Microsurgical reconstruction of the maxilla: Algorithm and concepts

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.

Maxillofacial Microvascular Free-Flap Reconstructions in Pediatric and Young Adult Patients-Outcomes and Potential Factors Influencing Success Rate

Background: Maxillofacial microvascular free-flap reconstructions are significant interventions in the management of congenital defects, traumatic injuries, malignancies, and iatrogenic complications in pediatric and young adult patients. Craniofacial disorders within this demographic can result in profound functional, cosmetic, and psychosocial impairments, highlighting the critical need for thorough investigation into factors that may influence procedural success and postoperative quality of life. This retrospective chart review aims to examine the outcomes and potential influencing factors, aiming to offer valuable insights into optimizing the effectiveness of these reconstructions and improving patient outcomes. Methods: A single head and neck surgical team performed all the included 136 procedures. Demographic and surgical patient data were recorded. Type of transfer performed in each recipient site and major complications were analyzed. Relevant influencing factors, such as age, gender, and etiology of defect were determined using the ANOVA test and χ2 test of independence. Results: The results indicate a 90% success rate. No significant relationship was found between the incidence of total flap loss and patient age, etiology, or graft source. The maxillary reconstructions showed a higher incidence of total flap loss compared to mandibular reconstructions (11 vs. 3 cases). Conclusions: Despite the high success rate, the findings underline the necessity for further research to validate these observations and enhance surgical methods for pediatric and young adult patients.

Midface microvascular reconstruction after maxillary complex tumor resection: A retrospective study

The study purpose is to review the surgical approach and evaluate the results in managing patients with advanced midface and maxillary complex tumors. The most common anatomical site of the primary tumor was the maxilla, sometimes with extension to the orbit and anterior fossa, parotid and middle ear or even the lip. Surgical resection included maxillectomy in the majority of cases, combined with orbital exenteration or orbitectomy and anterior fossa resection. Parotidectomy and mastoidectomy/core petrosectomy were also performed. Reconstruction was performed with radial forearm osteocutaneous free flap, latissimus dorsi myocutaneous flap with scapular bone flap, lengthening temporalis myoplasty, rectus abdominis free flap, anterolateral thigh flap, in combination with temporalis and vastus lateralis, as well as pectoralis major myocutaneous flap. A total of 36 midface tumor excisions were performed, followed by the appropriate reconstruction. The average follow-up period was 15 years. To date, 23 patients are disease free, while 6 patients presented disease recurrence and 7 patients died during the 15-year follow-up period. Surgical resection remains the gold standard for midface tumors management. When safely performed, combined with microvascular and dynamic face reconstruction, surgery can offer improvement in quality of life and prolong the overall survival.

Intraoral Microvascular Anastomosis in Immediate Free Flap Reconstruction for Midfacial Tumor Defects: A Retrospective Multicenter Study

(1) Background: The current landscape of midface reconstruction is marked by ongoing evolution, with notable advancements in surgical techniques, microvascular procedures, and the implementation of multidisciplinary approaches, all of which have significantly enhanced both functional and aesthetic outcomes. Conventionally, microvascular anastomoses for free flaps in midfacial reconstruction have been executed using cervical vessels. However, this approach necessitates neck access, resulting in extraoral scars and a substantial pedicle length. In light of these considerations, using intraoral anastomoses via the facial vessels emerges as a promising alternative. This retrospective multicentric study aims to provide a comprehensive account of immediate midface reconstruction through intraoral anastomoses. (2) Methods: Between 2020 and 2023, patients were included who underwent intraoral resection of midface/orbit segments (Brown Classes I-VI) as a result of malignant diseases. In all cases, immediate reconstruction was accomplished by utilizing the facial vessels through an intraoral approach. Outcome criteria were identification of vessels, parotid duct or facial nerve damage, success of vascular anastomoses, and flap survival. (3) Results: A total of 117 patients with 132 flaps (91 osseous and 41 cutaneous) were included. The intraoral preparation of facial vessels was successfully completed in less than 1 h, and no complications related to the dissection or anastomoses were observed. In two cases, the vessel diameter was insufficient to facilitate anastomoses, necessitating adopting an extraoral approach. During a follow-up period of 48 months, two osseous flaps were lost, accounting for a 1.5% loss rate out of 132 flaps used. Additionally, 3 flaps experienced partial loss, including a skin island of a scapula, the border zone of a femur, and a rectus flap, resulting in a 2.3% partial loss rate out of 130 flaps utilized. (4) Conclusions: This case series underscores the feasibility of employing intraoral anastomoses for immediate complex midface reconstruction following oncological resection. This approach is particularly advantageous for flaps with shorter pedicles, as it helps mitigate external scarring and minimizes the risk of facial nerve injury.

Recipient vessels for free flaps in advanced facial oncologic defects

OBJECTIVES

To prospectively compare the results of microvascular flap reconstruction of midface and scalp advanced oncologic defects using superficial temporal versus cervical as recipient vessels.

METHODS

This is a parallel group clinical trial with 1:1 allocation ratio of patients who underwent midface and scalp oncologic reconstruction with free tissue flap from April 2018 to April 2022 in a tertiary oncologic center. Two groups were analyzed: those in whom superficial temporal vessels were used as the recipient vessels (Group A) and those in whom cervical vessels were used as the recipient vessels (Group B). Patient gender and age, cause and localization of the defect, flap choice for reconstruction, recipient vessels, intraoperative outcome, postoperative course, and complications were recorded and analyzed. A Fisher's exact test was used to compare outcomes between the 2 groups.

