Current strategies in reconstruction of maxillectomy defects

Digitally Guided Advanced Prosthodontic Rehabilitation for Post-COVID-19 Mucormycosis Using Patient-Specific Implants: A Case Report

This case report describes the prosthodontic rehabilitation of a middle-aged male patient who underwent bilateral low-level maxillectomy due to post-COVID-19 mucormycosis. The oronasal communication was closed using an anterior base tongue flap. Two patient-specific subperiosteal implants were placed to rehabilitate the patient's bony defect. Using a postsurgical CT scan, a virtually customized subperiosteal titanium framework was created from grade IV titanium alloy. The fabricated framework was implanted over the patient's zygomatic bone bilaterally. Six months later, the right-sided patient-specific implant was infected and had to be surgically removed. After satisfactory healing, an open-tray impression was taken to create a computer-aided design/computer-aided manufacturing titanium Hader bar. An acrylic resin overdenture was then fabricated over this bar. A clasp assembly was fabricated by direct metal laser sintering of cobalt-chromium alloy for additional retention. The metal substructures were incorporated into the overdenture prosthesis to enhance the stability and retention.. This case report unveils an innovative approach to rehabilitating severely compromised maxillary bony defects and impaired oral functioning, offering a viable alternative when traditional reconstruction methods are inadequate. Prosthodontic treatment greatly affects the aesthetics, phonetics, and mastication of the patient, improving the overall quality of life of the patient.

Bioengineering from the laboratory to clinical translation in oral and maxillofacial reconstruction

Background

Conventional techniques used in oral and maxillofacial reconstruction focus mainly on utilizing autologous tissues that have unquestionably improved function and esthetics for many patients, worldwide. However, the success depends on countless factors such as: donor and recipient sites conditions, patient's medical history, surgeon's experience, restricted availability of high-quality autogenous tissues or stem cells, and increased surgical cost and time.

Materials and Methods

Lately, teaming researchers, scientists, surgeons, and engineers, to address these limitations, have allowed tremendous progress in recombinant protein therapy, cell-based therapy, and gene therapy.

Results

Over the past few years, biomedical engineering has been evolving from the laboratory to clinical applications, for replacement of damaged body tissues due to trauma, cancer, congenital or acquired disorders.

Conclusions

This review provides an outlook on the content, benefits, recent advances, limitations, and future expectations of biomedical engineering for salivary glands, oral mucosa, dental structures, and maxillofacial reconstruction.

Application of supraclavicular island flap in oral and maxillofacial reconstruction

Several surgical modalities are available for maxillofacial reconstruction as locoregional or microvascular free flaps.

PURPOSE

(a) Evaluate the reliability of the supraclavicular flap in cervico-orofacial region; (b) investigate the role of computed tomography angiography (CTA) in predicting the post-operative viability of the flap; (c) assess the speech, feeding, and esthetics after reconstruction using this flap.

METHODS

Eleven patients included in this study underwent either conventional or delayed harvesting of the supraclavicular flap (SCF). All the patients had diagnostic computed tomography angiography (CTA) of the supraclavicular flap before the surgery.

RESULTS

The mean harvesting time of the flap was 45.45 ± 4.16 min. The average length of the flap was 22.64 ± 1.12 cm, whereas the mean width of the flap was 6.14 ± 1.14 cm. The flap survived in 9 patients, while two patients had complete flap loss. After the surgery, three patients complained of speech difficulties. Two patients had swallowing problems. After the surgery, three patients complained of speech difficulties. Two patients had swallowing problems. Only two patients complained of weakness in the donor site. None of the patients reported that the weakness or pain at the donor site affected their daily activities or quality of life.

CONCLUSION

The pedicled SCF represents a safe and feasible option that can be used to reconstruct a wide array of maxillofacial oncologic defects. However, a study with a larger sample size is recommended to achieve more reliable clinical results for the modified delayed technique modification in terms of their effect on the survival of the supraclavicular flap.

Advances in Microvascular Reconstruction of the Orbit and Beyond: Considerations and a Checklist for Decision-Making

This paper aims to discuss the microvascular reconstruction of the orbit and adjacent regions and to propose a checklist to aid the reconstructive surgeon in this challenging undertaking. The discussion is based on a literature review that includes 32 retrospective case series, 5 case reports published in the last 34 years in PubMed, and 3 textbook chapters. Additionally, it relies on the senior author's expertise, described in a case series, and two case reports published elsewhere. Classifications and treatment algorithms on microvascular orbit reconstruction generally disregard patient-related factors. A more holistic approach can be advantageous: patient-related factors, such as age, comorbidities, prognosis, previous interventions, radiotherapy, and the wish for maximal dental rehabilitation and a prosthetic eye, have the same importance as defect-related considerations and can inform the choice of a reconstructive option. In this manuscript, we examine defect- and patient-related factors and new technologies, provide a checklist, and examine future directions. The checklist is intended as a tool to aid in the decision-making process when reconstructing the orbital region with microvascular flaps.

Effects of maxillofacial prosthetic treatment on oral health-related quality of life and masticatory ability of patients with head and neck tumors

PURPOSE

Using multivariate analysis, this study investigated the effectiveness of maxillofacial prosthetic treatment in relation to oral health-related quality of life (OHR-QoL), masticatory ability (food intake status score and gum-jelly test score) and related factors in patients who had undergone surgery for head and neck tumors.

METHODS

The study cohort comprised 112 patients who underwent surgical resection and prosthetic treatment among 224 patients with head and neck tumors seen at the Maxillofacial Prosthetics Clinic of Tohoku University Hospital in a 2-year period. Correlations between OHR-QoL, food intake status score, and gum-jelly test score (criterion variables), and age, sex, maxillary defect, tongue/soft tissue defect, reconstructive surgery, and chemoradiotherapy (explanatory variables) were investigated, and the data were examined statistically.

RESULTS

Maxillary defect, tongue and soft palate tissue defect, and chemoradiotherapy were identified as factors that hindered the effectiveness of maxillofacial prosthetic treatment for improvement of the OHR-QoL, food intake status score, and gum-jelly test score. On the other hand, reconstructive surgery was a factor that facilitated the improvement of OHR-QoL and masticatory ability with maxillofacial prosthetic treatment.

CONCLUSION

The factors identified to be related to the success or failure of maxillofacial prosthetic treatment suggest the importance of combining prosthetic intervention with surgical reconstruction.

Skull Base Reconstruction by Subsite after Sinonasal Malignancy Resection

Reconstruction after the resection of sinonasal malignancies is complex and primarily dependent on the defect size and location. While the reconstructive paradigm for sellar mass resection is well delineated, the challenges associated with reconstruction after sinonasal malignancy resection are less well described. This narrative review will address the goals of reconstruction after both endonasal endoscopic and open sinonasal malignancy resection and reconstructive options specific to these subsites. The goals of reconstruction include repairing cerebrospinal fluid leaks, restoring sinonasal function, providing a nasal airway, and optimizing the patient's quality of life. These goals are often complicated by the anatomic nuances of each involved sinus. In this review, we will discuss the methods of reconstruction specific to each sinonasal subsite and describe the factors that guide choosing the optimal reconstructive technique.

