Reconstruction of maxilla
- 2. Reconstruction of Maxilla by Dr.Anjum Iqbal Trainee Medical Officer Oral & Maxillofacial Surgery Khyber College of Dentistry.
- 3. Layout Anatomy of Maxilla Goals of Maxillary Reconstruction Classification of Maxillectomy Defects Planning and evaluation for reconstruction Reconstruction options Defect Specific Reconstruction
- 5. 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.
- 7. 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
- 8. Classification (Santamaria & Cordeiro or MSKCC) Type III (Total maxillectomy) – Resection of all six walls – Orbital preservation (IIIa) – Exenteration of orbital contents (IIIb)
- 9. Classification (Santamaria & Cordeiro or MSKCC) Type IV (Orbitomaxillectomy) – Upper 5 walls, preservation of palate
- 12. Planning For Reconstruction Clinical assessment Plain Radiograph – OPG – PNS View CT scan 3-D CT scan Stereolithographic Models
- 14. Reconstruction Options PROSTHETIC OBTURATION AUTOGENOUS FLAPS – Pedicled flaps Local Regional – Vascularized free flaps – Non vascularized autogenous bone grafts – Combination procedure
- 15. Reconstruction Options ALLOGENIC GRAFTS ALLOPLASTIC MATERIALS – Titanium mesh – Dental implant
- 17. Obturators Advantages – Shortens operative time – Shortens post op hospital stay – Better visualization for surveillance – Helps in speech and swallowing – Restores aesthetics
- 18. Obturators Disadvantages – Hypernasal speech – Regurgitation of food and fluids into nasal cavity – Difficulty maintaining hygiene – Need for repeated adjustments
- 19. 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)
- 20. 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
- 21. Obturators
- 23. Surgical Reconstruction Local Flaps Buccal Fat Pad Flap Palatal Island Flap Nasolabial Flap Tongue Flap Uvula Flap
- 24. 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
- 25. 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)
- 26. 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)
- 27. 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)
- 29. Surgical Reconstruction Regional Flaps Submental Flap Temoproparietal-galea Flap Temporalis Flap Platysma Flap Masseter Flap Sternocleidomastoid Mastoid Trapezius Flap
- 30. 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
- 31. 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
- 32. 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)
- 33. 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
- 34. Surgical Reconstruction Regional Flaps Platysma Flap – Myocutaneous – submental and facial arteries – thin, pliable and easily harvested – less reliability (By Dr.Muslim Khan)
- 35. Surgical Reconstruction Regional Flaps Masseter Flap – masseteric artery – useful for reconstruction of palatal defects – limited volume, trismus
- 36. 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
- 37. 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
- 39. 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
- 40. 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)
- 41. 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
- 42. 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
- 43. 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
- 44. 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
- 46. 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
- 47. Surgical Reconstruction Avascularized Bone Grafts Commonly used bone grafts – Calvarial bone graft – Iliac crest bone graft – Rib graft – Fibula bone graft – Scapula bone graft
- 49. 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
- 50. Surgical reconstruction Titanium Mesh (By Dr.Atta-ur-Rehman)
- 52. 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
- 53. 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
- 54. Defect Specific Reconstruction Bilateral Inferior Maxillectomy – only orbital supporting bone and zygomatic arch remain – Scapular osteocutaneous free flap and osseointegrated implants(min 4) – Prosthesis
- 55. 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
- 56. 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
- 57. 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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