indispensable

The common peroneal nerve runs around the fibular head

damage to the nerve & the knee joint can be prevented by leaving

approximately 8cm of proximal fibular end in the leg

Also distally 8cm are left in order to maintain the ankle joint fork

A fibula 40cm long can provide 26cm for the transplantation,this makes

the fibular graft the longest transplantable bone segmant in human

beings

Blood supply to the fibula is from peroneal artery

ADVANTAGES

Constant anatomical topography

Long bone & high stability

Minor donor site morbidity

Disadvantage is the short vascular pedicle

When used for the reconstruction of

maxilla , one must

use a vessel interponate because of

shortness of vascular pedicle.

RADIAL FOREARM FLAP

This flap is based on ascending & descending radicles from the

radial artery

Different variants like fascial flaps, double paddle fasciocutaneous

flaps, and

osteocutaneous flaps can be harvested

Maxillectomy defects are adequately reconstructed with a radial

forearm

fasciocutaneous flap

In osteocutaneous flap up to 16cm of bone may be harvested

ADVANTAGES

Thin, elastic, pliable skin paddle

Hairless

Drapes conveniently over the complex

shapes within the

oral cavity

Flap has relatively minimal bulk hence

provides little

resistance to tongue movements

DISADVANTAGES

Exposure of tendons at donor site

Poor aesthetics

Radius fracture

RECONSTRUCTION OF CLASS 2(B-C)

AIMS OF RECONSTRUCTION:

When the class 2 defect crosses the midline or involves

the entire dental alveolus, a composite flap is essential

to:

Restore the loss of bone including the anterior alveolus

Support the alar region & nasal columella

Provide adequate bony basis for implants

RECONSTRUCTION

Flaps for reconstruction depend on amount of bone

lost in the in

anterior maxilla and nasal septum

If loss of bone includes only the dental alveolus, then

a fibula flap is

the ideal choice

If, however, loss of bone includes a significant part of

nasal piriform ,

nasal septum and extending towards the nasal bone

(>2cm), then iliac

crest with internal oblique is the ideal flap.

ILIAC CREST This flap is based on the deep circumflex

iliac

artery(DCIA) & deep circumflex iliac vein

DCIA is a branch of the external iliac artery.

DCIA sends

some perforators into the bone & the muscle

attached to it

The skin component of the iliac crest

derives some of its

blood supply from these perforators

USE OF FLAP IN MAXILLECTOMY

Using the internal oblique muscle flap based

on the

ascending branch of DCIA, a well

vascularized piece of

soft tissue can be obtained on the same

pedicle as the iliac

crest

Reconstruction of the orbital floor & rim

may be achieved

using the inner table of iliac crest & the

attached soft tissue.

ADVANTAGES

Offers o large, curved piece of mainly cancellous bone,6 to 16cm

in length

Composite flap carries a significant soft tissue bulk, can be

useful in filling extensive resection defects

Skin paddle is reliable & may be as large as 16 x 20cm or

greater

Iliac crest is mainly cancellous bone, hence provides primary

bone union

size & depth of bone allows it to accommodate osteointegrated

dental implant

Cosmetically acceptable, as the scar is hidden in groin crease

Contour irregularity can be overcome by taking only the inner

cortex

DISADVANTAGES

Skin necrosis

Hernia

Hypertrophic scar

Local pain & pain on ambulation

Gait disturbances

Femoral neuropathy

Contour deformities.

RECONSTRUCTION OF CLASS 3(A-C)

AIMS

To close the oroantral fistula

Restore the functioning dental alveolus

Support for facial skin

Support the orbit & eyelids

Iliac crest with internal oblique is the ideal option to

meet these goals.

ILIAC CREST WITH INTERNAL OBLIQUE

It provides sufficient bone for the implant retained

dental prosthesis

Provides a platform for the reconstruction of the

orbital floor with titanium mesh

The muscle will close the oral defect & provide an

epethelialized lining for the lateral nose

Facial vessels overlying the body of mandible are

used for anastomosis

THE SCAPULA

Blood supply is from subscapular artery, a branch of the axillary artery

This flap is easy to elevate & the donor site defect is only moderate

For complex three dimensional reconstruction, two skin paddles can

be moved independently of each other

Angle of the scapula based on the angular artery & incorporating a

portion of latissimus dorsi , is used for orbital floor & maxillectomy

reconstruction

DISADVANTAGES

Does not provide adequate thickness

of bone to

retain dental implants

Skin paddles may be too bulky for

intra oral use

RECONSTRUCTION OF CLASS 4A

When the orbital contents have been exenterated, problems of diplopia,

enophthalmos, and ectropion are obviated by removal of the eye.

Provision of the prosthetic eye can mask some of the deformity

Again, iliac crest with internal oblique is the first choice in class 4A

reconstruction

The best compromised reconstruction is a large soft tissue flap such as the

rectus abdominis to obturate whole of the defect from roof of the orbit to

the

dental alveolus.

RECTUS ABDOMINIS

It is a strap like muscle, that spans the length of

the anterior

abdominal wall

Enclosed in rectal sheath, originates from the

cartilages of fifth,

sixth, and seventh ribs and front of the xiphoid

process

Lower tendinous attachment to the body and

symphysis of pubis

Blood supply is from superior & inferior

epigastric artery

USE OF FLAP IN MAXILLECTOMY

Used for larger defects

Ease of dissection of the vascular pedicle

Disadvantages are lack of uniform thickness

and

more tedious dissection in obese persons

No chance of dental rehabilitation

RECONSTRUCTION OF CLASS 4(B-C)

When the defect crosses the midline or involves

the nasal bone, iliac crest with internal oblique is

the only choice that can provide sufficient bone

to support the facial and nasal bone as well as

providing a choice for dental rehabilitation.

THANK YOU