There is not a more severely handicapped person than the patient with gross facial disfigurement.

Mc Gregor I.A., 1970

MAXILLARY DEFECTS AND RECONSTRUCTION

By Dr. Jaya Karamchandani, II yr Pg student, Dept of OMFS Under the guidance of Dr. Neelam Andrade, Prof & HOD, OMFS

Maxillary Bone

BONY BUTTRESSES OF MID-FACE

Vertical: Anterior Buttresses

Nasomaxillary Zygomaticomaxillary

Pterygomaxillary

Posterior Buttress

Fascia of Mid-face

SUPERFICIAL

DEEP

Superficial fascia: SMAS ( Superficial musculoaponeurotic system)

Was described by Mitiz and Peyronic in 1976

-as a network of dense fibrous and fatty tissues and

septae , -serving as cephalad extension of platysma muscle of neck. -ends at zygomatic arch, above which it is known as

Temporoparietal fascia -TP fascia extends cephalad onto temporal fossa and
eventually becomes galea aponeurosis of the scalp.

Deep fascia( Parotido-masseteric fascia)

-Facial extension of investing layer of deep cervical fascia. -Capsule of the parotid gland and wraps around the masseter muscle. -Reaching the zygomatic arch called as Deep Temporal fascia

Fat pads of Mid-face

Superficial: -Buccal fat pad. -Malar fat pad. Deep: -Suborbicularis oculi fat pad(SOOF). -Eislers fat pad.

MAXILLECTOM Y

Surgical excision of Maxilla or a part of it. Performed for treatment of tumours of the --maxilla, --palate, --oral cavity with maxillary involvement, --nose and sinuses --infective conditions, particularly osteomyelitis of invasive fungal etiology

The morbidity associated with maxillectomy is rarely petty and potentially includes:

inefficient mastication Inarticulate speech and hindered communication Uncontrollable nasal leakage of fluids Impairment of deglutition and nutrition Decreased or altered taste perception Inability to control saliva Inability to make lip closure Diplopia, distorted orbital function and vision Xerostomia (if undergone radiation) Difficulty in maintenance or oral hygiene Pain, and Psychological damage and social unacceptability.

Tumour concerns cycle

Facial disfigurement Ostracism Anger Depression Tumour illness disability Hopelessness/Frustration Chronicity Inferiorty/Anxiety Punishment Guilt Abondonement helplessness

Maxillectomy A Historical Perspective

Total maxillectomies performed by Dupuytren and Gensoul in 1820 and 1824? First recorded maxillectomy by Liston in 1841 Extensive review published by Ohngren in 1933

Ohngrens lines

CLASSIFICATION SYSTEM OF MAXILLARY DEFECTS

(Santamaria & Cordeiro)

Type I to IV

Type I (Limited maxillectomy)

One or two walls, preservation of palate

Type II (Subtotal maxillectomy)

Lower 5 walls, preservation of orbital floor

Type III (Total maxillectomy)

Resection of all six walls

Orbital preservation (IIIa)

Type III (Total maxillectomy)

Resection of all six walls

Orbital exoneration (IIIb)

Type IV (Orbitomaxillectomy)
Upper 5 walls, preservation of palate

BY Sessions and Humphrey in 1983

Medial Maxillectomy Posterior Maxillectomy Inferior Maxillectomy Total Maxillectomy

Also should be aware with terminologies

Limited: Removal of any one wall of antrum. Subtotal: Atleast 2 walls are removed, including the palate. Total: Complete resection of Maxilla. Partial: Used interchangeably with subtotal. Radical: Was previously used for surgery now addressed as total Maxillectomy. Extended:Removal of bony structures other than maxilla, like nasal bones. ethmoids.

Okay et al. 2001, Classification of Maxillary Defects.

Class 1a, 1b, 2, 3

Class Ia: defects that involve the hard palate but not the tooth bearing alveolus.

Class Ib: defects that involve any portion of the maxillary alveolus and dentition posterior to the canines or that which involved the premaxilla.

Class II: defects that involve any portion of the tooth bearing maxillary alveolus but included only 1 canine. Also included in this class are anterior transverse palatectomy defects that involve less than one half of the palatal surface.

Class III: defects that involve any portion of the tooth bearing maxillary alveolus and included both the canines,total palatectomy defects, and anterior transverse palactectomy that involve more than half of the palatal surface. These defects have a poor prosthetic prognosis.

Subclass f: includes defects that involve the inferior orbital rim.

Subclass z: includes defects that involve the body of the zygoma.

Classification by Brown et al
Vertical component: Class 1to 4 Horizontal component: Class a, b, c

Class1-Maxillectomy with no oro antral fistula, resection of alveolar bone only. Resection of hard palate producing oro antral communication leaving tooth bearing portion intact.

Class2-Low Maxillectomy-Resection of alveolus and antral walls.

Class 3-High Maxillectomy-Resection , orbital floor is sacrificed, may also include resection of skull base.

4-Radical Maxillectomy, include exanteration of the globe.

Horizontal Component:

a- Unilateral sparing the nasal septum.

b- Crossing the midline.

c- Total ablation of the alveolus and hard palate

Classification by Aramany 1978

Class 1: Resection performed along the midline of maxilla.

Class2: Defect is unilateral, retaining anterior teeth on contralateral side.

Class3: Palatal defect in the central portion of hard palate amd may involve part of soft palate.

