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Reconstruction of Maxilla
by
Dr.Anjum Iqbal
Trainee Medical Officer
Oral & Maxillofacial Surgery
Khyber College of Dentist...
Layout
 Anatomy of Maxilla
 Goals of Maxillary Reconstruction
 Classification of Maxillectomy Defects
 Planning and ev...
Anatomy of Maxilla
Goals of Maxillary Reconstruction
1. Obtain a healed wound.
2. Restore palatal competence and function.
3. Restore normal ...
Classification Of Maxillectomy
Defects
Classification
(Santamaria & Cordeiro or MSKCC)
 Type I (Limited maxillectomy)
– One or two walls, preservation of
palate...
Classification
(Santamaria & Cordeiro or MSKCC)
 Type III (Total maxillectomy)
– Resection of all six walls
– Orbital pre...
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
 Stereolith...
Reconstruction Options
Reconstruction Options
 PROSTHETIC OBTURATION
 AUTOGENOUS FLAPS
– Pedicled flaps
 Local
 Regional
– Vascularized free ...
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...
Obturators
 Disadvantages
– Hypernasal speech
– Regurgitation of food and fluids into nasal cavity
– Difficulty maintaini...
Staging of Obturators
 Surgical Obturator
– Placed at surgery
– Restores palatal contour
– Retains surgical pack
– Reduce...
Staging of Obturators
 Interim Obturator
– Used until healing completed
– Addresses both functional and aesthetic needs
...
Obturators
Surgical Reconstruction
Local Flaps
Surgical Reconstruction
Local Flaps
 Buccal Fat Pad Flap
 Palatal Island Flap
 Nasolabial Flap
 Tongue Flap
 Uvula Fl...
Surgical Reconstruction
Local Flaps
 Buccal Fat Pad Flap
– Rich vascular supply
– Commonly used for defects of
posterior ...
Surgical Reconstruction
Local Flaps
 Palatal Island Flap
– versatile and reliable local
flap
– greater palatine artery
– ...
Surgical Reconstruction
Local Flaps
 Nasolabial Flap
– closure of oroantral fistulae and
defects of anterior floor of mou...
Surgical Reconstruction
Local Flaps
 Tongue Flap
– closure of residual cleft and fistulae
of hard palate
– lingual artery...
Surgical Reconstruction
Regional Flaps
Surgical Reconstruction
Regional Flaps
 Submental Flap
 Temoproparietal-galea Flap
 Temporalis Flap
 Platysma Flap
 M...
Surgical Reconstruction
Regional Flaps
 Submental Flap
– fasciocutaneous or faciosubcutaneous
– submental branch of facia...
Surgical Reconstruction
Regional Flaps
 Temporoparietal-galea Flap
– Temporoparietal fascia and
subcutaneous
musculoapone...
Surgical Reconstruction
Regional Flaps
 Temporalis Flap
– fan shaped
– deep temporal arteries and middle
temporal artery
...
Surgical Reconstruction
Regional Flaps
 Temporalis Flap
– outer table of temporal bone can be taken
– ease, proximity,hid...
Surgical Reconstruction
Regional Flaps
 Platysma Flap
– Myocutaneous
– submental and facial
arteries
– thin, pliable and ...
Surgical Reconstruction
Regional Flaps
 Masseter Flap
– masseteric artery
– useful for reconstruction of palatal defects
...
Surgical Reconstruction
Regional Flaps
 Sternocleidomastoid Flap
– myocutaneous or myo-osseus
– occipital, superior thyro...
Surgical Reconstruction
Regional Flaps
 Trapezius Flap
– Myocutaneous
– may be used as composite flap with a portion of
c...
Surgical Reconstruction
Microvascular Free
Flaps
Surgical Reconstruction
Microvascular Free Flaps
 Radial Forearm Free Flap
 Radial Forearm Osteo-fascio-cutaneous Flap
...
Surgical Reconstruction
Microvascular Free Flaps
 Radial Forearm Free Flap
– faciocutaneous or
osteofasciocutaneous
– rad...
Surgical Reconstruction
Microvascular Free Flaps
 Rectus Adominus Flap
– Large skin surface
– Large volume of soft tissue...
Surgical Reconstruction
Microvascular Free Flaps
 Fibula Osteo-cutaneous Flap
– peroneal artery and vein
– provides great...
Surgical Reconstruction
Microvascular Free Flaps
 Scapular Osteo-myocutaneous Flap
– circumflex scapular artery
– pedicle...
Surgical Reconstruction
Microvascular Free Flaps
 Vascularized Iliac Crest
– most successful
– deep circumflex iliac arte...
Surgical Reconstruction
Avascularized Bone
Grafts
Surgical Reconstruction
Avascularized Bone Grafts
 Requirements Of Ideal Bone Grafts
– Stability
– Potential for graft in...
Surgical Reconstruction
Avascularized Bone Grafts
 Commonly used bone grafts
– Calvarial bone graft
– Iliac crest bone gr...
Surgical Reconstruction
Titanium Mesh
Surgical reconstruction
Titanium Mesh
 Alternative in patients where bone
grafts are not available or disallowed
 Can al...
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
conse...
Defect Specific Reconstruction
 Inferior Maxillectomy (Brown
Class 2,MSKCC Type II)
– Obturators
– Temporalis flap with o...
Defect Specific Reconstruction
 Bilateral Inferior Maxillectomy
– only orbital supporting bone and zygomatic arch
remain
...
Defect Specific Reconstruction
 Total Maxillectomy with Orbital
Preservation (Brown class 3,
MSKCC Type IIIa)
– reconstru...
Defect Specific Reconstruction
 Total Maxillectomy with Orbital
Exenteration (Brown Class 4,
MSKCC Type IIIb)
– Prosthesi...
Defect Specific Reconstruction
 Orbitomaxillctomy (MSKCC
Type IV)
– simpler to reconstruct
– no horizontal bone must be
r...
THANK YOU
Reconstruction of maxilla
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Reconstruction of maxilla