RESULTS

On the basis of the different recipient vessels, 32 patients were randomized into 2 groups, and of these 27 patients completed the study: Group A with superficial temporal recipient vessels (n = 12) and Group B with cervical recipient vessels (n = 15). There were 18 male and 09 female patients with an average age of 53.92 ± 17.49 years. The overall flap survival rate was 88.89%. The overall complication rate for vascular anastomosis was 14.81%. The total flap loss rate in patients with superficial temporal recipient vessels was higher than the complication rate in those with cervical recipient vessels but with no statistical significance (16.67% vs. 6.66%, p = 0.569). Minor complications occurred in 05 patients without statistical significance between the groups (p = 0.342).

CONCLUSION

In the group with superficial temporal recipient vessels, the postoperative rate of free flap complications was similar than the cervical recipient vessel group. Therefore the use of superficial temporal recipient vessels for midface and scalp oncologic reconstruction could be a reliable option.

Composite grafts made of polycaprolactone fiber mats and oil-based calcium phosphate cement pastes for the reconstruction of cranial and maxillofacial defects

OBJECTIVES

Synthetic bone substitutes which can be adapted preoperatively and patient specific may be helpful in various bony defects in the field of oral- and maxillofacial surgery. For this purpose, composite grafts made of self-setting and oil-based calcium phosphate cement (CPC) pastes, which were reinforced with 3D-printed polycaprolactone (PCL) fiber mats were manufactured.

MATERIALS AND METHODS

Bone defect models were acquired using patient data from real defect situations of patients from our clinic. Using a mirror imaging technique, templates of the defect situation were fabricated via a commercially available 3D-printing system. The composite grafts were assembled layer by layer, aligned on top of these templates and fitted into the defect situation. Besides, PCL-reinforced CPC samples were evaluated regarding their structural and mechanical properties via X-ray diffraction (XRD), infrared (IR) spectroscopy, scanning electron microscopy (SEM), and 3-point-bending testing.

RESULTS

The process sequence including data acquisition, template fabrication, and manufacturing of patient specific implants proved to be accurate and uncomplicated. The individual implants consisting mainly of hydroxyapatite and tetracalcium phosphate displayed good processability and a high precision of fit. The mechanical properties of the CPC cements in terms of maximum force and stress load to material fatigue were not negatively affected by the PCL fiber reinforcement, whereas clinical handling properties increased remarkably.

CONCLUSION

PCL fiber reinforcement of CPC cements enables the production of very freely modelable three-dimensional implants with adequate chemical and mechanical properties for bone replacement applications.

CLINICAL RELEVANCE

The complex bone morphology in the region of the facial skull often poses a great challenge for a sufficient reconstruction of bony defects. A full-fledged bone replacement here often requires the replication of filigree three-dimensional structures partly without support from the surrounding tissue. With regard to this problem, the combination of smooth 3D-printed fiber mats and oil-based CPC pastes represents a promising method for fabricating patient specific degradable implants for the treatment of various craniofacial bone defects.

Classification of maxillectomy in edentulous arch defects, algorithm, concept, and proposal classifications: A review

OBJECTIVES

Aramany's classification of postsurgical maxillectomy defects was introduced for partially edentulous situations, and has been widely used for education and effective communication among practitioners. Numerous classifications of maxillofacial defects, based on surgical procedure, resultant defects, or prosthodontist's perspective after rehabilitation, exist in the literature. However, no single classification has incorporated all these factors. The purpose of this review was to highlight the classification systems and describe a pragmatic classification series for edentulous maxillary arch defects (maxillectomy) by applying the Aramany classification criteria, to enhance treatment outcomes and communication among practitioners.

MATERIAL AND METHODS

An electronic search of the literature published in English was conducted using the PubMed/MEDLINE and Google Scholar database. Keywords used were "maxillectomy classification" AND "surgical resection," "maxillectomy classification" AND "complete edentulous." In addition, a manual search was also performed followed the same criteria in the following journals: Journal of Prosthetic Dentistry and Journal of Prosthodontics.

RESULTS

Several classification systems for partial dentition were found in terms of size, location, dentition, and extension of the defect (isolated or communication defects). The findings revealed a variety of maxillectomy defect classifications for partially dentate, considering surgical factors and rehabilitation. However, no study or classification system exist for the edentulous arch defects.

CONCLUSIONS

Different classification systems for maxillectomy defects exist in the literature, only for partially dentate patients. To the authors best knowledge, no classification system for completely edentulous maxillary arch defects have been proposed till date. A simple classification system with clear characteristics for edentulous maxillectomy dental arch defects has been proposed. This classification was modeled after Aramany classification for easier memorization and application.

The Role of Full-Thickness Skin Grafts in Patient’s Rehabilitation after Maxillectomy and Midface Defects

(1) Background: Nowadays, microvascular grafts are the gold standard in the reconstruction of midface defects after maxillectomy, however, not all patients may qualify for this type of surgery. The purpose of present study is to evaluate the benefits of alternative reconstruction methods such as full-thickness skin grafts for these conditions. (2) Methods: The research group consisted of 37 patients who underwent maxillectomy due to cancer of the mid-face and had full-thickness skin graft reconstruction. The study covered the period from 2011 to 2020. (3) Results: Based on the clinical examination and the subjective assessment of patients, a positive effect of the use of free skin grafts on their convalescence and rehabilitation was found. In particular, they contributed to the reduction in postoperative pain and pain associated with prosthetic stages (VAS Scale). (4) Conclusion: Full-thickness skin grafts in combination with individual prosthetic restorations are a good alternative to rehabilitation in patients who do not qualify for microsurgical treatment.

