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by Dr.Anjum Iqbal Trainee Medical Officer Oral & Maxillofacial Surgery Khyber College of Dentistry.
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Anatomy of Maxilla Goals of Maxillary Reconstruction Classification of Maxillectomy Defects Planning and evaluation for reconstruction Reconstruction options Defect Specific Reconstruction
Anatomy of Maxilla
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.
Resection of all six walls Orbital preservation (IIIa) Exenteration of orbital contents (IIIb)
Type IV (Orbitomaxillectomy)
Classification (Brown)
Reconstruction Options
Reconstruction Options
Pedicled flaps
Local Regional
Vascularized free flaps Non vascularized autogenous bone grafts Combination procedure
Reconstruction Options
ALLOGENIC GRAFTS
ALLOPLASTIC MATERIALS
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
Obturators
Surgical Reconstruction
Local Flaps
Buccal Fat Pad Flap Palatal Island Flap Nasolabial Flap Tongue Flap Uvula 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
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)
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
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
Submental Flap Temoproparietal-galea Flap Temporalis Flap Platysma Flap Masseter Flap Sternocleidomastoid Mastoid Trapezius Flap
Submental Flap
fasciocutaneous or faciosubcutaneous submental branch of facial artery provides 7-15cm tissue reconstruction of anterior defects hidden donor site scar
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
Temporalis Flap
fan shaped deep temporal arteries and middle temporal artery direct access through defect (high maxillectomies) access via infratemporal fossa(low maxillectomies)
Temporalis Flap
outer table of temporal bone can be taken ease, proximity,hidden incision,reliable blood supply potential facial nerve injury and temporal hollowing
Platysma Flap
Myocutaneous submental and facial arteries thin, pliable and easily harvested less reliability
Masseter Flap
masseteric artery useful for reconstruction of palatal defects limited volume, trismus
Sternocleidomastoid Flap
myocutaneous or myo-osseus occipital, superior thyroid and supra scapular arteries proximity to defect site, lack of requirement for another incision
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
Radial Forearm Free Flap Radial Forearm Osteo-fascio-cutaneous Flap Rectus Abdominus Flap Fibula Osteo-cutaneous Flap Scapular Osteo-myocutaneous Flap Vascularized Iliac Crest
faciocutaneous or osteofasciocutaneous radial artery up to 16cm of vascularized bone segment long pedicle and reliable good size vessels fracture of remaining radius
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
peroneal artery and vein provides greatest length of available bone usual pedicle length about 6-7cm provides sufficient bone for implant placement
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
most successful deep circumflex iliac artery(DCIA) accompanying internal oblique muscle provides excellent soft tissue less donor site morbidity
Surgical Reconstruction
Calvarial bone graft Iliac crest bone graft Rib graft Fibula bone graft Scapula bone graft
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
(By Dr.Atta-ur-Rehman)
greater functional than aesthetic consequence may be allowed to heal by secondary intention palatal island flap best suited
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
only orbital supporting bone and zygomatic arch remain Scapular osteocutaneous free flap and osseointegrated implants(min 4) Prosthesis
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
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
simpler to reconstruct no horizontal bone must be reconstructed myocutaneous rectus abdominus suitable to fill the defect
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