Maxillary and total nasal reconstruction with a scapulo dorsal perforator flap

Facial gunshots injuries remain challenging and present functional and aesthetic problems. Such defects generally require composite tissue flaps for reconstruction. Rebuilding the palate and the maxilla is especially delicate because it requires reconstitution of the facial buttresses, and replacement of bony hard palate, based on occlusion, as well as the restoration of the thin intraoral and intranasal lining which normally constitute the soft palate. Various methods of reconstruction have been applied to this area in search of an ideal soft tissue and bone flap to restore the bony framework of the maxilla and palate while providing an internal lining. The scapula dorsal perforator flap is used in the case of a patient to successfully reconstruct the palate, the maxilla and the nasal pyramid in one stage. Free tissue transfer using thoracodorsal perforator flaps and scapula bone free flap have been already described in literature but never to perform the nasal pyramid reconstruction at the same time. Good functional and aesthetic results have been obtained in this case. This article also reviews, through the authors experience and literature, anatomical landmarks, indications, technical surgical tricks, advantages and disadvantages of this flap for palatal, maxillary and nose reconstruction.

Stacked fibula flap for unilateral total maxillectomy reconstruction with orbital preservation

Unilateral total maxillectomy is indicated for locally advanced maxillary tumors that require complete removal of the midface bony structure and inferior orbital rim. Reconstruction of this defect is challenging due to aesthetic and functional concerns. A retrospective review of patients at two tertiary-care institutions undergoing unilateral total maxillectomy reconstruction with a stacked fibula flap from 2018 to 2022 was performed. Each patient's clinical course was reviewed, and attention was focused on the demonstration of surgical steps with photos. Twenty patients underwent stacked fibula flap reconstruction for unilateral total maxillectomy orbital preservation defects. Surgical extirpation was performed for malignancy (80%, 16/20) and for osteoradionecrosis or benign tumor in 20% (4/20). The complication rate was 30% (6/20). Most flaps survived (95%, 19/20). We present a modified, reproducible method of fibula flap reconstruction for unilateral total maxillectomy with orbital preservation that only requires two segments and maintains positive aesthetic and functional results.

Comparative analysis of surgical and prosthetic rehabilitation in maxillectomy: A systematic review and meta-analysis on quality-of-life scores and objective speech and masticatory measurements

STATEMENT OF PROBLEM

Patients with oro-antral communication, whether from trauma, disease, or congenital anomalies, have options for surgical reconstruction or prosthetic obturation, but guiding interdisciplinary protocols are lacking.

PURPOSE

The purpose of this systematic review and meta-analysis was to compare surgical reconstruction and prosthetic obturation, identifying correlations with baseline characteristics to determine the most effective approach for specific patients.

MATERIAL AND METHODS

A systematic search was conducted in 4 databases. Searching, screening, data extraction, and risk of bias assessment were performed by 2 reviewers. Eligible studies focused on patients with palatomaxillary defects from cancer-related maxilla surgeries. Traumatic or congenital defects were excluded. The study compared prosthetic restoration (either with surgical or definitive obturators) to surgical reconstruction using flaps or grafts. Patients with surgical restoration after tooth extraction were excluded. Both subjective and objective outcomes were used for comparison.

RESULTS

Thirteen articles were included in the qualitative synthesis and 9 in the meta-analysis. Patient scores on quality-of-life questionnaires, objective speech, and masticatory ability evaluations were compared. The number of patients who underwent surgical reconstruction was 206, whereas 260 patients received prosthetic obturators. Results showed no significant differences. In the "activity" domain of the University of Washington QoL questionnaire, however, the 1.92 (0.45, 3.40) score difference was not clinically relevant. However, the heterogeneity of trials, the transient nature of subjective evaluations, the low number of participants, and major confounding biases did not allow a solid conclusion to be drawn.

CONCLUSIONS

The growing number of maxillectomy patients demands firm evidence on which rehabilitation to choose and when it should be done. The result suggests that obturator devices and surgical reconstruction have similar effects on quality of life and health outcomes. A multicentric registry in which patient strata could be analyzed separately by age, adjuvant therapies, defect sizes, and remaining dentition is advocated.

Chondrosarcoma of the maxilla

A woman in her 70s reported to the outpatient department of our tertiary care hospital with chief complaints of painless swelling in the right cheek and palatal area. The patient was a known case of diabetes mellitus and hypertension on medications with controlled sugars and blood pressure. The swelling was 10×8 cm in size extending from right infraorbital region up to the lower mandible. CT demonstrated a permeative lytic pattern of bone destruction noted involving the hard palate and maxillary bone.Using the Weber Ferguson approach, a surgical resection was carried out under general anaesthesia. Resection included from right total maxillectomy (excluding roof of maxilla), nasal septum up to left medial maxillectomy including hard palate and the tumour was resected en bloc. The palatal obturator was fixed. On the basis of histopathology, grade 1 well-differentiated chondrosarcoma was diagnosed. The patient received postoperative radiotherapy and had a good recovery.

Bone reconstruction of extensive maxillomandibular defects in adults

Reconstruction of significant maxillomandibular defects is a challenge that has been much discussed over the last few decades. Fundamental principles were developed decades ago (bone bed viability, graft immobilization). Clinical decision-making criteria are highly relevant, including local/systemic factors and incision designs, the choice of material, grafting technique, and donor site morbidity. Stabilizing particulated grafts for defined defects-that is, via meshes or shells-might allow significant horizontal and vertical augmentation; the alternatives are onlay and inlay techniques. More significant defects might require extra orally harvested autologous bone blocks. The anterior iliac crest is often used for nonvascularized augmentation, whereas more extensive defects often require microvascular reconstruction. In those cases, the free fibula flap has become the standard of care. The development of alternatives is still ongoing (i.e., alloplastic reconstruction, zygomatic implants, obturators, distraction osteogenesis). Especially for these complex procedures, three-dimensional planning tools enable facilitated planning and a surgical workflow.

Stress Trajectory Variations During Occlusal Loading in Human Skull with a Maxillofacial Defect: A Finite Element Analysis

Background and Aim

Biting forces from the teeth are distributed to the facial bones and to the skull through the stress trajectories. The presence of a bony defect in either the maxilla or mandible might lead to variations in the stress distribution. The aim of this study was to evaluate the stress distribution and variations in stress trajectories from biting forces in a human skull with maxillofacial defect using a finite element (FE) model.

Methodology

In this study, a cone beam computed tomography (CBCT) of an adult male patient with a maxillectomy defect consequent to surgical treatment of mucormycosis is evaluated for the stress distribution from the biting forces of the remaining posterior teeth. Finite element model without the mandible was constructed from the patient's CBCT data. Occlusal loading forces of 600 N were applied on each side of the maxillary teeth. Stress trajectories were visualised through the stress distribution pattern.