Changing trends in the microvascular reconstruction and oral rehabilitation following maxillary cancer

Purpose

The maxillectomy defect is complex and the best means to achieve optimal reconstruction, and dental rehabilitation is a source of debate. The refinements in zygomatic implant techniques have altered the means and speed by which rehabilitation can be achieved and has also influenced the choice regarding ideal flap reconstruction. The aim of this study is to report on how the method of reconstruction and oral rehabilitation of the maxilla has changed since 1994 in our Institution, and to reflect on case mix and survival.

Methods

Consecutive head and neck oncology cases involving maxillary resections over a 27-year period between January 1994 and November 2020 were identified from hospital records and previous studies. Case note review focussed on clinical characteristics, reconstruction, prosthetic rehabilitation, and survival.

Results

There were 186 patients and the tumour sites were: alveolus for 56% (104), hard palate for 19% (35), maxillary sinus for 18% (34) and nasal for 7% (13). 52% (97) were Brown class 2 defects. Forty-five patients were managed by obturation and 78% (142/183) had free tissue transfer. The main flaps used were radial (52), anterolateral thigh (27), DCIA (22), scapula (13) and fibula (11). There were significant changes over time regarding reconstruction type, use of primary implants, type of dental restoration, and length of hospital stay. Overall survival after 24 months was 64% (SE 4%) and after 60 months was 42% (SE 4%).

Conclusion

These data reflect a shift in the reconstruction of the maxillary defect afforded by the utilisation of zygomatic implants.

Technical Considerations in Pedicle Management in Upper and Midfacial Free Flap Reconstruction

OBJECTIVES

Mid and upper face free flaps frequently are associated with challenges due to pedicle length. We sought to evaluate the frequency at which alternative pedicle maneuvers were required for these reconstructions and determine if there was any association with flap survival or postoperative complications.

STUDY DESIGN

Retrospective review at three tertiary care institutions.

METHODS

Database review.

RESULTS

Free flap reconstruction of the upper and midface was performed in 295 patients (108 bony, 187 soft tissue). In 82% of cases, the vessels reached the ipsilateral neck for anastomosis to traditional target vessels. Arterial grafts were required in 2% of reconstructions (4% bony and 1% soft tissue). Venous grafting was required in 7% of reconstructions (21% fibula, 16% scapula, and 3% soft tissue) and was associated with an increase in flap failure rate (19% vs 3%, P = .003). The most common recipient artery for revascularization was the cervical facial artery (78%). Alternate recipient vessels were selected in 13% of cases, including the superficial temporal vessels (7%), distal facial branches through a separate facial incision (4%), and angular vessels (2%). Vein grafting was associated with a higher flap failure rate. Alternative maneuvers did not affect need for intraoperative pedicle revision or complications.

CONCLUSIONS

In upper and midface reconstruction, vascular grafting, targeting more distal branches of the facial system, or additional maneuvers to optimize pedicle orientation is often required to secure revascularization. Vein grafting is associated with a higher free flap failure rate. Scapular border flaps often require vascular grafting or atypical anastomotic locations.

LEVEL OF EVIDENCE

3-Non randomized cohort study 4 Laryngoscope, 2021.

Dentoalveolar outcomes in maxillary reconstruction: A retrospective review of 85 maxillectomy reconstructions

BACKGROUND

Although microvascular free flaps are often used to reconstruct maxillary defects, dentoalveolar rehabilitation is arguably less common despite its importance to midface function and aesthetics. The aim of this study is to review the contemporary management of maxillary defects in a single quaternary referral institution to identify factors that assist or impede dentoalveolar rehabilitation.

METHODS

A retrospective review of maxillary reconstructions performed between February 2017 and December 2020 was performed. Patient characteristics, defect classification, operative techniques, complications and dentoalveolar outcomes were recorded.

RESULTS

A total of 85 maxillary reconstructions were performed in 73 patients. Of the 64 patients where dental rehabilitation was required, 31 received a functional denture (48%) with 24 (38%) being implant-retained. Significant predictors of successful rehabilitation included the use of virtual surgical planning (VSP; 86% vs. 25%, p < 0.001), preoperative prosthodontic assessment (82% vs. 21%, p < 0.001), prefabrication (100% vs. 40%, p = 0.002) and use of the zygomatic implant perforator flap technique (100% vs. 39%, p = 0.001). Preoperative prosthodontic consultation was associated with 21-fold increase in the odds of rehabilitation (odds ratio 20.9, 95% confidence interval 6.54-66.66, p < 0.005).

CONCLUSION

Preoperative prosthodontic evaluation, VSP and reconstructive techniques developed to facilitate implant placement are associated with increased dental rehabilitation rates. Despite using an institutional algorithm, functional dentures are frequently prevented by factors including soft tissue constraints, disease recurrence and patient motivation.

