reconstruction of oral and maxillofacial region after neoplastic disease and truma or any defect affect tissue and bone

2. Reconstruction
 Reconstructive maxillofacial surgery
refers to the wide range of procedures
designed to rebuild or enhance soft or
hard tissue structures of the
maxillofacial region
 Maxillofacial reconstruction is of prime
importance in the management of
orofacial defects caused by disorders
such as neoplastic disease

3. indicated in patients with oral squamous
cellcarcinoma (SCC), also employed
in cases ofbenign tumours, trauma,
osteoradionecrosis, infection, chronic
non-union of bone, clefts, congenital
deformitieas

4. Early wound closure and the restoration
ofform, cosmetics and function are
the goals of reconstructive surgery.

5. Rehabilitation
Maxillofacial rehabilitation is the second
important step in the management of
patients with orofacial defects, as it
restores the function of the region

6. Functional Considerations
Oral sphincter
Speech, mastication and
deglutition
Provides a watertight closure
for bolus
preparation
Prevents escape of saliva

7. Functional Considerations
Alveolar Ridges
Covered with thin, adherent mucosa
Elevated above floor of mouth
Lingual and buccal sulci direct the flow
of food
and saliva during bolus processing

8. Functional Considerations
Floor of the mouth
Allows unrestricted mobility of the oral
tongue
Collects food and saliva (bolus
preparation)

9. Functional Considerations
Oral (mobile) tongue
Speech and deglutition
Mobility allows for:
Articulation of speech
Bolus manipulation in preparation for
deglutition
Sensory functions: proprioception,
pain, taste
Assists in mastication and bolus
processing

10. Functional Considerations
Hard palate
Opposes tongue
Important for speech and bolus
preparation

11. Functional Considerations
Buccal Mucosa
Lines the cheek
Functions in mastication and deglutition
Allows expansion for mastication
Thin to avoid restriction of dental closure

12. Functional Considerations
Base of tongue
Often involved with oral cavity defects
Participates in taste, deglutition and
speech
Must occlude oropharynx during
deglutition
Some consonants require BOT to touch
hard
palate

13. Patient Factors
Individualize options
Type of tissue
Anticipated functional gain
Anticipated donor morbidity
Need for innervation
Success rate
Intraoperative positioning
Operative time
Dental restoration
Overall medical status

14. Patient Factors
Preoperative counseling
Complete medical history
Diabetes, atherosclerosis, previous
radiation
Cardiopulmonary status (operating time,
aspiration risk)
Smoking history
Patient expectations and motivation are
very important

16. flaps
Flaps are segments of tissue that
retain some form of blood supply, which
allows it to beliving tissue, when
transferred
Grafts do not have an intact blood
supply or drainage, i.e., skin grafts and
bone grafts, and have to re-establish a
blood supply and drainage from the
recipient bed.

17. flaps
Soft tissue flaps can be classified
according to the method of
movement (i.e., local or distant);
according to blood supply, such as
axial or random pattern; according to
the composition
of the flap, such as cutaneous,
myocutaneous, osteomyocutaneous, or
fasciocutaneous.

18. flaps
Axial flaps receive their blood supply
from asingle nutrient vessel while
random pattern flaps receive capillary
blood supply in a random pattern from
all directions and notfrom a single
nutrient vessel The The
buccal advancement flap is a good
example of random flap

19. Local flaps
those that are derived from the
immediate area of resection and
common examples ofthese include
the buccal pad of fat flap, naso-labial
flap, facial artery musculo-mucosal
(FAMM) flap
These types of flaps are advanced,
transposed or rotated into position

20. Local flap
buccal pad of fat flap
One of the most common and most
versatile flaps used for reconstruction of
small to medium defects in mouth
blood supply derived from the buccal
and deep temporal branches of the
maxillary from vessels from the
transverse facial artery

21. It has been used reliably to reconstruct
soft and hard palatal, retro-molar fossa,
buccal mucosa ,and oro-pharyngeal
defects

25. Facial artery musculo-
mucosal flap
flap based on the facial artery utilizing
buccal mucosa and a small amount of
buccinator it can be used either in the
anterior maxilla region, the lips ,
anterior floor of mouth

28. Nasolabial flap
These flaps are cutaneous flaps based
on thefacial artery
They have been found to be useful as
either superiorly based for anterior
maxilla or oro-nasal defects or inferiorly
based for floor of mouth defects

31. Regional flap
pectoralis major
This is a myocutaneous flap utilizing the
pector major muscle and its overlying
skin
It is based on the pectoral branch of the
thoraco-acromial artery
for soft tissue reconstruction of mucosa
and bony defects of the jaws

34. Temporalis flap
has been used for reconstruction of
maxillary,orbito- zygomatic , and
anterior cranial fossa defects
The blood supply is from the deep
temporal branches of the maxillary
artery

37. Free flaps
radial forearm free flap
is the workhorse of oral reconstruction
due toits versatility, reliability and
Flexibility
It is particularly suitable for
reconstruction of the floor of mouth, soft
palate , tonsillar fossa when restoring
the anterior maxilla and non-tooth
bearing areas of the mandible and when
soft tissues need to reconstructed

38. The main disadvantages of this flap are
inadequacy of available bone and donor
site morbidity such as limited motion, grip
strength
Note = The cutaneous component of the
radial forearm free flap, when placed intra-
orally, appears white due to the epidermal
nature of the epithelium
dermal structures, such as hair follicles, are
preserved in the transfer of flaps with a
cutaneous component hair may grow from
these flap