Results

The results showed deviations in the normal stress distribution during occlusal loading and variations in zygomatic and pterygoid stress trajectories in the maxillofacial and skull regions in our FE model due to the bony defect.

Conclusion

We conclude that a skeletal maxillofacial defect should be reconstructed to resume proper stress distribution during functional forces to maintain a healthy craniofacial skeleton.

Trismus after partial maxillectomy and radiotherapy: Free flap reconstruction versus prosthetic obturation

OBJECTIVE

Partial maxillectomy and postoperative radiotherapy are both risk factors associated with trismus. This retrospective study aimed to evaluate the incidence and severity of trismus in patients following partial maxillectomy with or without postoperative radiotherapy and to compare free flap reconstruction and prosthetic obturation.

METHODS

A retrospective review of 40 oral cancer patients who underwent partial maxillectomy with or without postoperative radiotherapy was performed. Maximum interincisal distance recorded at least 6 months after surgery was classified according to a revised subjective-objective management-analytical (SOMA) scale and compared between the free flap reconstruction group (n = 12) and the prosthetic obturation group (n = 28).

RESULTS

Trismus was observed in 16/40 (40%) patients, and severe trismus was observed in 4/40 (10%) patients. Although no significant difference in trismus grade was observed between the free flap reconstruction and prosthetic obturation groups, both severe trismus and radiation-induced osteonecrosis were only seen in the prosthetic obturation group with postoperative radiotherapy.

CONCLUSION

Free flap reconstruction was preferable to prosthetic obturation to avoid severe trismus and radiation-induced osteonecrosis in patients who underwent both partial maxillectomy and postoperative radiotherapy.

Subperiosteal inferior maxillectomy in mucormycosis patients: case series

OBJECTIVE

Mucormycosis is a rapidly progressive and fulminant fungal infection mainly affecting the nose and paranasal sinuses and often requiring aggressive surgical debridement, which commonly includes inferior maxillectomy. Conventional inferior maxillectomy involves removal of the bony hard palate and its mucoperiosteum. This can lead to formation of an oroantral fistula and thereby increase the morbidity in these patients leading to prolonged rehabilitation. Subperiosteal inferior maxillectomy involves sparing of the uninvolved mucoperiosteum of the hard palate. This flap is used for closure of the oroantral fistula, which preserves the functional capabilities of the patient, such as speech, mastication and deglutination.

METHOD

This case series describes the experience of using the technique of mucosa-preserving subperiosteal inferior maxillectomy in five patients with mucormycosis.

RESULTS

With the technique used in this study, complete oronasal separation was achieved in all six patients. The overall surgery time was also decreased when compared with free tissue transfer. Patients also did not have to bear the weight of prosthesis.

CONCLUSION

Mucoperiosteal palatal flap-preserving subperiosteal inferior maxillectomy is an excellent approach for all patients with mucormycosis and healthy palatal mucosa.

Vascularized Free Fibular Flap in Oral and Maxillofacial Reconstruction: A 20-year Experience at a Single Institution Using 2640 Flaps

BACKGROUND

This retrospective study reviewed all patients who underwent oral and maxillofacial reconstruction with fibular flaps in the last 2 decades at a single hospital.

MATERIALS AND METHODS

We reviewed all patients with fibular flaps from 1999 to 2018. The following data were collected: sex; age; reconstruction region; diagnosis; the number of days spent in the hospital after surgery; time spent using a tourniquet for harvesting a fibula flap; vessels at the recipient site; the prevalence of unplanned reoperations; the prevalence of flap failure; history of preoperative radiotherapy; virtual surgical planning; segments of the fibula.

RESULTS

In total, 2640 patients were included. The mean age was 45.5 years. The most prevalent region of reconstruction was the mandible (n=2347, 88.9%). The most common diagnosis was squamous cell carcinoma (n=1057, 40.0%). The mean number of days spent in the hospital after surgery decreased year-by-year from 18.3 days to 10.4 days. The first choice of recipient artery was the facial artery (n=1643, 62.2%) and that of the recipient vein was the external jugular vein (n=1196, 45.3%). The prevalence of surgical success was 97.6%. Prevalence of unplanned reoperations was 7.5%.

CONCLUSIONS

The fibular flap was a good choice for oral and maxillofacial bony reconstruction in most cases.

Reconstruction of nasal airway in patients of class IIId maxillary defect with vastus lateralis muscle-chimeric double skin paddle ALT flap

BACKGROUND

A reconstructive challenge in patients with class IIId maxillary defect is how to obliterate the defect and restore a patent nasal airway. The current strategy using the single anterolateral thigh (ALT) fasciocutaneous flap for reconstruction may result in permanent mouth breathing. As the ALT flap was a common option in reconstruction processes, this study aimed to evaluate the benefits of vastus lateralis (VL) muscle-chimeric double skin paddle ALT flap in simultaneous defect and nasal airway reconstruction.

METHODS

This study included 21 patients with class IIId maxillary defect who underwent free ALT flap reconstruction (n = 11, single ALT flap group; n = 10, VL muscle-chimeric double skin paddle ALT flap (chimeric ALT flap) group) at the China Medical University Hospital from August 2015 to September 2019. Associated parameters collected for analysis included gender, age, body mass index (BMI), operative time, hospitalization, clinical stage, preoperative treatment, flap/defect size, comorbidities, postoperative RT, mouth breathing and short/long term complications.

RESULTS

No significant differences were observed in age, BMI, hospitalization, clinical stage, preoperative treatment, defect size, comorbidities, and postoperative RT between the two groups; however, the chimeric ALT flap group as dominated by male patients (p = 0.009), and had longer operative times (12.1 h vs. 10.1 h, p = 0.002) and larger flap sizes (180 cm² vs. 96.7 cm², p = 0.013). Compared with the chimeric ALT flap group, the single ALT flap group suffered from permanent mouth breathing.

CONCLUSION

Nasal airway reconstruction should be considered in patients with class IIId maxillary defect. Compared to the single ALT flap, the chimeric ALT flap is a superior reconstructive option for patients with class IIId maxillary defect, although a longer surgical duration and larger flap size are required.

Virtual Surgical Planning in Free Tissue Transfer for Orbito-Maxillary Reconstruction

Since its introduction, virtual surgical planning (VSP) has been rapidly adopted as a part of reconstructive surgeon's armamentarium. VSP allows reconstructive surgeons to simulate resection, plan osteotomies, and design custom plates. These unique advantages have been especially beneficial for head and neck reconstructive surgeons as there is small room for error and high technical demand in head and neck reconstruction. Despite its popularity, most surgeons have limited experience in using VSP for orbito-maxillary reconstruction as tumors that involve the midface are relatively rare compared with other head and neck oncologic defects. In our institution, we routinely use VSP for orbito-maxillary reconstruction using free fibula flap to provide support for orbit, to restore normal dental occlusion, and to restore midface projection. In this chapter, we will discuss the role of virtual surgical planning and our algorithmic approach of performing orbito-maxillary reconstruction using free tissue transfer.