Partial and Total Flap Failure after Fibula Free Flap in Head and Neck Reconstructive Surgery: Retrospective Analysis of 180 Flaps over 19 Years

Fibula free flap (FFF) is widely used in head and neck reconstructive surgery and is considered as a standard and therapy of choice after ablative cancer surgery. The aim of this retrospective monocenter study was to determine the success rates of fibula free flaps for jaw reconstruction after ablative tumor surgery. The disease course of patients who underwent jaw reconstructive surgery with FFF from January 2002 to June 2020 was evaluated regarding the flap success rate. Flap failure was analyzed in detail and categorized into two groups: partial flap failure (PFF) and total flap failure (TFF). A total of 180 free fibular flaps were performed over the last 19 years and a total of 36 flap failures were recorded. TFF occurred in n = 20 (56.6%) and PFF in n = 16 cases (44.4%) cases. No statistically significant differences were found concerning patients' age at flap transfer, sex, BMI, ASA-Score, preoperative non-virtual or virtual surgical planning (non-VSP vs. VSP), and time of reconstruction (immediately vs. delayed). Duration of hospitalization shows statistically significant differences between both groups (p = 0.038), but no differences concerning operating time and duration on Intensive Care Unit (ICU). Partial flap failure appears to be underreported in literature. Sub- and complete failure of the skin paddle leads to clinical complaints like uncovered bone segments and plate exposure. Partial or complete FFF failure lead to infections on the recipient site and prolonged wound healing and therefore may cause a delay of the beginning of adjuvant radiation therapy (RT). PFF of hard tissue can be induced by RT.

Considerations in Free Flap Reconstruction of the Midface

Midface reconstruction has been a consistent challenge for reconstructive surgeons even with the significant advances in technology and technique achieved over the recent years. A meticulous preoperative assessment of the patient is required to properly assess the defect or anticipated defect, determine proper reconstructive surgical plan, and discuss expected functional and aesthetic outcomes with the patient. For years we have employed local flaps, regional flaps, obturators, alloplastic implants, free flaps, or a combination of the previously mentioned techniques to address complex midface reconstruction. Free flap reconstruction in the midface requires special considerations for the pedicle, flap selection, and flap design to ensure an optimal outcome. The introduction of virtual surgical planning for reconstruction has enhanced patient outcomes to include advances in immediate dental rehabilitation at the time of free flap surgery. Postoperative considerations including quality of life, functional and aesthetic outcomes, and management of complications will also be discussed.

Serializing prosthetic rehabilitations to minimize time for patients with a maxillectomy without dentoalveolar support

An oral prosthesis can help maintain a sense of normalcy by preserving psychosocial and physiologic function in the aftermath of a maxillary resection. Rehabilitating the resulting defect in a timely manner requires strategic choices in treatment sequencing and prosthetic design. This clinical report describes the process of fabricating a series of removable and implant-retained prostheses to minimize a patient's time without the restoration of critical craniofacial structures.

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.

Role of multi-detector CT in analysis of the greater and lesser palatine foramina

Background

The objective of this study was to assess variation in number, size, shape, and location of greater and lesser palatine foramina using multiple anatomical landmarks through data obtained from adult head CT scans. CT skulls of 200 adult persons were included in this study. There were 100 males and 100 females, aged from 22 to 65 years old. An e-film DICOM viewer version 2 was applied to estimate morphological parameters and to calculate the linear measurements related to the greater palatine foramen.

Results

On the basis of CT findings, regarding the position of GPF in relation to maxillary molar teeth, the most frequent location was opposite the third maxillary molar (41%). Regarding the dimensions of the GPF, the mean AP diameter was 3.94 ± 1.13 mm on the right side and 4.22 ± 1.21 mm on the left. The mean LM diameter was 2.17 ± 0.59 mm on the right side and 2.28 ± 0.74 mm on the left. It was concluded that the GPF was AP elongated in 90.5% and circular in 9.5% of the examined CT scans. Linear measurements from the center of GPF to surrounding anatomical landmarks were done and showed no statistically significant difference existed between sides, but a statistically highly significant difference existed between males and females.

Conclusions

Proper localization of GPF is important to facilitate therapeutic, local anesthetic, and surgical manipulation in the maxillofacial region. Based on CT findings, we demonstrated that the GPF is most often located opposite the M3 in the majority of the cases. The maxillary molars are the best landmarks for locating the GPF.

Primary Maxillary Reconstruction With Fibula Flap and Dental Implants: A Comparative Study Between Virtual Surgical Planning and Standard Surgery in Class IIC Defects

PURPOSE

Oncological patients who undergo bilateral subtotal maxillectomies develop functional and esthetic sequelae that require immediate reconstruction. The purpose of this study is to evaluate the primary reconstruction of maxillary defects with fibula flap and dental implants assisted by virtual surgical planning (VSP) and to assess the postoperative outcomes compared with standard surgery.

MATERIAL AND METHODS

A retrospective study was designed between January 2016 and April 2020 with 12 oncologic patients who underwent subtotal bilateral maxillectomy. Six consecutive patients were treated by standard surgical procedure (SS) at the beginning of the study. In 2018, the VSP was implemented, and 6 consecutive patients were treated using this technique. All patients were rehabilitated with Ticare implants and implant prostheses. Anatomic position of the bone, bone apposition, change of vertical distance, and horizontal shift, the operative and ischemia time, the esthetic results, and the functional rehabilitation were evaluated and compared.

RESULTS

The position of the bone in anatomical position was 100% in the VSP group vs 66% in the SS group. The bone apposition was 100% in the VSP group vs 83.3%. The change of vertical distance and the horizontal shift were lower in the VSP group (P < .05). The ischemia time and operative time were shorter in the VSP group (P < .05). A good esthetic result was achieved in 83.3% in the VSP group vs 33.3% in the SS group; 81 dental implants and 1 zygomatic implant were placed. The success rate was 95% in the VSP group and 92.6% in the SS group. All patients were rehabilitated with implant prosthesis.