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Brief outline of the various maxillary defects and their reconstruction options.

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Reconstruction of maxilla

  1. 1. Reconstruction of Maxilla by Dr.Anjum Iqbal Trainee Medical Officer Oral & Maxillofacial Surgery Khyber College of Dentistry.
  2. 2. Layout  Anatomy of Maxilla  Goals of Maxillary Reconstruction  Classification of Maxillectomy Defects  Planning and evaluation for reconstruction  Reconstruction options  Defect Specific Reconstruction
  3. 3. Anatomy of Maxilla
  4. 4. 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.
  5. 5. Classification Of Maxillectomy Defects
  6. 6. 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
  7. 7. Classification (Santamaria & Cordeiro or MSKCC)  Type III (Total maxillectomy) – Resection of all six walls – Orbital preservation (IIIa) – Exenteration of orbital contents (IIIb)
  8. 8. Classification (Santamaria & Cordeiro or MSKCC)  Type IV (Orbitomaxillectomy) – Upper 5 walls, preservation of palate
  9. 9. Classification (Brown)
  10. 10. Planning For Reconstruction
  11. 11. Planning For Reconstruction  Clinical assessment  Plain Radiograph – OPG – PNS View  CT scan  3-D CT scan  Stereolithographic Models
  12. 12. Reconstruction Options
  13. 13. Reconstruction Options  PROSTHETIC OBTURATION  AUTOGENOUS FLAPS – Pedicled flaps  Local  Regional – Vascularized free flaps – Non vascularized autogenous bone grafts – Combination procedure
  14. 14. Reconstruction Options  ALLOGENIC GRAFTS  ALLOPLASTIC MATERIALS – Titanium mesh – Dental implant
  15. 15. Prosthetic Obturation
  16. 16. Obturators  Advantages – Shortens operative time – Shortens post op hospital stay – Better visualization for surveillance – Helps in speech and swallowing – Restores aesthetics
  17. 17. Obturators  Disadvantages – Hypernasal speech – Regurgitation of food and fluids into nasal cavity – Difficulty maintaining hygiene – Need for repeated adjustments
  18. 18. 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)
  19. 19. 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
  20. 20. Obturators
  21. 21. Surgical Reconstruction Local Flaps
  22. 22. Surgical Reconstruction Local Flaps  Buccal Fat Pad Flap  Palatal Island Flap  Nasolabial Flap  Tongue Flap  Uvula Flap
  23. 23. 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
  24. 24. 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)
  25. 25. 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)
  26. 26. 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)
  27. 27. Surgical Reconstruction Regional Flaps
  28. 28. Surgical Reconstruction Regional Flaps  Submental Flap  Temoproparietal-galea Flap  Temporalis Flap  Platysma Flap  Masseter Flap  Sternocleidomastoid Mastoid  Trapezius Flap
  29. 29. 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
  30. 30. 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
  31. 31. 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)
  32. 32. 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
  33. 33. Surgical Reconstruction Regional Flaps  Platysma Flap – Myocutaneous – submental and facial arteries – thin, pliable and easily harvested – less reliability (By Dr.Muslim Khan)
  34. 34. Surgical Reconstruction Regional Flaps  Masseter Flap – masseteric artery – useful for reconstruction of palatal defects – limited volume, trismus
  35. 35. 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
  36. 36. 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
  37. 37. Surgical Reconstruction Microvascular Free Flaps
  38. 38. 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
  39. 39. 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)
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. Surgical Reconstruction Avascularized Bone Grafts
  45. 45. 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
  46. 46. Surgical Reconstruction Avascularized Bone Grafts  Commonly used bone grafts – Calvarial bone graft – Iliac crest bone graft – Rib graft – Fibula bone graft – Scapula bone graft
  47. 47. Surgical Reconstruction Titanium Mesh
  48. 48. 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
  49. 49. Surgical reconstruction Titanium Mesh (By Dr.Atta-ur-Rehman)
  50. 50. Defect Specific Reconstruction
  51. 51. 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
  52. 52. 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
  53. 53. Defect Specific Reconstruction  Bilateral Inferior Maxillectomy – only orbital supporting bone and zygomatic arch remain – Scapular osteocutaneous free flap and osseointegrated implants(min 4) – Prosthesis
  54. 54. 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
  55. 55. 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
  56. 56. Defect Specific Reconstruction  Orbitomaxillctomy (MSKCC Type IV) – simpler to reconstruct – no horizontal bone must be reconstructed – myocutaneous rectus abdominus suitable to fill the defect
  57. 57. THANK YOU

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