43. Fibula free flap
fibula free flap is now the mainstay of
reconstruction of bony continuity defects
of the jaws, particularly Mandible ,
bony reconstruction of the maxilla and
orbital floor,
can be osteotomized and thus can be
contoured into the shape of the resected
mandible without compromising the
blood supply

44. Disadvantages include donor site
morbidity and numbness of the foot and
toe

50. Lliac crest flap
The iliac crest free flap offers the best
bone
stock for dental implants The natural
contours of the bone are helpful for
reconstructing lateral and
hemimandiblectomy defects

51. Iliac crest free flap prepared for
recipient site

52. Iliac crest free flap at recipient
site, with internal fixation

55. Scapular free falp
A scapular free flap is an
osteocutaneous flap and is a
recommended choice for complex
defects involving skin, bone and mucosa
This flap,
in general, accepts osseointegrated
dental implants well

61. Floor of Mouth Reconstruction
Requires soft and mobile tissue
Allow mobility of oral tongue
Avoid scar contracture (i.e., secondary
intention)
Avoid bulk (glossoptosis, obliteration of
lower lip sulcus

62. Floor of Mouth Reconstruction
Smaller defects
Split thickness skin graft
Harvest from lateral thigh at 0.017 in
Provides water-tight closure, no hair
Stabilize with bolster
Survives over muscle and cancellous
bone (via
imbibition and neovascularization)

63. Floor of Mouth Reconstruction

64. Floor of Mouth Reconstruction
Moderate defects involving a larger
portion of mylohyoid
Nasolabial flap
Based on angular artery
Better for older patients with lax skin
Requires two stages and temporary
fistula
Bite block necessary

65. Floor of Mouth Reconstruction
Moderate defects (continued)
Regional flaps
Forehead flap (rarely used)
Platysma flap
Facial artery musculomucosal flap
(FAMM)
Deltopectoral flap (historical
significance)

66. Floor of Mouth Reconstruction
Forehead flap
Superficial temporal artery
Reliable 2/3 across the forehead
Tunneled into cheek below zygoma
Requires orocutaneous fistula
Obvious donor site (skin graft)
Second stage to inset flap

67. Floor of Mouth Reconstruction
Submental artery island flap
Thin, supple skin
Submental branch of facial artery
Primary closure of donor site
Poor reliability if:
Facial artery sacrificed
Irradiated necks

73. FAMM flap
Branch of facial artery
Contains mucosa, buccinator muscle,
and fat
2 x 8 cm flap without injury to facial
nerve

74. Fasciocutaneous free flaps
Thin nature and pliability
Radial forearm has low incidence of
failure to
this site
Provides tongue mobility and free
movement
of food during deglutition

75. Anterior Tongue Reconstruction
Very difficult to reconstruct
Complex intrinsic musculature and
Function
Redundancy is advantageous
Near hemiglossectomy does not
significantly
alter function

76. Anterior Tongue Reconstruction
Defects <50% can be closed primarily +/-
STSG
Larger or composite defects require more
bulk (i.e, fasciocutaneous free flap)
Lateral arm free flap is good for defects
including posterior aspect of tongue/FOM

77. Anterior Tongue Reconstruction

78. Anterior Tongue Reconstruction

79. Lateral Arm free flap
Posterior radial collateral artery
Paired venae comitantes
12 x 18 cm paddle possible (6 x 8 cm allows
for primary closure)
Potential sensate flap (posterior cutaneous
nerve)
Disadvantages: donor site appearance, hair
growth, elbow pain, lateral forearm
numbness

81. Buccal Cavity
Reconstruction
Small defects – primary closure possible
Larger superficial defects
Quilted skin/mucosal grafts
Temporoparietal fascial flap (STSG for
lining)
Large full-thickness defects
Pectoralis major myocutaneous flap
Latissimus dorsi myocutaneous flap
Fasciocutaneous free flaps

83. Mandibular Reconstruction
Goals
Reconstitute
mandibular continuity
Allow for future dental
restoration
Anterior defects
Worst functional
defects
“Andy Gump”
deformity
Lateral defects
Easier to reconstruct
Less functional
problems
Mandibular

84. Mandibular Reconstruction
Fibula osseocutaneous free flap ideal for
anterior defects (minimal soft tissue
defect)
Based on peroneal vessels
Multiple osteotomies allowable (for
contouring)
25 cm of bone available (entire defects)
Sensate (lateral cutaneous nerve)
Reliable for osseointegrated dental
implants

85. Mandibular Reconstruction
Scapular free flap for anterior defects with
massive soft tissue loss (i.e., total glossectomy)
Circumflex scapular artery and vein
14 cm of bone available (lateral aspect)
Allows osseointegrated implants
Long pedicle to axillary artery
Multiple fasciocutaneous/musculocutaneous flaps
available (scapular, parascapular, latissimus dorsi,
serratus anterior)
Major drawback: patient positioning

86. Mandibular Reconstruction
Lateral mandible defects
Regional/Distant/Free flap with mandibular
swing
Low profile reconstruction plate with soft
tissue coverage
Patient factors which prevent dental
restoration
Plate exposure rate of about 5%
Compared to anterior exposure rate near 20%
Osseocutaneous free flaps (iliac, scapular,
fibula)

87. Iliac crest free flap for lateral
defects
Internal oblique musculature included
Contour similar to native mandible
Reliable for osseointegrated implants
Deep circumflex iliac artery
Disadvantages (difficult harvest, donor site
deformity, abdominal weakness,
postoperative hematoma, lateral thigh
pain/anesthesia)
Split inner cortex modification reduces
morbidity

88. Thank you