CONCLUSIONS

VSP improves the accuracy of midface reconstruction (class IIC defect) with a better anatomical position of the bone, a higher rate of bone contact, and a lower change in vertical distance compared with standard surgery. It significantly improves the esthetic result, reduces ischemia time, and operation time.

Outcomes of microvascular bone flaps versus osteocutaneous flaps in head and neck reconstruction

BACKGROUND

Surgical resection of head and neck (H&N) neoplasms requiring osseous reconstruction have underdefined complication profiles. This study aimed to characterize postoperative outcomes of patients with H&N neoplasia undergoing osteocutaneous flap (OCF) or bare bone flap (BBF) reconstructions.

MATERIALS AND METHODS

Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) 2005-2017 databases. Queried for diagnosis and procedural codes extracted patients with H&N neoplasms undergoing BBF or OCF reconstruction. Postoperative complications were evaluated. Multivariable regression generated adjusted odds ratios.

RESULTS

A cohort of 746 patients were identified. Of reconstructions, 24.9% (n = 186/746) were BBFs while 75.1% (n = 560/746) were OCFs. 58.1% of the BBF cohort and 59.9% of the OCF cohort experienced an all-cause complication (p = .654). Sub-stratified, 24.2% of BBF and 17.5% of OCF patients experienced a wound complication (p = .045). Regression analysis demonstrated no difference in risk for medical complications between cohorts. However, patients receiving OCFs had a decreased likelihood of developing a wound complication (OR 0.652; 95%CI 0.430-0.989; p = .044) compared to patients receiving BBFs.

CONCLUSION

The incidence of complications following osseous reconstruction of the H&N is considerable. Although several complication outcomes do not seem to differ between BBF or OCF reconstructions, OCFs is associated with a decreased likelihood of wound complications.

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.

Are zygomatic implants a simple and reliable technique for the stabilization of obturator prostheses? Case report and review of the literature

Zygomatic implants have been used for several years for the treatment of extremely resorbed maxilla. Indications were extended for oral rehabilitations after maxillectomy in oncologic patients. A 24-year old patient with a triple A syndrome who underwent a left maxillectomy due to a spinocellular tumour was addressed for prosthetic rehabilitation. As his obturator prosthesis failed, surgical closure of the defect combined with 2 zygomatic implants to support the prosthesis was proposed. Despite a small persistent oro-antral fistula, the new obturator prosthesis restored the patient's functions and esthetics and improved his quality of life. The literature reports less than 40 cases of maxillectomy patients rehabilitated with zygomatic implants (with or without flap closure of the defect). Regardless of implant placement, there is no significant difference between reconstructive surgery and obturator prosthesis. Thus, zygomatic implants seem to be a reliable method for the stabilization of obturator prosthesis, without complex surgical procedure. Nonetheless, reservations should be expressed given the lack of data in terms of long-term follow up.

Mirror Image Based Three-Dimensional Virtual Surgical Planning and Three-Dimensional Printing Guide System for the Reconstruction of Wide Maxilla Defect Using the Deep Circumflex Iliac Artery Free Flap

A patient was diagnosed with squamous cell carcinoma of the maxillary sinus and consequently underwent a unilateral total maxillectomy and reconstruction using an anterolateral thigh (ALT) free flap. Soft tissue transplantation without a bone graft at the large maxillary defect site caused a midfacial collapse, which worsened, especially after radiotherapy. The 3-dimensional positioning of the composite flap for wide maxillary reconstruction is aesthetically important. To achieve ideal symmetry and aesthetics, a mirror image was created using the normal contralateral side. Through computer simulation, the function and symmetry of the virtually reconstructed maxilla was evaluated, and the surgical guide was made using a 3D printing system. Based on the prepared surgical guide, a deep circumflex iliac artery (DCIA) free flap was harvested, and its implementation in the reconstruction ultimately led to satisfactory results. Utilization of mirror image based virtual surgical planning and a 3D printing guide is a significantly effective method for maxilla reconstruction with DCIA flaps.

Soft tissue reconstruction with anterior pedicled inferior turbinate flap in conjunction with palatal flap for standard inferior maxillectomy with hard palate resection

BACKGROUND

The defect after surgical resection of sinonasal malignant tumors is normally reconstructed using free flaps obtained from donor sites. There is no report of using the palatal island flap to reconstruct defects after surgery. We aimed to describe our technique of soft tissue reconstruction through anterior pedicled inferior turbinate (APIT) flap in conjunction with palatal flap for standard inferior maxillectomy with hard palate resection and its outcomes and to discuss its advantages and disadvantages compared with free-flap reconstruction.

METHODS

For resection of malignant tumors arising from the anterior nasal septum, we preserved the hard palate during maxillectomy using a palatal island flap and an anterior pedicled inferior turbinate flap.

RESULTS

One patient developed a small oroantral fistula, which was sealed with a denture. The other patient had a good outcome.

CONCLUSION

Our technique of maxillectomy is useful for selected cases of sinonasal malignancy that require maxillary floor resection.

Classification, History, and Future Prospects of Maxillofacial Prosthesis

This review presents a classification system for maxillofacial prostheses, while explaining its types. It also aims to describe their origin and development, currently available materials, and techniques, predicts the future requirements, and subsequently discusses its avenues for improvement as a restorative modality. A literature search of the PubMed/Medline database was performed. Articles that discussed the history, types, materials, fabrication techniques, clinical implications, and future expectations related to maxillofacial prostheses and reconstruction were included. Fifty-nine articles were included in this review. Maxillofacial prostheses were classified as restorative or complementary with subclassifications based on the prostheses finality. The origin of maxillofacial prostheses is unclear; however, fabrication techniques and materials have undergone several changes throughout history. Currently, silicones and acrylic resins are the most commonly used materials to fabricate customized prostheses. Maxillofacial prostheses not only restore several types of orofacial defects but also improve the patients' quality of life. Although the current clinical scenario concerning the field of maxillofacial prostheses is promising, improvements in material quality and techniques for maxillofacial prostheses may be expected in the future, to produce better results in the treatment of patients.

