MAXILLECTOMY CLASSIFICATION IS COVERED MAINLY IN THIS SESSION

1. Namitha AP
III rd MDS
DEPT. OF PROSTHODONTICS

2.  Introduction
 Role of Prosthodontist
 Goals and objectives
 Psychological intervention
 Pre-surgical Prosthodontic
intervention
 Post surgical prosthodontic
rehabilitation of maxilla
- Classification of maxillectomy
defects
- Prognostic indicators
- Design principles in cpd
Maxillary obturators
surgical
Interim
Definitive
 Velopharyngeal prostheses
 Recall and continuous support

3.  Post surgical prosthodontic
rehabilitation of Mandible
 Classification of mandibulectomy
defects
 Prognostic indicators and challenges
Inclined plane guidance prostheses
Positioning prosthesis
Palatal based and
Mandibular guidance prostheses
 Tongue prostheses
 Implants in maxillofacial
rehabilitation
 Irradiated bone- considerations
 Materials – history, recent advances
 Splints and stents in radiotherapy
 Current trends
 Future of MFP
 Related articles
 References

4. Loss of tissue volume or structural
Anchor
dentition
framework for the
softtissues of the face
and muscles of facial
expression
provide
attachment to
muscles of
mastication
Loss of tissue volume or structural integrity
Function Esthetics
Social
distress

5.  maxillary resection mak΄sa-lĕr΄e rĭ-
sĕk΄shun: the surgical removal of a
part or all of the maxillae; syn,
MAXILLECTOMY
 Mandibular resection man-dĭb΄u-l
ĕk΄ta-me n: the removal of part or
the entire mandible ;syn,
MANDIBULECTOMY

6.  Rehabilitation of patient with acquired defects is quite challenging and requires a
multidisciplinary team for comprehensive care and optimal treatment outcome.
OTOLARYNGOLOGIST
SPEECH
THERAPIST
PSYCHOLOGIST SOCIAL WORKERS
NURSING STAFF
RADIATION
OCOLOGIST
MEDICAL
ONCOLOGIST
MAXILLOFACIAL
SURGEON
PROSTHODONTISTROLE depends on the modality
of treatment
PRE
SURGICAL
POST
SURGICAL

7. Speech
Therapist
Maxillofacial
surgeon
The patient should be educated regarding possible
short term and long term complication of
chemotherapy and radiotherapy , train in oral
hygiene methods and therapeutics for oral health
preservation(oral prophylaxsis, fluoride application)
Extent of the disease
Precise surgical technique
Anticipated post-operative
defects
Healing time

8.  provide proshetic support to the surgeon by preparing
the facial moulages and surgical stents to aid
postoperative recovery
Komala J, Vinnakota DN, Banda TR, Vadapalli SB. Early prosthetic
management of maxillectomy, hemimandibulectomy patient with a lateral mid
facial defect: A case report. The Journal of Indian Prosthodontic Society. 2014
Sep 1;14(3):321-5.

9. Nutritional and
psychological
intervention
Pre surgical
records
Mouth
preparation
Modification of
oral structures
modification of
existing dental
prosthesis
CAD CAM
technology for
pre prosthetic
planning
articulate
diagnostic cast
jaw relation
records
profile template
of the midline of
the face
matching tooth
shape and shade
radiographs
and
photographs
Facial moulage
Eliminate existing local infection
Extraction of teeth with poor
prognosis
Restoration of teeth that has to be
retained for support of the prosthesis
Alveoloplasty
Gingivoplasty
serve as treatment prosthesis or preparation of
surgical stent
An optimum oral environment should be maintain in
order to provide freedom from infection and facilitate
early recovery of the tissues.

