This paper describes a novel transoral surgical approach for resecting tumors involving the posterolateral maxilla and infratemporal region. The approach involves a curvilinear incision in the maxillary buccal sulcus, followed by a temporalis myotomy and coronoidectomy. This provides direct visualization of the posterolateral maxilla and infratemporal region, allowing resection of maxillary tumors extending into the posterior sinus wall and pterygoid plates via a transoral route. Previous approaches required transcutaneous incisions that resulted in significant morbidity. The novel transoral approach enables controlled tumor resection while avoiding complications of other techniques.

1. GOOD AFTERNOON
JOURNAL CLUB
Novel Transoral Approach to the
Posterolateral Maxilla and Infratemporal
Region
Dr. RAHUL TIWARI
POST GRADUATE STUDENT
DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY
SIBAR INSTITUTE OF DENTAL SCIENCES

2. JOURNAL, ARTICLE & AUTHOR
PII: S0278-2391(16)31174-0
DOI: 10.1016/j.joms.2016.11.007
Reference: YJOMS 57540
To appear in: Journal of Oral and
Maxillofacial Surgery
Received Date: 14 August 2016
Revised Date: 2 November 2016
Accepted Date: 8 November 2016
David K. Lam
Oral & Maxillofacial Surgery, University
of Toronto, 124 Edward Street, Room
143, Toronto, Ontario,
Canada M5G 1G6
Telephone: 416-979-4922 Ext 4329
Facsimile: (416) 979-4936
Email: david.lam@utoronto.ca

3. INTRODUCTION
Surgical resection of maxillary tumors - posterior sinus wall &
pterygoid plate.
Upper cheek flap via modified Weber-Ferguson incision with
subciliary extension.
Posterolateral maxilla and pterygoid plates remains poor.
Author - Transoral approach using a curvilinear incision -
temporalis myotomy & coronoidectomy - posterolateral maxilla
and infratemporal region.
Easily accessible through the open mouth.

4. The ITF approaches are categorized as:
Anterior
1. Transfacial
2. Transmaxillary
3. Transoral
4. Transpalatal
Lateral
1. Transzygomatic
2. Lateral infratemporal
Inferior
1. Transmandibular
2. Transcervical

6. Transmandibular approach The lower cheek flap

7. CASE REPORT
58-year-old woman - 2.5 x 2.0 x 2.5 cm solid multicystic ameloblastoma -
Rt. posterior maxilla, sinus & pterygoid plates.
Ipsilateral curvilinear incision - temporalis myotomy & coronoidectomy
Visualizes ipsilateral pterygoid palates and hamulus.
Partial right maxillectomy - wide local excision - supraperiosteal
dissection of tumor - with a 1 cm margin of normal tissue including the
pterygoid plates.
An obturator was placed to reconstruct the defect.
The patient is doing well with no evidence of recurrence at 2 years follow-
up.

8. OPG

9. CT SCAN – axial & coronal

10. CT SCAN – Sag.
Sagittal computed tomography
views of a well-defined 2.5 x
2.0 x 2.5 cm lesion in the right
posterolateral maxilla with
extension into the maxillary
sinus and pterygoid plates.
Red arrows indicate tumor
extent.

11. SURGICAL TECHNIQUE
Curvilinear incision made in the
maxillary buccal sulcus starting
at the midline, carried posteriorly
to the base of the
zygomaticomaxillary buttress,
and extended inferiorly along the
buccal surface of the ipsilateral
mandibular ramus.

12. SURGICAL TECHNIQUE
A temporalis myotomy and
coronoidectomy is then performed

13. SURGICAL TECHNIQUE
For direct visualization of the
posterolateral maxilla
and infratemporal region.

14. SURGICAL TECHNIQUE
The posterolateral maxilla and
pterygoid muscles are readily
visible following temporalis
myotomy and
coronoidectomy to allow
transoral removal of an
ameloblastoma involving the
right maxillary sinus and
pterygoid plates.

15. SPECIMEN - Appearance of surgical specimen including pterygoid plates.

16. SURGICAL SITE
View of surgical site following
partial right maxillectomy including
removal of involved pterygoid
plates.
1= osteotomy lines,
2= zygoma,
3= lateral pterygoid muscle,
4= medial pterygoid muscle,
5= masseter muscle;
M= medial,
L= lateral,
A= anterior,
P= posterior

17. DISCUSSION
Transcutaneous incisions such as a modified Weber-Ferguson
incision with subciliary extension or a lower cheek flap
Other approaches - coronoidectomy - retromaxillary-infracranial or
parapharyngeal spaces.
These approaches and methods are often associated with significant
morbidity.
The modified Weber- Ferguson incision, running from the oral
commissure to the anterior aspect of the zygomatic arch, often
provides suboptimal posterolateral maxilla exposure since it is
limited by the presence of the infra-orbital nerve.

18. DISCUSSION
The subciliary incision may also result in esthetic and
functional compromise due to ectropion of the lower eyelid.
Lower cheek flap incision - injury to the mental nerve branches
- ipsilateral sensory disturbance.
The midline or paramedian lower lip cutaneous incision may
also result in poor cosmesis due to the visible scar - marginal
mandibular nerve injury - lower lip asymmetry and oral
incompetence.
The addition of a paramedian mandibulotomy with the lower
cheek flap improve access - result in trismus, malunion, non-
union and/or malocclusion.

19. DISCUSSION
Another surgical approach involves utilizing a Le Fort 1
approach and down fracturing the maxilla to provide access
to the posterior maxilla - challenging for tumors that may
extend posterolaterally.
Restablishing the occlusion, application of rigid fixation,
changes to nasal base and the increased bleeding risk from
descending palatine vessels.

20. DISCUSSION
Transoral approach using a curvilinear incision, temporalis
myotomy and coronoidectomy enables controlled resection of
tumors that involve the posterolateral maxilla and
infratemporal region.
Most tumors are easily accessible using this transoral
approach even when the tumor is large and involves the
posterior sinus and pterygoid plates.

21. SUMMARY
Surgical access to tumors involving the posterolateral maxilla and infratemporal
region remains a considerable challenge for surgeons.
Various surgical approaches for treating posterior maxillary lesions require
transcutaneous incisions, such as an upper or a lower cheek flap, but they often
result in significant morbidity.
This paper describes a novel transoral approach involving a curvilinear incision,
temporalis myotomy and coronoidectomy to allow direct visualization of the
posterolateral maxilla and infratemporal region.
This surgical technique may be used for the surgical resection of maxillary tumors
that extend into the posterior maxillary sinus wall and pterygoid plate region via a
transoral approach.

22. REFERENCES
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maxillary ameloblastoma. J Can Dent Assoc 61:1048, 1995

23. THANK YOU