Quality of life in patients with cancer-related Brown IIb maxillary defect: A comparison between conventional obturation rehabilitation and submental flap reconstruction

OBJECTIVES

The purpose of this retrospective study was to compare the differences in quality of life (QOL) outcomes between the conventional obturator prostheses (COP) and the pedicled submental artery island flap (SAIF) in the reconstruction of Brown IIb maxillary defects.

MATERIALS AND METHODS

The QOL of 116 eligible patients who had a lapse ≥ 12 months after the cancer-related maxilla ablation was evaluated by the University of Washington quality of life scale (UW-QOL), Performance Status Scale for Head and Neck (PSS-HN), and Obturator Functioning Scale (OFS).

RESULTS

Patients in the SAIF group reported statistically and clinically significant higher overall QOL scores but lower chewing scores in the UW-QOL scale when compared with those in the COP group (P < 0.05). Clinically significantly higher scores were also observed in the recreation and anxiety domains in the UW-QOL scale for the SAIF group, but there was no statistical significances. The COP group reported more complaints about the nasal leakage when swallowing and the shape of the upper lip, and had a stronger willingness to avoid family or social events in the OFS (P < 0.05).

CONCLUSIONS

For patients with Brown IIb defects, SAIF reconstruction can achieve reduced nasal leakage when swallowing, improved upper-lip contour, increased social activity, and superior overall QOL than COP. The inferior chewing function in the SAIF group indicated the need for dental rehabilitation with a conventional denture or osseointegrated implants.

Dynamic navigation for prosthetically driven zygomatic implant placement in extensive maxillary defects: Results of a prospective case series

BACKGROUND

Zygomatic implants (ZIs) that are anchored in remote locations can significantly improve the retention and stability of prosthetic obturation in maxillary defect sites without the need for complex surgical reconstruction. However, ZI placement without alveolar bone guidance is challenging, especially when identifying the ideal three-dimensional location of the "coronal part" of the implant fixture for further rehabilitation.

PURPOSE

To investigate the feasibility and accuracy of surgical navigation for ZI placement using prosthetically driven plans to treat extensive maxillary defects.

MATERIAL AND METHODS

Software was used to virtually plan the number and distribution of ZIs for maxillary defect patients according to the existing residual maxillofacial bone. The "coronal part" of the ZI was identified based on the existing maxillodental prosthetic flange, virtually planned infrastructure framework and superstructure. ZI placement was fully guided by surgical navigation.

RESULTS

Ten patients were enrolled. One patient had loose reflective spheres, which resulted in an inaccurate back-reflection of the position during navigation. A total of 27 ZIs in the remaining 9 patients were placed uneventfully. The mean of the "coronal part" of the ZI, entry point of the zygomatic bone, apical deviation, and apical angle deviation were 1.50 mm, 1.39 mm, 1.95 mm, and 2.32°, respectively. A Computer-aided design and computer-aided manufacture milled bar and additional attachments were fabricated according to preoperative planning. No osseointegrated implant loss was detected. Six ZIs in three patients received implant surface polishing to reduce soft tissue irritation, and one ZI was submerged.

DISCUSSION

Surgical navigation facilitated the accurate and feasible placement of prosthetically driven ZIs that were preoperatively planned in patients with extensive maxillary defects.

Current trends in craniofacial reconstruction

Reconstruction of the head and neck continues to pose a variety of difficult functional and aesthetic challenges to the plastic surgeon. While the surgical treatment for midfacial and skull base tumours continues to advance, the three-dimensional reconstruction predicaments continue to increase in complexity. Reconstructive strategies of the head and neck require the restoration of intricate skeletal architecture and large volumes of both internal and external soft tissue envelopes that can withstand adjuvant therapies. Vascularized bone grafts in combination with microsurgical techniques is the current trend of most reconstruction and has replaced local and pedicle flaps as the preferred modality for large defects. This article will focus on concise areas of difficulty in craniofacial reconstruction, including mandibular, midfacial, scalp and base of skull reconstruction. As our goals now move from flap survival to refinement, more complex and innovative reconstructions are executed. The problems with each modality are examined, and the frontiers of head and neck reconstruction are explored. With the potential combination of virtual surgery and tissue engineered biotechnology, we may someday be able to expand our reconstructive capabilities beyond free tissue transfer.

Modified Reconstruction of Brown II Defects With Anterolateral Thigh Flaps Following Tumor Resection

OBJECTIVE

Maxillary defects reconstructed with flaps usually cause nasalomaxillary fistula, discomfort oral lining, and poor function of denture. To resolve these problems, this study introduces a modified method of anterolateral thigh flap (ALTF) with skin and myofascial paddles to reconstruct nasal and oral lining of maxillary defects.

METHODS

This study retrospectively reviewed 66 consecutive patients of Brown II maxillary defects following tumor resection reconstructed with ALTFs of modified or conventional methods. In modified group, oral lining was reconstructed with myofascial paddle and nasal lining was reconstructed with skin paddle. The functional and aesthetic outcomes, and the scores based on the University of Washington quality of life questionnaire were assessed.

RESULTS

All flaps were successful in reconstruction of Brown II maxillary defects. No nasalomaxillary fistula and obstruction of the nasal cavity were found in modified ALTFs group. The functions of removable denture were better in modified ALTFs group. There was no significant difference about tumor recurrence, range of mouth opening, and aesthetic outcomes between the 2 groups.

CONCLUSIONS

The modified method of ALTF with skin and myofascial piddle to reconstruct Brown IIa and IIb defects following tumor resection is simple and reliable, which improves the oral comfortability and function of denture, and avoids obstruction of the nasal cavity.

Unraveling of Advances in 3D-Printed Polymer-Based Bone Scaffolds

The repair of large-area irregular bone defects is one of the complex problems in orthopedic clinical treatment. The bone repair scaffolds currently studied include electrospun membrane, hydrogel, bone cement, 3D printed bone tissue scaffolds, etc., among which 3D printed polymer-based scaffolds Bone scaffolds are the most promising for clinical applications. This is because 3D printing is modeled based on the im-aging results of actual bone defects so that the printed scaffolds can perfectly fit the bone defect, and the printed components can be adjusted to promote Osteogenesis. This review introduces a variety of 3D printing technologies and bone healing processes, reviews previous studies on the characteristics of commonly used natural or synthetic polymers, and clinical applications of 3D printed bone tissue scaffolds, analyzes and elaborates the characteristics of ideal bone tissue scaffolds, from t he progress of 3D printing bone tissue scaffolds were summarized in many aspects. The challenges and potential prospects in this direction were discussed.