10. The objective of prosthetic
rehabilitation of patients
undergoing surgical resection
as primary modality of
treatment of head and neck
cancers
Mastication
and swallowing
dysfuction
Restore facial
disfigurement
Control oral
secretions
Maxillary
defects
Mandibular
defects

11. SURGERY OF
MALIGNANT
TUMORS
ACCIDENTS TUBERCULOSIS
NECROSIS
CAUSED BY
EXTENSIVE
INFLAMMATION
EXTENSIVE
FRACTURES
GUN SHOT
WOUNDS
ADVANCED AGE
OF SYPHILIS
HARD
PALATE
MAXILLARY
SINUS
BUCCAL
MUCOSA
NASAL
CAVITY
Taylor TD, editor.
Clinical maxillofacial
prosthetics. Berlin;
2000.91
METASTASIS FROM
DISTANT SITES

13. Ambroise Pare (1541) :
probably the first person to
close a defect
In his device a dry
sponge was attached
to the upper surface of
the disc. When the
sponge becomes moist
by the secretion it
expands and hold the
prosthesis in place
Pierre Fouchard
(1728) : Father of
modern dentistry.
He described two
types of palatal
obturators
wings in the
shape of
propellers
which can be
folded together
while being
inserted and
spread out
after insertion
retaining
feature is in
the form of
butterfly wings
which were
made to open
by a key after
the closed
wings have
been inserted
through the
palatal
perforation.

14. The complex 3-dimensional anatomy of this
multifunctional region presents not only a technical
surgical challenge to restoring the preoperative state but
also difficulties with the development of a uniformly
accepted classification system to allow the comparison of
technique
Each schemes approaches the problem from a slightly
different angle and no single scheme has achieved
universal acceptance
Andrades P, Militsakh O, Hanasono MM, Rieger J, Rosenthal EL. Current
strategies in reconstruction of maxillectomy defects. Archives of Otolaryngology–
Head & Neck Surgery. 2011 Aug 15;137(8):806-12.

15. Ohngren LG. Malignant tumours of the maxilloethmoidal region: a clinical study
with special reference to the treatment with electrosurgery and irradiation. Acta
Otolaryngol [Suppl](Stockh). 1933;19:1-476.
Tumors extending superior to a line drawn
between the medial canthus and the angle
of the mandible on lateral x-rays of the
head had a worse survival in spite of
intervention
Earliest and simplest classification
scheme for diseases of the maxilla
proposed by Ohngren .he didn’t believe
the effectiveness of radical surgical
extirpation of maxillary tumors. He
favoured radiation therapy instead.

16. anteroinferior
to the line -
more benign
posterosuperior
to the line -
more lethal
His concern was prognostic
and hence his scheme placed
a little emphasis on
maxillectomy defects.

17.  The first classification
to take surgical
defects into account
was proposed by
Armany in 1978.
 He divided these
defects into 6
categories, based upon
the relationship of the
defect with the
abutment teeth
Aramany MA. Basic principles of obturator design for partially edentulous
patients. Part I: classification. Journal of Prosthetic Dentistry. 1978 Nov
Armany classification remains the standard until date.

18. the resection in the class1 defect didn’t cross the
midline and preserved the teeth on the
contralateral side of the maxillary arch.
Aramany MA. Basic principles of obturator design for partially edentulous patients.
Part I: classification. Journal of Prosthetic Dentistry. 1978 Nov 1;40(5):554-7.
most frequent
maxillarydefect,
and most
patients fall into
this category
Midline resection of the maxilla to eradicate
adenoid cystic carcinoma of the antrum.

19. Class II defect. The anterior teeth are
preserved on the defect side of the dental
arch.
The defect in this group is unilateral,
retaining the anterior teeth on the
contralateral side
The recommended design is similar to the design
of a Class II Kennedy removable partial denture,
in which indirect retention minimizes the
possibility of dislodgement of the prosthesis under
gravity

20.  .
 The palatal defect occurs in the
central portion of the hard palate
and may involve part of the soft
palate
 The surgery does not involve the
remaining teeth.
 The design for these patients is
simple, and retention, stabilization,
and reciprocation can be effectively
planned.