Technique for secondary modification after maxillary resection and reconstruction for soft tissue flap fixation before prosthesis addition: a case report

Background

The removal of maxillary carcinoma causes various types of tissue defects, which can be corrected by free flap reconstruction. In flap reconstruction after maxillary cancer resection, ensuring prosthesis stability is frequently difficult owing to the flap’s weight. Therefore, a second modification technique is required for improvement of configuration. This case where flap suspension and flap modifying surgery were performed using anchor system for the extensive complete maxillectomy case.

Case presentation

The patient was a 56-year-old male, who underwent an extensive total maxillectomy and flap reconstruction using the rectus abdominus muscles in May 2005. Postoperatively, due to the difficulties of wearing a maxillary denture, he was transferred to our department with the chief complaint of morphological improvement. The maxillary bone had already been removed from the midline with the rectus abdominus muscle flap sutured directly to the soft palate without oral vestibule, and the flap margin was moving together with the surrounding soft tissue. The flap size was 70 × 50 mm, which was sagging due to its own weight and was in contact with mandibular molars, reducing the volume of the oral cavity without a denture being worn. Flap reduction and lifting the flap were performed under general anesthesia using 3 Mitek anchors implanted in the zygomatic bone, and the anchor suture was placed through the subcutaneous tissue to lift the flap. Postoperatively, the prosthesis was stable. No recurrence of flap sagging or wound infection was seen 3 years after surgery.

Conclusions

The second modification technique after maxillary cancer resection is useful for ensuring prosthesis stability. This method can be used before prosthesis addition. We could obtain remarkable denture stability by flap suspension using anchor system and a flap-modifying operation for the patient who had undergone maxilloecotomy. The denture was stabilized by using anchors for the elevated flap and flap loss technique and by performing vestibuloplasty for support.

Frontal sinus augmentation: Preliminary results of a new approach in prosthetic orbital reconstruction

PURPOSE

Reliable application of endosseous implants for prosthetic facial reconstruction depends on the bone volume available at the defect site. Regarding the orbit, sufficient bone presentation in the medial superior orbital rim is limited due to the frontal sinus. The aim of this article is to report for the first time on the augmentation of the frontal sinus for gaining bone volume for supraorbital implant placement.

MATERIALS AND METHODS

Between 2007 and 2014, five patients with orbital exenteration were treated by frontal sinus augmentation using autogenous cancellous bone graft from the ilium. Extraoral implants for prosthetic orbit reconstruction were placed 4-7 months later. In advance, cadaver surgery was performed to prove the feasibility of the method. Surgical technique is described, and intraoperative images are provided.

RESULTS

The frontal sinus was successfully augmented in all five patients. No major complications related to the procedure were observed. A total of nine orbital implants were inserted in the augmented bone, thereof one sleeping implant. Six implants were restored prosthetically, two implants were lost at exposure. The observation period ranged from 6 to 97 months (mean: 52.8 months). Mean time for patient rehabilitation was 13 months. High patient satisfaction was achieved with the implant-retained orbital prosthesis.

CONCLUSION

The augmentation of the frontal sinus allows implant placement by providing sufficient bone volume in the medial supraorbital rim. Considering the surgical success of this method and patient satisfaction, this new approach is concluded to be a viable option in a unique subset of patients.

Soft Tissue Reconstruction for Head and Neck Ablative Defects

Soft tissue reconstruction of head and neck ablative defects is a broad, challenging, and subjective topic. The authors outline goals to keep in mind when deciding on a primary reconstructive option for defects created by oncologic resection. Factors considered in local, regional, and distant flap selection are discussed. Based on the goals of reconstruction and factors involved in flap selection, a defect-based reconstructive algorithm is developed to help choose the ideal reconstructive option. The authors also discuss indications, pearls, pitfalls, and challenges in the harvest and inset of commonly used soft tissue flaps for head and neck reconstructive surgery.

Free Flap Reconstruction of the Maxilla

Tumors of the maxilla and midface are some of the most difficult to manage, not only in terms of treatment but also in terms of achieving acceptable orofacial reconstruction. Today, free flaps dominate the reconstructive field. Many patients can achieve successful reconstruction after free flap transfer with a return of intelligible speech, a regular diet, and acceptable cosmesis. Herein, the authors review free flap reconstruction of the maxilla, with a focus on the classifications of defects, when obturators are appropriate, types and sources of free flaps, and complications for which to beware.

Primary vs secondary zygomatic implant placement in patients with head and neck cancer-A 10-year prospective study

BACKGROUND

Zygomatic implants can provide excellent remote anchorage to support the prosthetic rehabilitation of patients treated for maxillary and midfacial tumors.

METHODS

Patients who underwent zygomatic implant placement by the author between 2006 and 2016 as part of their oncology treatment were followed prospectively.

RESULTS

Forty-nine consecutively treated patients received 131 zygomatic implants of which 9 failed and were removed from 4 patients; 24 patients (49%) received radiotherapy either before or after implant insertion. The overall 12-month survival estimate was 94% and the 60-month estimate was 92%.

