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PROBLEMS AFTERMAXILLECTOMY

Airway problem

Oronasal communication

Facial disfigurement

Masticatory & feeding problem

Deviation of the mandible


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CLASSIFICATION OFDEFECTS AFTER

MAXILLECTOMY

A. SURGICAL COMPONENT(VERTICAL)

B. DENTAL COMPONENT(HORIZONTAL)


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A. SURGICALCOMPONENT(VERTICAL)

CLASS 1

Minimal loss of alveolar bone without an

oroantral fistula

Loss of hard palate only with no breach of

oral cavity or lose of the alveolus.


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CLASS 2

It includes the alveolus and antral walls, but

not extending to the orbital rim and adnexae

CLASS 3

Similar to class 2 but including the orbital

floor or medial wall.

CLASS 4

maxillectomy with orbital exenteration


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B. DENTAL COMPONENT

(HORIZONTAL)

CLASS a

less than or equal to half the dental alveolus.

CLASS b

more than half the dental alveolus or crossing

the mid line.

CLASS c

the entire maxillary alveolus


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RECONSTRUCTION OF

CLASS 1 (A TO C)

Can be simply treated with obturator or a soft

tissue flap

Can even be left without obturation to be healed

by secondary intention


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ADVANTAGES

Simple & quick procedure

Donor site is not required

Immediate facial & dental restoration

Inspection of the cavity & check for recurrence

is available


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DISADVANTAGES

Difficult obturator fit & high risk of failure in

class 3 and 4.

Oro nasal reflux can be a problem

Reconstruction remains an option in the longer

term


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Pedicled Flaps

o Temporalis Flap

o Buccal fat pad

o Temporoparietal

Fascia Flap

RECONSTRUCTION OF

CLASS 2A

o Submental island flap

o Uvula flap

oTongue flap

o Masseter flap

o Nasolabial flap


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FREE TISSUE TRANSFER

Composite Fibula Flap

Radial Forearm Flap


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TEMPORALIS FLAP

Originates along the lateral skull at the temporal

line and inserts on the coronoid process of the

mandible.

It is a powerful elevator of the mandible

Blood supply is from anterior deep temporal and the

posterior deep temporal arteries.


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ADVANTAGES

Ease of Elevation

Reliable blood supply

Proximity to the maxillofacial structures

Camouflage of the incision with in the hair line


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DISADVANTAGES

Sensory Disturbances

Potential facial nerve Injury

Temporal Hollowing

Limited arc of rotation


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BUCCAL FAT PAD

First reported to be used in 1977 for closure of oroantral or oronasal

communication

In 1983 Neder used fat pad as a free graft in the oral cavity

Buccal fat pad epithelializes within two to three weeks when used as a

Pedicled flap.

Blood supply is from buccal and deep temporal branches of maxillary

artery.


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ADVANTAGES

Can be used in conjunction with free bone

grafting

Provides increased soft tissue bulk over

reconstruction bars.

Donor site complications are rare.


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NASOLABIAL FLAP

Blood supply is from perforators of the facial and angular arteries

The superiorly based flap is used for the closure of oroantral

fistula

Limited donor tissue, facial scaring and limited arc of rotation are

the main disadvantages

`flap is extremely difficult to use in dentate patients


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UVULA FLAP

In patients who have a long redundant uvula and have undergone a resection of

the posterior hard palate or part of the soft palate, the uvula provides an easily

harvested source of muscle & mucosa

Blood supply is from random perforators from local palatal vessels

Can be used to provide mucosa for the oral and nasal surface of the hard palate

Flap is not available in total palatal resections

Its dimensions are inadequate for larger defects


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TONGUE FLAP

May be based anteriorly, dorsally, posteriorly, or bipedicled dorsally

Dorsally based flap is used for closure of hard palate

Blood supply is from lingual artery

The mobility of the pedicles caused by normal tongue movement can

cause the flap to pull away from the defects

Alteration of the natural tongue contour & bulk at the tip can alter

speech


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MASSETER FLAPHas been used for many years in the reanimation of paralyzed face

Langdon modifies the procedure by resecting the anterior portion of

the vertical ramus & coronoid process to allow transfer of the flap to

defects of the palate

Blood supply is from the masseteric artery, a branch of the transverse

facial artery

Major disadvantage is the potential for trismus and limited volume of

tissue


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TEMPOROPARIETAL FASCIA

Provides a rapidly re-epetheliazed coverage in oral cavity

Can be elevated, grafted with skin or cartilage, or both

Flap receives its blood supply from the superficial

temporal artery


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ADVANTAGES

Robust Blood Supply

Ease of Elevation

Lack of hair

Well camouflaged donor site

Vascular anatomy is constant & reliableSurface of the fascia readily accepts grafts


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DISADVANTAGES

Numbness of the donor site

Alopecia

Lack of skin paddle for flap monitoring.


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SUBMENTAL ISLAND FLAP

Blood supply is from the submental artery, a branch of facial artery.

Appropriate for cases in which no prior neck surgery has obliterated

the vascular pedicles

Provides abundant regional tissue with a reliable blood supply

Flap may be used without skin as a fascio-subcutaneous flap for the

augmentation of contour defects

Also used for reconstruction of most anterior oral cavity defects


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ADVANTAGES

Excellent color match

Excellent aesthetics

Transfer of tissues with like thickness & texture

Reliable vascular anatomy

The only disadvantage is the incisional scar.