Prosthetic Rehabilitation of Rhino Orbital Mucormycosis Associated with COVID-19: A Case Series

Mucormycosis, a rare fungal infection seen in diabetes, is now very frequent owing to the deadly triad of COVID-19 infection, diabetes, and rampant use of corticosteroids. Immediate management revolves around therapeutic drugs like antifungals, antibiotics, and aggressive surgical debridement. The cases described in the article explain prosthetic rehabilitation of maxillectomy defects. The findings focus on prosthetic rehabilitation of patients with acquired maxillectomy defects after mucormycotic necrosis post-COVID-19 infection and the techniques to overcome the complications like lack of supporting tissues and post-surgical microstomia. The maxillectomies were performed on patients who suffered a superinfection of mucormycosis after COVID-19 contraction and uncontrolled blood sugar levels. Case 1 elaborates a technique to overcome the complications like lack of supporting structures and microstomia by fabrication of sectional and hollow obturator prostheses using sectional impression technique and lost salt technique. Case 2 explains the management of an extensive defect with a mobile soft tissue flap and lone standing tooth by using a functional impression technique to gain retention and support from the remaining soft and hard tissues. Both the techniques overcome the clinical complications and give predictable outcomes. Prosthetic rehabilitation of such challenging cases needs modifications depending upon the clinical challenges encountered.

Influence of socioeconomic status on psychological distress and treatment satisfaction levels among patients undergoing prosthetic rehabilitation following maxillectomy: An observational study

Aim:

The aim of this study was conducted to evaluate the effect of socioeconomic status (SES) on psychological distress and treatment satisfaction levels of patients who underwent maxillectomy and rehabilitation with obturator prosthesis.

Settings and Design:

Prospective, observational, analytic study.

Materials and Methods:

Forty-three patients undergoing maxillectomy were enrolled and divided into upper, middle, and lower SES groups, according to the updated Kuppuswamy SES scale. Psychological distress levels were assessed using Hospital Anxiety and Depression Scale (HADS) before maxillectomy (T0) and at 3 weeks after delivery of definitive obturator (T1). Treatment satisfaction levels with obturator prosthesis were assessed using Obturator Functioning Scale (OFS) at T1. HADS and OFS scores were then correlated with the SES of the participants.

Results:

Out of 43 participants, 7 were lost to follow up. The total number of participants in upper, middle, and lower SES groups was 14, 11, and 11, respectively. Before surgery, there was no significant difference in anxiety levels (P > 0.05) among different SES groups. However, the depression levels were the highest in the lower SES and decreased significantly with increasing SES. Prosthetic rehabilitation led to statistically significant (P < 0.05) fall in the levels of both anxiety and depression assessed at 3 weeks after delivery of prosthesis. The upper SES group was found to be less anxious and depressed compared to middle and lower SES groups after prosthodontic rehabilitation. Treatment satisfaction level was found to be significantly low (P = 0.005) in lower SES group as compared to upper SES group while no difference was found in between the middle SES when compared to higher or lower SES groups.

Conclusions:

SES has a profound impact on the patient's psychosocial well-being and treatment satisfaction. Patients of lower SES reported with higher psychological distress and lesser treatment satisfaction compared to those belonging to upper SES.

A New Strategy for Patient-Specific Implant-Borne Dental Rehabilitation in Patients With Extended Maxillary Defects

Purpose of the Study

Patients undergoing ablative tumor surgery of the midface are faced with functional and esthetic issues. Various reconstructive strategies, such as implant-borne obturator prostheses or microvascular tissue transfer, are currently available for dental rehabilitation. The present study shows the first follow-up of patients treated with patient-specific implants (IPS Implants^® Preprosthetic) for the rehabilitation of extended maxillary defects following ablative surgery.

Patients and Methods

All patients treated with patient specific implants due to postablative maxillary defects were included. 20 implants were placed in the 19 patients (bilateral implants were placed in one of the cases). In 65.75% of the cases, resection was performed due to squamous cell carcinoma. In addition to the primary stability, the clinical implant stability, soft tissue management, successful prosthodontic restoration, and complications were evaluated at a mean follow-up period of 26 months.

Results

All patient-specific implants showed primary stability and were clinically stable throughout the observation period. Definitive prosthodontic restorations were performed in all patients. No implant loosening was observed. Major complications occurred only in previously irradiated patients with insufficient soft tissue conditions (p = 0.058). Minor complications such as exposure of the underlying framework or mucositis were observed, but they never led to failure of restorations or implant loss.

Conclusions

Treatment of postablative maxillary defects with patient-specific implants offers a safe alternative with predictable results for full and rapid dental rehabilitation, avoiding time-consuming augmentation procedures and additional donor-site morbidity.

Case Report: Reconstruction of a Large Maxillary Defect With an Engineered, Vascularized, Prefabricated Bone Graft

The reconstruction of complex midface defects is a challenging clinical scenario considering the high anatomical, functional, and aesthetic requirements. In this study, we proposed a surgical treatment to achieve improved oral rehabilitation and anatomical and functional reconstruction of a complex defect of the maxilla with a vascularized, engineered composite graft. The patient was a 39-year-old female, postoperative after left hemimaxillectomy for ameloblastic carcinoma in 2010 and tumor-free at the 5-year oncological follow-up. The left hemimaxillary defect was restored in a two-step approach. First, a composite graft was ectopically engineered using autologous stromal vascular fraction (SVF) cells seeded on an allogenic devitalized bone matrix. The resulting construct was further loaded with bone morphogenic protein-2 (BMP-2), wrapped within the latissimus dorsi muscle, and pedicled with an arteriovenous (AV) bundle. Subsequently, the prefabricated graft was orthotopically transferred into the defect site and revascularized through microvascular surgical techniques. The prefabricated graft contained vascularized bone tissue embedded within muscular tissue. Despite unexpected resorption, its orthotopic transfer enabled restoration of the orbital floor, separation of the oral and nasal cavities, and midface symmetry and allowed the patient to return to normal diet as well as to restore normal speech and swallowing function. These results remained stable for the entire follow-up period of 2 years. This clinical case demonstrates the safety and the feasibility of composite graft engineering for the treatment of complex maxillary defects. As compared to the current gold standard of autologous tissue transfer, this patient’s benefits included decreased donor site morbidity and improved oral rehabilitation. Bone resorption of the construct at the ectopic prefabrication site still needs to be further addressed to preserve the designed graft size and shape.

Free double-paddle superficial circumflex iliac perforator flap transfer for partial maxillectomy reconstruction: A case report

Partial maxillectomy for maxillary sinus cancer treatment requires soft tissue reconstruction with enough bulk to occupy the large-volume defect. Deep inferior epigastric artery-based flaps and subscapular artery-based flaps are commonly used, but necessitate invasive muscle dissection or position change and a large recipient vessel. The aim of this report was to present a case of partial maxillectomy defect successfully reconstructed with a superficial circumflex iliac artery (SCIA) perforator (SCIP) flap, to address these drawbacks. A 67-year-old female underwent partial maxillectomy for maxillary sinus cancer. The defects included the medial and the caudal aspects of the maxillary sinus with unilateral palate loss. A double-paddle SCIP flap (19 × 9 cm and 10 × 6 cm) was elevated in a free-style manner based on the superficial branches of the SICA. The SCIP and its concomitant vein were anastomosed to a facial artery perforator and the angular vein with supermicrosurgical perforator-to-perforator anastomosis. Two skin paddles were utilized to reconstruct the defects of the nasal wall and the oral aspects of the palate. Postoperative course was uneventful, and the patient could resume normal oral diet 5 days after surgery. Three years after surgery, there was no cancer recurrence or any postoperative complication, and the patient was satisfied with normal speech and diet, and with concealable donor and recipient scars. Double-paddle SCIP flap transfer may be an option for reconstruction of a partial maxillectomy defect.