CONCLUSIONS

The use of zygomatic implants in the management of maxillary and midfacial malignancy is a predictable prosthetic treatment modality to support complex oral and facial prostheses. Their use with or without free tissue transfer can provide effective prosthetic rehabilitation with high implant survival irrespective of the timing of placement or the need for adjuvant radiotherapy.

CLINICAL SIGNIFICANCE

Zygomatic Implants provide an excellent platform for the restoration of the dentition and facial structures affected by maxillary and midfacial malignant disease.

Maxillary reconstruction using rectus femoris muscle flap and sagittal mandibular ramus/coronoid process graft pedicled with temporalis muscle

BACKGROUND

Maxillary reconstruction using various pedicled and free-tissue transfer techniques with bone graft or without bone graft has some drawbacks. In this study, we demonstrate maxillary reconstruction using femoris rectus muscle flap and sagittal mandibular ramus/coronoid process graft pedicled with temporalis muscle through the modified lateral lip-submandibular approach.

MATERIAL AND METHODS

Nine patients suffering from maxillary defects secondary to maxillary cancer ablation, who underwent maxillary reconstruction using rectus femoris muscle flap and sagittal mandibular ramus/coronoid process graft pedicled with temporalis muscle, were enrolled into this study between November 2015 and August 2017.

RESULTS

All patients who underwent the maxillary reconstruction using femoris rectus muscle flap and sagittal mandibular ramus/coronoid process graft pedicled with temporalis muscle presented satisfactory postoperative function, with adequate mouth opening, optimal esthetic outcome and no restrictions on the diet. Every rectus femoris muscle flaps mucosalized well within five weeks. No donor site functional impairment or complications were observed.

CONCLUSIONS

The technique is a feasible and acceptable technique for the maxillary reconstructions. It is safe, quick and simple to harvest. It also presents an optimal esthetic and satisfactory functional outcome with the advantage of low morbidity of the donor site. Combined with the three-dimension reconstruction, this technique can improve the postoperative outcomes.

Oral rehabilitation of patients after maxillectomy. A systematic review

Patients who have maxillectomy can be rehabilitated with reconstructive surgery or obturator prostheses with or without osseointegratable implants. To identify studies on possible treatments in this group, we systematically searched the Scopus, Embase, PubMed/Medline, and Cochrane databases to collect data on patients' characteristics, radiotherapy, and results related to speech, swallowing, mastication or diet, chewing, aesthetics, and quality of life. Of the 1376 papers found, six were included, and one other was included after an additional search of references. A total of 252 patients were included, and of them, 86 had reconstructive surgery, 91 were treated with obturator prostheses, 39 had reconstructive surgery or obturator prostheses associated with implants, and 36 had reconstruction plus an obturator prosthesis. Data on radiotherapy were incomplete. There is a lack of consensus about the indication for rehabilitation, as the treatment must be based on the individual characteristics of each patient.

Prosthetic versus surgical rehabilitation in patients with maxillary defect regarding the quality of life: systematic review

PURPOSE

To assess the ability of prosthetic rehabilitation versus surgical rehabilitation in improving the QOL for patients with maxillary defects.

MATERIAL AND METHODS

A systematic search of PubMed, Scopus data base, Cochrane database, Ovid database, and Latin America & Caribbean database for articles published before September 2017 was performed by two independent reviewers. A manual search of articles published from January 2000 to September 2017 was also conducted. Only English studies were included which evaluate the QoL in patients with head and neck cancers. Any confusion between the two independent reviewers was resolved by means of a moderated discussion between the reviewers.

RESULTS

Five studies fulfilled the inclusion criteria for this study. Many parameters were used regarding evaluation of QOL as the EORTC Head and Neck 35 assessment, UW-QOL, OHIP-14, VAS, OFS, MHI, HAD, Body Satisfaction Scale, Oral symptom check list, Swallowing, Diet consist, Pain control, Postoperative complication, and Speech. Two studies supported the surgical line of treatment for improving the QOL as compared to the prosthetic one; another two studies showed a statistically insignificant improvement in the patients' QOL with the surgical line, while only one revealed insignificant difference in QoL with both lines of treatment.

CONCLUSIONS

Surgical rehabilitation provides a better line of treatment in improving the QOL for patients with maxillary defects. On the other hand, prosthetic has proved effectiveness in the immediate post-surgical times as temporary strategy, and it has represented a good alternative when the surgical obturation is compromised.

Double palatal flap for oro-nasal fistula closure

INTRODUCTION

The management of oral fistula to the nose depends on its etiology, its size and its location. Here, we describe a simple technique, inspired by the ones initially developed by Bardach for cleft palates repair. The surgical alternatives are discussed.

TECHNICAL NOTE

The double palatal flap is a simple technique, allowing closure in a single session of a central or centro-lateral palate fistula. The key of this technique is the dissection between nasal and palate mucous layers, providing a sufficient amount of laxity to close the defect without tension.

DISCUSSION

The double palatal flap can cover centro-lateral palate mucosal fistulae. It provides both aesthetic and functional results in a single stage. Reliability, simplicity and quickness are its main advantages. Outcomes are usually simple; Velar insufficiency may occur, that can be corrected by speech therapy.