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FREE TISSUE TRANSFER1. COMPOSITE FIBULA FLAP

only long & straight bone that is not indispensable

The common peroneal nerve runs around the fibular head

damage to the nerve & the knee joint can be prevented by leaving approximately 8cm of

proximal fibular end in the leg

Also distally 8cm are left in order to maintain the ankle joint fork

A fibula 40cm long can provide 26cm for the transplantation,this makes the fibular graft

the longest transplantable bone segmant in human beings

Blood supply to the fibula is from peroneal artery


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ADVANTAGES

Constant anatomical topography

Long bone & high stability

Minor donor site morbidity

Disadvantage is the short vascular pedicle

When used for the reconstruction of maxilla , one must

use a vessel interponate because of shortness of vascular

pedicle.


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RADIAL FOREARM FLAP

This flap is based on ascending & descending radicles from the

radial artery

Different variants like fascial flaps, double paddle fasciocutaneous flaps, and

osteocutaneous flaps can be harvested

Maxillectomy defects are adequately reconstructed with a radial forearm

fasciocutaneous flap

In osteocutaneous flap up to 16cm of bone may be harvested


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ADVANTAGES

Thin, elastic, pliable skin paddle

Hairless

Drapes conveniently over the complex shapes within the

oral cavity

Flap has relatively minimal bulk hence provides little

resistance to tongue movements


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DISADVANTAGES

Exposure of tendons at donor site

Poor aesthetics

Radius fracture


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RECONSTRUCTION OF

CLASS 2(B-C)

AIMS OF RECONSTRUCTION:

When the class 2 defect crosses the midline or involves

the entire dental alveolus, a composite flap is essential to:

Restore the loss of bone including the anterior alveolus

Support the alar region & nasal columella

Provide adequate bony basis for implants


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RECONSTRUCTION

Flaps for reconstruction depend on amount of bone lost in the in

anterior maxilla and nasal septum

If loss of bone includes only the dental alveolus, then a fibula flap is

the ideal choice

If, however, loss of bone includes a significant part of nasal piriform ,

nasal septum and extending towards the nasal bone (>2cm), then iliac

crest with internal oblique is the ideal flap.


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ILIAC CRESTThis flap is based on the deep circumflex iliac

artery(DCIA) & deep circumflex iliac vein

DCIA is a branch of the external iliac artery. DCIA sends

some perforators into the bone & the muscle attached to it

The skin component of the iliac crest derives some of its

blood supply from these perforators


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USE OF FLAP IN

MAXILLECTOMY

Using the internal oblique muscle flap based on the

ascending branch of DCIA, a well vascularized piece of

soft tissue can be obtained on the same pedicle as the iliac

crest

Reconstruction of the orbital floor & rim may be achieved

using the inner table of iliac crest & the attached soft tissue.


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ADVANTAGES

Offers o large, curved piece of mainly cancellous bone,6 to 16cm in length

Composite flap carries a significant soft tissue bulk, can be useful in filling extensive

resection defects

Skin paddle is reliable & may be as large as 16 x 20cm or greater

Iliac crest is mainly cancellous bone, hence provides primary bone union

size & depth of bone allows it to accommodate osteointegrated dental implant

Cosmetically acceptable, as the scar is hidden in groin crease

Contour irregularity can be overcome by taking only the inner cortex


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DISADVANTAGES

Skin necrosis

Hernia

Hypertrophic scar

Local pain & pain on ambulation

Gait disturbances

Femoral neuropathy

Contour deformities.


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RECONSTRUCTION OF

CLASS 3(A-C)

AIMS

To close the oroantral fistula

Restore the functioning dental alveolus

Support for facial skin

Support the orbit & eyelids

Iliac crest with internal oblique is the ideal option to meet these goals.


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ILIAC CREST WITH

INTERNAL OBLIQUE

It provides sufficient bone for the implant retained dental prosthesis

Provides a platform for the reconstruction of the orbital floor with

titanium mesh

The muscle will close the oral defect & provide an epethelialized lining

for the lateral nose

Facial vessels overlying the body of mandible are used for anastomosis


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THE SCAPULA

Blood supply is from subscapular artery, a branch of the axillary artery

This flap is easy to elevate & the donor site defect is only moderate

For complex three dimensional reconstruction, two skin paddles can

be moved independently of each other

Angle of the scapula based on the angular artery & incorporating a

portion of latissimus dorsi , is used for orbital floor & maxillectomy

reconstruction


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DISADVANTAGES

Does not provide adequate thickness of bone to

retain dental implants

Skin paddles may be too bulky for intra oral use


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RECONSTRUCTION OF

CLASS 4A

When the orbital contents have been exenterated, problems of diplopia,

enophthalmos, and ectropion are obviated by removal of the eye.

Provision of the prosthetic eye can mask some of the deformity

Again, iliac crest with internal oblique is the first choice in class 4A

reconstruction

The best compromised reconstruction is a large soft tissue flap such as the

rectus abdominis to obturate whole of the defect from roof of the orbit to the

dental alveolus.


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RECTUS ABDOMINIS

It is a strap like muscle, that spans the length of the anterior

abdominal wall

Enclosed in rectal sheath, originates from the cartilages of fifth,

sixth, and seventh ribs and front of the xiphoid process

Lower tendinous attachment to the body and symphysis of pubis

Blood supply is from superior & inferior epigastric artery


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USE OF FLAP IN

MAXILLECTOMY

Used for larger defects

Ease of dissection of the vascular pedicle

Disadvantages are lack of uniform thickness and

more tedious dissection in obese persons

No chance of dental rehabilitation


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RECONSTRUCTION OF

CLASS 4(B-C)

When the defect crosses the midline or involves

the nasal bone, iliac crest with internal oblique is

the only choice that can provide sufficient bone

to support the facial and nasal bone as well as

providing a choice for dental rehabilitation.


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