21.  The defect crosses the midline and
involves both sides of the maxillae.
There are few teeth remaining which
lie in a straight line, which may
create a unique design problem
similar to the unilateral design of
conventional removable partial
dentures.
The anterior teeth are
resected on the contralateral
side of the defect

22.  This situation involves a bilateral
posterior surgical defect located
posterior to the remaining teeth.
 Many or all of the teeth are present
anterior to the defect.
 Labial stabilization and the use of
splinting, especially of the terminal
abutments, is desirable.
 The surgical defect in this situation
is bilateral and lies posterior to the
remaining abutment teeth.
 Labial stabilization may be needed,
and splinting of remaining
abutments is advisable.

23.  This situation involves a bilateral
posterior surgical defect located
posterior to the remaining teeth.
 Many or all of the teeth are present
anterior to the defect.
 Labial stabilization and the use of
splinting, especially of the terminal
abutments, is desirable.
 It is rare to have an acquired
maxillary defect anterior to the
remaining abutment teeth
 This occurs mostly in trauma or in
congenital defects rather than as a
planned surgical intervention.
 In this class, cross-arch stabilization
is derived through a system of cross-
arch bars which will provide wide

24. •LIMITED
MAXILLECTOMY
TYPE
1
•SUB TOTAL
MAXILLECTOMY
TYPE
2
•TOTAL
MAXILLECTOMY(WITH
OR WITHOUT ORBITAL
EXENTERATION)
TYPE
3
 published a revise scheme based on
retrospective review of 403
maxillectomy perform over a 9 year
period.This scheme based on the
procedure performed rather than the
resultant tissue lost .
Spiro RH, Strong EW, Shah JP. Maxillectomy and its classification. Head & Neck:
Journal for the Sciences and Specialties of the Head and Neck. 1997 Jul;19(4):309-
MEDIAL
LATERAL
ANTERIOR
INFERIOR

25.  Any maxillectomy which primarily removed
one wall of the antrum, usually the medial
wall or the floor.
 Minor portions of other walls might also be
included in the resection.
 No attempt was made to distinguish between
patients who had only a hard palatectomy, as
opposed to resection of the alveolar process or
removal of the entire floor of the antrum

26.  Any maxillectomy which removed at least two
walls, including the floor of the antrum, but
not the posterior wall.
 Usually, access involved elevation of an upper
cheek flap, but the resection was occasionally
accomplished through a craniofacial
approach.
 Possible extensions of this procedure included
excision of the pterygoid plates, the soft
palate, portions of the contralateral maxilla,
the zygoma, and the nasal complex

27.  Complete removal of the maxilla,
usually including orbital
exenteration. Preservation of orbital
contents was possible in a few
instances, which is a modification
that must be included in the
descriptive terminology.
 As with SM, the approach was either
by way of an upper cheek flap, or
was craniofacial.
 In these more radical procedures,
mandibulectomy is another possible
extension in addition to those listed
above for SM

28. Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy
and midfacial defects. Plastic and reconstructive surgery. 2000 Jun 1;105(7):2331-46.
• limited or partial maxillectomy: involving resection of only 1 or 2
walls of the maxilla not including the hard palateTYPE 1
• subtotal maxillectomy involving resection of 5 of the 6 walls of the
maxilla with the preservation of floor of the orbitTYPE 2
• (a) - total with preservation of orbital contents(all 6 wall resected)
• (b)- total with orbital exenteration (all 6 walls resected)TYPE 3
• orbitomaxillectomy: upper five walls of the maxilla (orbital floor,
A,P,L,M) and the contents of the orbit with preservation of the hard
palate.TYPE 4

34. Brown JS, Rogers SN, McNally DN,
Boyle M. A modified classification for
the maxillectomy defect. Head & Neck:
Journal for the Sciences and Specialties
of the Head and Neck. 2000
Jan;22(1):17-26.
 This classification focus on tissue
loss.
 Also proposed reconstructive
technique for each defects.
 Classified the defects based on
vertical and horizontal components