Use of Immediate Obturator Prosthesis as a Rehabilitation Option in Cases of Squamous Cell Carcinoma

ABSTRACT

Maxillary defects caused by surgical resection generate abnormal communication between the nasal and oral cavities, hindering proper eating and phonetics, and causing aesthetic damage. Prosthetic intervention is necessary to rehabilitate these patients, in order to block communication and allow correct speech and swallowing functions. This article reports the manufacture of an immediate palatal obturator prosthesis after hemimaxillectomy due to the surgical removal of an intraoral squamous cell carcinoma, which guaranteed better conditions for postoperative recovery, as well as better adaptation to the definitive prosthesis and the use of the prosthetic apparatus.

Simple, but effective: Nasal splinting for airway securement in free flap reconstruction following orbital exenteration

Orbital exenteration is a disfiguring procedure that often results in free tissue transfer for reconstructive purposes. The reconstructive focus is the obliteration of dead space while sparing the nasal airway, particularly if the medial orbital wall was resected. Prolapse of transferred tissue into the nasal airway may cause breathing difficulties drastically compromising quality of life. The objective of this study was to demonstrate the effectiveness and feasibility of temporary nasal septum splints as mechanical support for transferred tissue, to prevent airway obstruction. This novel application technique was employed in three patients between 2017 and 2018. No flap loss or sino‐orbital fistulas were observed. On postoperative MRI and endoscopy, a patent nasal airway was observed at all times. Temporary nasal splinting in combination with free tissue transfer proved to be a simple, but effective reconstructive option for securing the nasal airway following orbital exenteration with resection of the medial orbital wall.

Reconstruction of maxillary palatal defects after partial maxillectomy using a pedicled buccal fat pad and a nasolabial flap

The novelty of this procedure is the reconstruction of a maxillary palatal defect with two pedicled flaps: a pedicled buccal fat pad and a nasolabial flap. This use of combination flaps makes the surgery simple, short, and useful for a wide defect.The novelty of this procedure is the reconstruction of a maxillary palatal defect with two pedicled flaps: a pedicled buccal fat pad and a nasolabial flap. This use of combination flaps makes the surgery simple, short, and useful for a wide defect.

Sinonasal Issues After Maxillectomy With Free Flap Reconstruction: Incidence and Clinical Approach

OBJECTIVE

To characterize the clinical features associated with sinonasal complaints after maxillectomy with free flap reconstruction as well as propose a screening and treatment algorithm.

METHODS

Retrospective review of patients who underwent maxillectomy and free flap reconstruction at a tertiary care center.

RESULTS

Fifty-eight patients were included, 25 (43.1%) of them had documented sinonasal complaints postoperatively. Eleven patients subsequently underwent revision surgery for sinonasal complaints. Among the 25 patients with sinonasal complaints, 22 patients (88.0%) had nasal crusting, 17 (68.0%) had nasal obstruction, 12 (48.0%) had rhinorrhea, 9 (36.0%) had facial pain or pressure, and 7 (28.0%) had foul odor. Twenty-two patients (88.0%) had multiple sinonasal complaints. There was a higher incidence of both sinonasal complaints and surgical intervention in patients who underwent adjuvant radiation, but this was not statistically significant (47.7% vs 28.6%, P = .235; 29.4% vs 7.1%, P = .265).

CONCLUSIONS

Sinonasal complaints are common following free flap reconstruction for a maxillectomy defect and should be screened for at postoperative visits, with early referral to a rhinologist for consideration of endoscopic sinus surgery. Nonsurgical treatment strategies include large-volume nasal saline irrigations, xylitol irrigations for persistent inflammatory symptoms, and culture-directed antibiotic irrigations for persistent infectious symptoms.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Immediate implant-retained prosthetic obturation after maxillectomy based on zygomatic implant placement by 3D-guided surgery: a cadaver study

Background

The aim of this study was to introduce a complete 3D workflow for immediate implant retained prosthetic rehabilitation following maxillectomy in cancer surgery. The workflow consists of a 3D virtual surgical planning for tumor resection, zygomatic implant placement, and for an implant-retained prosthetic-obturator to fit the planned outcome situation for immediate loading.

Materials and methods

In this study, 3D virtual surgical planning and resection of the maxilla, followed by guided placement of 10 zygomatic implants, using custom cutting and drill/placement-guides, was performed on 5 fresh frozen human cadavers. A preoperatively digitally designed and printed obturator prosthesis was placed and connected to the zygomatic implants. The accuracy of the implant positioning was obtained using 3D deviation analysis by merging the pre- and post-operative CT scan datasets.

Results

The preoperatively designed and manufactured obturator prostheses matched accurately the per-operative implant positions. All five obturators could be placed and fixated for immediate loading. The mean prosthetic point deviation on the cadavers was 1.03 ± 0.85 mm; the mean entry point deviation was 1.20 ± 0.62 mm; and the 3D angle deviation was 2.97 ± 1.44°.

Conclusions

It is possible to 3D plan and accurately execute the ablative surgery, placement of zygomatic implants, and immediate placement of an implant-retained obturator prosthesis with 3D virtual surgical planning.The next step is to apply the workflow in the operating room in patients planned for maxillectomy.

Mucosal resurfacing of the suprastructure maxillectomy cavity using nasal cavity mucosa flaps

OBJECTIVE

We analyzed clinical data of patients in which the suprastructure maxillectomy site was covered with nasal cavity mucosa flaps with or without free mucosa graft from the nasal septum, to determine the usefulness of this procedure.

PATIENTS AND METHODS

A total of four edentulous patients who had the suprastructure maxillectomy site covered using nasal cavity mucosa flaps with or without free mucosa graft from the nasal septum between 2014 and 2020, were analyzed.

RESULTS

All patients underwent suprastructure maxillectomy using the external approach. There were no major complications resulting from surgical intervention. Radiotherapy (RT) was performed in all patients after surgery. All nasal cavity mucosa flaps survived after RT. There was mild cheek retraction, but to a degree that was cosmetically tolerable in all patients. Local recurrence and distant metastasis to the orbit occurred in one patient. Among four patients, two patients died during follow-up, including one tumor related death and one death from old age.

CONCLUSION

We demonstrated that the use of nasal cavity mucosal flap to cover the suprastructure maxillectomy cavity was effective in improving the patient's quality of life by minimizing wound problems and facial contour changes such as cheek retraction despite postoperative RT.