Class 4: Defect crosses midline and involves both sides of maxilla.

Class 5: Surgical defect is bilateral and lies posterior to reamaining abutment teeth.

Class6:Anterior to remaining abutment teeth.

SURGICAL PROCEDURES:

Incisions for Subtotal and Total Maxillectomy: -Weber-Ferguson incision. -Weber-Ferguson incision with Lynch extension. -Weber-Ferguson incision with lateral subciliary extension. -Weber-Ferguson incision with lateral subciliary and supraciliary extension

TREATMENT MODALITIES FOR MAXILLARY RECONSTRUCTION:

Ideal reconstruction of maxillary defects particularly requires:

The presence of a healed wound; Separation of oral and nasal cavities; Support and suspension of dynamic facial soft tissue, including avoidance of ectropion; Restoration of the midfacial contour Restoration of maxillary buttresses; Restoration of functional dentition, Mastication, and deglutition; Maintenance of a patent nasal airway; and, Reestablishment of globe position or addressing an exenterated cavity cosmetically.

Approach to Reconstruction

Extent of resection
Volume

vs. surface area requirements

oral commisure, nasal airway, eyelids

Assessment of critical structures

Palate,

Need for bone replacement

Orbital

floor Anterior arch of maxilla

Need for soft tissue bulk or resurfacing

Maxillectomy and midface defects result in major functional and aesthetic abnormalities Reconstruction depends on the size and individual components of the resected tissue Large defects often require the use of free tissue transfer Obturation can result in good functional results, but requires constant patient care

Treatment modality based on Browns

classification:

Pedicled flaps ( Temporalis flap)Class 1 or 2a Obturators, soft tissue free flap, or composite free flaps-- Class 1,2,or 3,a or b. Free flap reconstruction Class 2c,3c or 4.

VERTICAL COMPONEN T

HORIZONTAL COMPONENT

1 Local flap Pedical flap Obturator Soft tissue FF

Rehabilitation with Maxillary Prosthesis:

Require a solid anchor point to be successful. Additional support with: Transmalar placement of Steinmann pins. Zygomaticus implants.

OBTURATOR:

In favour: -Can be removed-early detection of reccurence. -Retention better than prosthesis constructed on a surgical flap. -Support for soft tissues- better facial appearance.

Against of: -Requires frequent adjustment. -May be bulky and difficult to insert. -Open cavity , when prosthesis removed. -Frequent crusting is unpleasant to patie nt.

Use of Buccal fat pad( Bichats fat pad)

Best suited for medium sized defects up to a maximum of 4cm in diameter. Can be used to cover Class 1 and 2a Maxillectomy defects with extension to the midline.

FLAPS FOR RECONSTRUCTION

In favour of: -Allows immediate one stage reconstruction. -Psychologically acceptable- surgical defect closed. -Avoids discomfort and nasal reflux associated with an obturator.

Against: Prolonged operative procedure Donor site morbidity. Difficult to visually detect early recurrence of tumour.

Temporalis system in Maxillary Reconstruction.

Free Flaps

Indicated for large defects Matching to three-dimensional shape of defect

Provide bone, palatal and nasal lining, skin, soft tissue

Requires vascular pedicle 10-15 cm long Multiple different options

Myocutaneous Osteomyocutaneous Combination with free bone grafts

-Osseocutaneous composite flaps allows potential to place ossointegrated implants, providing superior retentive surfaces and support.

Free flaps( Osseocutaneous composite flaps) which can be used:

Radial forearm flap. Scapular/ Parascapular flap. The fibular flap Iliac crest .

DCIA based Iliac Crest graft:

Colemann 1988 advocated first the use of Deep circumflex Iliac Artery based Composite flap. In low Maxillectomy defect iliac crest graft can be placed horizontally , with the crest buccally and main body of the bone lying in the plane of the palate. Internal oblique muscle can then be attached to iliac crest and draped mediallly and sutured to medial residual plate.

In the high or complex Maxillectomy defects, iliac crest can be oriented vertically with the crest, replacing the alveolus and the main body of bone replacing the maxillary buttress and anterior maxilla. Drilling holes in the iliac crest can also be done to facilitate placement of sutures. Also has been possible to osteotomize the iliac crest.

ADVANTAGES:

Reconstruction of extensive composite defect cam be accomplished in single stage. Endosteal and Periosteal circulation ensures sufficient osseus circulation and rapid bone healing. Muscle can be mobilized sufficiently for restoration of soft tissues of the midface. Internal oblique muscle provides an ideal lining for the mouth and nose. Most abundant bone for the placement of Implants and support of the orbit. Concealment of donor site is possible.

Disadvantages:

Bulk complicates reconstruction in certain recipient site defects. May cause sensory loss of lateral thigh resulting from loss of lateral cutaneous nerve. Abdominal herniation may be a problem if closure is not possible. May cause denervation of rectus abdominis through interruption of its motor nerve supply.

Prosthetic guidelines for surgical reconstruction of maxilla: A classification system of defects.

Maxillary reconstruction

J Prosthetic dentistry,2001:86---- Devin Okay

Indian jounral of Plastic Surgery,2007:40-- Brown JS

The main tissue loss in the maxillectomy defect without the loss of facial or nasal skin is bone, which we can reconstruct in terms of from and true function. Any algorithm must therefore be based on the restoration of the bony skeleton as the most important part of the proposed reconstruction.

THANK YOU