This document summarizes reconstruction of the maxilla following maxillectomy. It describes the anatomy and goals of maxillary reconstruction. Maxillectomy defects are classified and reconstruction options are outlined, including prosthetic obturators, local and regional pedicled flaps, microvascular free flaps, bone grafts, and titanium mesh. Defect-specific reconstruction approaches are provided for different types of maxillectomy defects, such as palate defects, inferior maxillectomies, total maxillectomies with and without orbital exenteration, and orbitomaxillectomies.

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

4. Anatomy of Maxilla

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.

6. Classification Of Maxillectomy
Defects

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

10. Classification
(Brown)

11. Planning For Reconstruction

12. Planning For Reconstruction
 Clinical assessment
 Plain Radiograph
– OPG
– PNS View
 CT scan
 3-D CT scan
 Stereolithographic
Models

13. Reconstruction Options

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

16. Prosthetic Obturation

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

22. Surgical Reconstruction
Local Flaps

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)

28. Surgical Reconstruction
Regional Flaps

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

38. Surgical Reconstruction
Microvascular Free
Flaps

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

45. Surgical Reconstruction
Avascularized Bone
Grafts

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

48. Surgical Reconstruction
Titanium Mesh

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)

51. Defect Specific
Reconstruction

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

58. THANK YOU