Midface Reconstruction: Planning and Outcome

Reconstruction of the complex anatomy and aesthetics of the midface is often a challenge. A careful understanding of this three-dimensional (3D) structure is necessary. Anticipating the extent of excision and its planning following oncological resections is critical.

In the past over two decades, with the advances in microsurgical procedures, contributions toward the reconstruction of this area have generated interest. Planning using digital imaging, 3D printed models, osseointegrated implants, and low-profile plates, has favorably impacted the outcome. However, there are still controversies in the management: to use single composite tissues versus multiple tissues; implants versus autografts; vascularized versus nonvascularized bone; prosthesis versus reconstruction.

This article explores the present available options in maxillary reconstruction and outlines the approach in the management garnered from past publications and experiences.

Mastication in maxillectomy patients: A comparison between reconstructed maxillae and implant supported obturators: A cross-sectional study

OBJECTIVE

The aim of this study was to compare masticatory performance and patient reported eating ability of maxillectomy patients with implant-supported obturators and patients with surgically reconstructed maxillae.

METHODS

This cross-sectional study was conducted at the University of Alberta, Edmonton, Canada and at Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands. Eleven surgically reconstructed maxillectomy patients have been included at University of Alberta and nine implant-supported obturator patients at MUMC+. The mixing ability test (MAT) was used to measure masticatory performance. In addition, the oral health related quality of life (OHRQoL) was measured with shortened versions of the oral health impact profile (OHIP) questionnaire. Values of the implant-supported obturator group versus the surgical reconstruction group were compared with independent t-tests in case of normal distribution, otherwise the Mann-Whitney U test was applied.

RESULTS

Patients with reconstructed maxillae and patients with implant-supported obturator prostheses had similar mean mixing ability indices (18.20 ± 2.38 resp. 18.66 ± 1.37; P = .614). The seven OHRQoL questions also showed no differences in masticatory ability between the two groups.

CONCLUSION

With caution, the results of this study seem to confirm earlier results that implant-supported obturation is a good alternative to surgical reconstruction for all Class II maxillary defects. With both techniques, the masticatory performance is sufficiently restored, with careful planning being highly desirable.

Prosthodontic rehabilitation of head and neck cancer patients-Challenges and new developments

Head and neck cancer treatment can severely alter oral function and aesthetics, and reduce quality of life. The role of maxillofacial prosthodontists in multidisciplinary treatment of head and neck cancer patients is essential when it comes to oral rehabilitation and its planning. This role should preferably start on the day of first intake. Maxillofacial prosthodontists should be involved in the care pathway to shape and outline the prosthetic and dental rehabilitation in line with the reconstructive surgical options. With the progress of three‐dimensional technology, the pretreatment insight in overall prognosis and possibilities of surgical and/or prosthetic rehabilitation has tremendously increased. This increased insight has helped to improve quality of cancer care. This expert review addresses the involvement of maxillofacial prosthodontists in treatment planning, highlighting prosthodontic rehabilitation of head and neck cancer patients from start to finish.

Prosthetic Reconstruction of the Maxilla and Palate

Maxillary defects commonly present following surgical resection of oncologic processes. The use of rotational and free flaps has largely replaced the use of prosthetic options for hard palate and maxillary reconstruction, but prostheses remain a useful tool. Prosthetic devices may be invaluable in patients considered poor candidates for surgical reconstruction secondary to poor vascularity, need for postoperative radiation, or medical comorbidities that place them at high risk for healing following reconstruction. Obturators may also be considered over soft tissue options if oncologic surveillance via direct visualization of the surgical site is warranted.

A Novel Approach for Rehabilitation of a Subtotal Maxillectomy Patient with Immediately Loaded Basal Implant-Supported Prosthesis: 4 Years Follow-Up

The prosthetic rehabilitation of maxillary defect can be achieved successfully by using an implant-supported prosthesis. The use of remote bony areas such as the zygomatic bone in cases of large defects provides an innovative substitute for free vascularized osteocutaneous flaps and the solution to flap failures. This report describes the rehabilitation of a 22-year-old female with a subtotal maxillectomy using an immediately loaded basal implant-supported prosthesis. Four basal cortical screw implants (BCS®) are inserted; 1 on the contralateral nasal floor, 2 implants in the pterygoid plates, and the last in the zygomatic bone using cone beam computed tomography scans. The prosthesis was constructed and cemented in 3 days. The surgical and prosthetic procedures were performed without any obstacles. After 4 years in function, the patient was highly satisfied with the treatment as it improved her mastication, speech, aesthetic and returned her self-esteem. To our knowledge, this is the first clinical report detailing the use of basal implant-retained obturator in a subtotal maxillectomy patient.

Masticatory performance and oral health-related quality of life in edentulous maxillectomy patients: A cross-sectional study to compare implant-supported obturators and conventional obturators

OBJECTIVE

The aim of this cross-sectional study was to compare the masticatory performance and oral health-related quality of life (OHRQoL) of edentulous maxillectomy patients with and without implant-supported obturator prostheses.

MATERIAL AND METHODS

Nineteen edentulous maxillectomy patients with completed prosthetic obturator treatment in the upper jaw participated in this study. In nine patients, the obturator prosthesis was supported by implants in the remaining bone of the midface and/or skull base to improve retention. Masticatory performance was measured objectively by the mixing ability test (MAT) and subjectively by three OHRQoL questionnaires: (a) the Oral Health Impact Profile for EDENTulous people (OHIP-EDENT), (b) the Obturator Function Scale (OFS), and (c) the Dutch Liverpool Oral Rehabilitation Questionnaire version 3 (LORQv3-NL). The independent t test and the Mann-Whitney U test were used to test for differences in outcomes of patients with and without implant-retention of their obturator prostheses.

RESULTS

Patients with implant-supported obturator prostheses had significantly better masticatory and oral function, reported fewer chewing difficulties, and had less discomfort during food intake than did patients with a conventional obturator.

CONCLUSION

Supporting prosthetic obturators after maxillectomy with implants improve oral functioning, chewing, and eating comfort. This treatment modality is a viable technique to improve the functionality of prosthetic rehabilitation in patients who have undergone maxillectomy.

Rehabilitation after maxillectomy in patients with implant-retained obturator: A preliminary report

OBJECTIVE

The aim of this study was to evaluate the clinical outcomes of implant-retained obturator rehabilitation after maxillectomy, based on quality of life (QOL) and masticatory function.

STUDY DESIGN

The present study included 12 patients who underwent dental implant surgery after maxillectomy. Oral health-related QOL and masticatory function before and after completion of implant-retained obturator rehabilitation were evaluated.