35. •Maxillectomy with no oro-antral
fistula
Class 1
•Low maxillectomy
Class 2
•High maxillectomy
Class 3
•Radical maxillectomy
Class 4
a. Unilateral alveolar maxilla
and hard palate resected.
Less than or equal to half the
alveolar and hard palate
resection not involving the
nasal septum or crossing the
midline
b. Bilateral alveolar maxilla
and hard palate resected.
Includes a smaller resection
that crosses the midline of
the alveolar bone including
the nasal septum
c . The removal of the entire
alveolar maxilla and
Class 2–4 is qualified by the addition of a letter (a–c),
which refers to the horizontal or palatal aspect of the
maxillectomy, including the nasal septum, contralateral
sinuses,and alveolus that have been excised.

36.  The removal of alveolar bone not
resulting in an oro-nasal or oro-
antral fistula.
 Resections of the ethmoid and frontal
sinus cavity defects or removal of the
lateral nasal wall would fit into this
part of the classification.
 Included in this group is the removal
of only palatal bone, which will
inevitably result in an oro-nasal
fistula but leaves the dental-bearing
part of the maxilla intact.
(A and B) Lesion
at the junction of
the hard and soft
palate
reconstructed
with a radial
forearm because
half the soft
palate was
excised (Class 1)

37. • The alveolus and antral walls but not
including the orbital floor or rim.
Class 2
• Including the floor of the orbit with or
without peri-orbita and with or without
skull base resection.
Class 3
• Plus orbital exenteration with or without
anterior skull base resection.
Class 4

40.  Palatomaxillary defects were
divided into 3 major classes and
2 subclasses.
 Eight different defects of the
hard palate and maxilla were
characterized within this
classification system.
REMAINING
DENTITION
SIZE AND
LOCATION OF
DEFECT
PALATE
Influenced the design
of the microvascular
free flap and
prosthodontic
restoration

41. rehabilitated with an obturator,
a local advancement flap, or a
fasciocutaneous free flap. In
general,
prostheses - were stable and
well tolerated
These defects involved a small
portion of the dental arch; the
anterior sextant and a unilateral
posterior quadrant of teeth
remained intact. As a result, the
theoretic cantilever forces over
the defect were minimized. It
was projected that the movement
of the obturator around the
fulcrum line could be stabilized

42. Okay DJ, Genden E, Buchbinder D,
Urken M. Prosthodontic guidelines
for surgical reconstruction of the
maxilla: a classification system of
defects. The journal of prosthetic
dentistry. 2001 Oct 1;86(4):352-63.

43. Prosthetic rehabilitation of Class II defects
was less predictable than that of Class I
defects. Factors that contributed to
instability included fewer teeth for clasping,
reduced arch size and form, and a
significantly diminished supporting palate.
An obturator alone was inadequate to
restore cosmesis to the midface if the orbital
floor or the zygoma was resected
Okay DJ, Genden E, Buchbinder D, Urken M.
Prosthodontic guidelines for surgical reconstruction of
the maxilla: a classification system of defects. The
journal of prosthetic dentistry. 2001 Oct 1;86(4):352-63.

44. These defects left little or no residual palate or dentition for the
secure retention of an obturator, which led to a poor prosthetic
prognosis. Class III defects were best restored with a VBCFF.
Although soft tissue reconstruction of a Class III defect served to
effectively partition the oral cavity from the nasal cavities and
maxillary sinuses, orodental rehabilitation was severely
compromisedPalatal reconstruction with bone
provided a stable base to oppose
the restored mandibular arch

45.  Extensive palatomaxillary defects
commonly involve a vertical component
of the maxilla.
 orbital floor and zygomatic body play
both functional and cosmetic roles.
 Ablation of the vertical maxilla
commonly results in a significant
disruption of the midface and orbit and
has a profound impact on function.
 Enophthalmoses and diplopia can
occur if the orbital contents are not
supported.
 cosmetic deficit (caused by the loss of
midface symmetry and projection) that
is almost impossible to restore with an
obturator

46. Will be continued….