RESULTS

Oral Health Impact Profile-Short Form (OHIP-14) scores showed significant differences in the domain for functional limitation (before, 4.08 ± 2.47; after, 1.33 ± 0.98; P < .01); physical pain (before, 2.75 ± 2.05; after, 0.42 ± 0.51; P < .01); physical disability (before, 3.24 ± 2.11; after, 1.33 ± 1.30; P < .01), psychological disability (before, 3.83 ± 2.48; after, 1.67 ± 2.50; P < .01); social disability (before, 2.17 ± 1.75; after, 1.08 ± 1.38; P < .05); handicap (before, 3.17 ± 1.90; after, 1.08 ± 1.00; P < .01); and total score (before, 22.41 ± 10.17; after, 8.83 ± 6.82; P < .01) Furthermore, masticatory function score was significantly higher after completing implant-retained obturator rehabilitation (before, 38.75 ± 22.97; after, 69.17 ± 21.41; P < .01).

CONCLUSIONS

Implant-retained obturator rehabilitation contributed to improved masticatory function and oral health-related QOL after maxillectomy.

Predicting individualized mortality probabilities for patients with squamous cell carcinoma of the maxilla: Novel models with clinical and histopathological predictors

BACKGROUND

The aim of this article was to develop prediction models that calculate postoperative 2- and 5-year mortality probabilities of patients with squamous cell carcinoma of the maxilla (MSCC).

METHODS

Data were collected from the medical records of patients who had been operated between 2000 and 2015 for MSCC. Potential clinical and histopathological predictors were identified. Confounding-(un)adjusted multivariate Cox and logistic regression models were computed with stepwise backward selection. Internal validation was performed to assess calibration and discriminatory ability.

RESULTS

Ninety-five patients with MSCC were included. Two-year follow-up was complete, and 85 patients had 5-year follow-up. Age, neck treatment, surgical margins, bone invasion, spindle growth, and vasoinvasive growth were associated with mortality. Models were adjusted for confounding with Charlson's comorbidities index. C-indexes were .841 and .770 respectively, and .838 and .749 after bootstrapping.

CONCLUSION

The MSCC-specific mortality probability can be calculated with new prediction models.

Orbital Floor and Maxillary Reconstruction With Titanium Mesh and Anterolateral Thigh Free Flap

A 57-year-old woman with a 15-year history of a slowly growing fibrous dysplastic maxillary bony tumor underwent total left maxillectomy with subsequent maxillary reconstruction with anterolateral thigh single perforator free flap and orbital floor reconstruction with a titanium mesh implant.

Cortical bone resorption of fibular bone after maxillary reconstruction with a vascularized fibula free flap: a computed tomography imaging study

This study was performed to evaluate the cortical bone resorption of fibular bone after maxillary reconstruction with a fibula free flap. A total of 35 patients with maxillary defects that were repaired using a fibula flap (62 fibula segments) between January 2011 and January 2016 were enrolled. Computed tomography (CT) images taken 1 week and 1 year postoperative were used to evaluate cortical bone resorption. The 62 fibula segments were measured on four different surfaces in the CT images. At 1 week, the thickness of the cortical bone was 2.57 ± 0.58 mm, 2.72 ± 0.46 mm, 3.84 ± 0.98 mm, and 4.36 ± 0.90 mm for the exterior, interior, superior, and inferior sides, respectively. At approximately 1 year, the cortical bone thickness was significantly reduced to 2.00 ± 0.65 mm (P <  0.01), 2.25 ± 0.60 mm (P <  0.01), 3.37 ± 0.90 mm (P <  0.01), and 2.96 ± 0.84 mm (P <  0.01) for the exterior, interior, superior, and inferior sides, respectively. The cortical bone thickness of fibular bone is significantly reduced 1 year after the restoration of maxillary defects with a fibula free flap, most significantly on the inferior side.

Tissue response to porous high density polyethylene as a three-dimensional scaffold for bone tissue engineering: An experimental study

High density polyethylene (HDPE) is a synthetic biomaterial used as a three-dimensional scaffold for bone defect reconstruction. Reports differ with regard to its biological response, particularly its osteoconductive capacity. The aim of the present work was to histologically and histomorphometrically evaluate tissue response to porous HDPE. An in vivo study was conducted in rat tibia to evaluate osteogenic capacity, angiogenesis, inflammatory response, and the presence of multinucleated giant cells 14 and 60 days post-biomaterial implantation. Histological examination 14 days post-implantation showed fibrovascular tissue inside pores and on the surface of porous HDPE, acute inflammatory response, scant multinucleated giant cells (MNGCs), and lamellar bone in contact with the biomaterial. An increase in the proportion of lamellar bone tissue, no inflammatory response, and a decrease in the number of MNGCs were observed at 60 days. The histomorphometric study showed a significant time-dependent increase both in the area of bone tissue formed in contact with the porous HDPE (14d: 24.450 ± 11.623 µm² vs. 60d: 77.104 ± 26.217 µm², p < 0.05) and in the percentage of bone tissue in contact with the porous HDPE (osseointegration). A significant decrease in the number of MNGCs was also observed at 60 days post-implantation. Porous HDPE showed adequate osteoconductive properties, and only caused an initial inflammatory response. Although this biomaterial has traditionally been used juxtaosseoulsy, its adequate osteoconductive properties broaden the scope of its application to include intraosseous placement.

Anchorage possibilities in case of a unilateral maxillary defect using the concept of Strategic Implant®

The aim of this article was to present the treatment method applied to a patient who suffered from a multiple fracture of the right maxilla, as a result of an accident that happened to him at an early age. The main consequence of this injury was an inhibited growth of the maxillary bone segment due to the lack of functional stimulus. The treatment consisted of four phases: the removal of all the teeth in the upper right maxilla, the immediate restoration with bicortical implants, the immediate prosthetic rehabilitation, and closing the oroantral communication.

Obturators versus flaps after maxillary oncological ablation: A systematic review and best evidence synthesis

Maxillary defects can be resolved by prosthetic obturation, autologous tissue reconstruction, or a combination of both. However, there is still controversy in the selection of the optimal approach. Therefore, the aim of this study was to systematically review evidences comparing the performance of obturators and flaps in patients after maxillary oncological ablation. Both electronic and manual searching approaches were conducted to identify eligible evidence. Two reviewers independently assessed the risk of bias. In addition, the same reviewers independently extracted the data. Meta-analyses were performed using Revman 5.3, and best evidence synthesis was performed. Sixteen studies were included and a total of 528 participants were analyzed. All studies were assessed at low quality. Results of this meta-analysis showed weak evidence in the difference between obturators and flaps on the outcome regarding word intelligibility (P = 0.004) and masticatory efficiency (P = 0.002). However, no differences were detected regarding speech intelligibility and nasalance. All studies were compiled into the best evidence synthesis. The sum of 31 evidences was considered. Twelve evidences were evaluated at a moderate level, such as speech, mastication, pain, salivation, taste sensations, and mouth opening. Except the outcomes of word intelligibility, masticatory efficiency, and mouth pain, other moderate evidences showed no difference between obturators and flaps. In conclusion, both obturators and flaps might be effective in patients' rehabilitation functions after maxillary ablation. However, some advantages were observed when using surgical reconstruction over prosthetic rehabilitation. Additional high-quality studies are needed to provide more solid evidence before applying these results into clinical practice.