Clinicopathological Characteristics and Prognosis of Ossifying Fibroma in the Jaws of Children: A Retrospective Study

BACKGROUND: Ossifying fibroma in the jaws is a benign tumor and easily recurs in children, of which the treatment methods and prognosis still remain controversial. In this study, we aimed to review the clinicopathological characteristics, treatment, and prognosis of ossifying fibroma in the jaws of children, and offer recommendations for clinical decision-making. METHODS: A retrospective study was carried out on patients below the age of 18 years with ossifying fibroma in the jaws. Patients with complete clinical, pathological, and radiological records were included and followed-up. RESULTS: Sixty-three cases were collected with a preliminary search. After screening, fifty patients were included for general information analysis, of which forty-two patients were included in the recurrence analysis. Twelve patients showed a relapse, with a recurrence rate of 28.6% (12/42). The recurrence rates in cases with different surgical approaches and different X-ray boundaries were statistically different. Besides, twenty-three patients underwent reconstruction by free tissue grafting and the success rate was 96% (22/23). CONCLUSIONS: There was significant difference in the recurrence rates among different X-ray manifestations and surgical methods. An extended resection and reconstruction with free tissue grafting was a reliable method with a 96% success rate.

Free-flap surgical correction of facial deformity after anteromedial maxillectomy

Anteromedial maxillectomy is typically performed in conjunction with low-dose radiotherapy and intraarterial chemotherapy. In doing so, the extent of surgical defects is reduced. However, nasal deviation and oral incompetence may ensue, due to cicatricial contracture of wounds, and may be distressing to these patients. Herein, we report a series of eight free perforator flap procedures (anterolateral thigh [ALT] flap, 6; thoracodorsal artery perforator [TAP] flap, 2) used to correct such deformities. The TAP flap was combined with scapular tip [ST] osseous flap in patients with added zygomatic prominence defects. Three adipocutaneous parts developed from each perforator flap were applied as follows: two to reconstruct nasal lining and oral vestibule, and one to augment cheek volume. All aesthetic results proved satisfactory, although orbital dystopia and contracture of mimic muscles were not resolved completely. These secondary interventions are suitable for sequelae of simple anteromedial maxillectomy. Immediate reconstruction should be considered if orbital floor and mimic muscles are involved.

Maxillary Reconstruction Using Submental Artery Island Flap and Sagittal Mandibular Ramus/Coronoid Process Graft Pedicled With Temporalis Muscle

PURPOSE

The purpose of this study is to describe maxillary reconstruction using the submental artery island flap and the sagittal mandibular ramus and coronoid process graft pedicled with the temporalis muscle through the modified lateral lip and submandibular approach.

MATERIALS AND METHODS

From May 2013 to September 2016, 11 patients with maxillary defects secondary to maxillary cancer ablation who underwent maxillary reconstruction using a submental artery island flap and a sagittal mandibular ramus and coronoid process graft pedicled with the temporalis muscle through the modified lateral lip and submandibular approach were enrolled in this prospective study.

RESULTS

All submental artery island flaps and sagittal mandibular ramus and coronoid process grafts were successful, with satisfactory functional and esthetic outcomes. No functional impairment at the donor site occurred in any case.

CONCLUSION

The submental artery island flap combined with the sagittal mandibular ramus and coronoid process graft is a feasible and acceptable technique for maxillary reconstruction in older patients because it is safe, quick, and straightforward to harvest and it offers a very acceptable esthetic and satisfactory outcome, with the advantage of low morbidity of the donor site. When combined with the 3-dimensional virtual operative method, the technique can improve postoperative outcomes.

Novel approach to maxillary reconstruction using osteocutaneous free tissue transfer with a customized stent

BACKGROUND

Computer-guided 3D virtual planning and customized templates are novel and effective methods aiding maxillary reconstruction, particularly during osteocutaneous free tissue transfer of complex defects. However, virtual planning and modelling is often expensive.

METHODS

We present a new method to reconstruct complex defects with a surgical stent designed from presurgical casts. We present 2 patients who underwent this technique. Reconstruction in both cases was aided by a surgical stent fashioned preoperatively to approximate the anatomic dimensions of the defect, guiding the shape and orientation of the flap during inset to aid in dental rehabilitation.

RESULTS

Surgery was performed without evidence of malocclusion, oronasal separation, or osteoradionecrosis with both patients undergoing successful rehabilitation and showing good postoperative oral intake.

CONCLUSION

Utilization of our novel surgical stent allowed reconstruction of complex maxillectomy defects and facilitated the design of a reconstructive flap without the need of pre-bent plates, cutting guides, or associated expenses.

Reconstruction of midface defect from idiopathic destructive process using Medpor implant

IMPORTANCE

Reconstruction of the midface remains a challenging task for even the most experienced surgeon, with a host of reconstructive options including free tissue transfer, allografts, or prosthetic implants. Presented here is a case of idiopathic bony destruction of the right midface in a 19year old female, creating a unique defect requiring repair.

OBJECTIVE

Demonstrate a unique case of severe maxillary degeneration and discuss the associated reconstructive challenges and final repair with a prosthetic implant.

DESIGN

Case report.

RESULTS

The patient presented with a 7month history of an idiopathic progressive deformity of the right cheek. Computed tomography of the paranasal sinuses revealed extensive bone loss of the right midface and orbit. The patient underwent facial reconstruction using a customized Medpor (Stryker Corp, Kalamazoo, MI) implant. At 6month follow-up the patient and physician were both pleased with the patient's overall appearance. The patient did have some residual lower lid retraction present as well as some lateral pull at the lateral canthus outward from the orbit itself.

CONCLUSIONS

Preoperative planning for midface reconstruction requires a deep understanding of the aesthetic, functional, and supportive roles this structure holds. Computer assistance allows the creation of custom made implants, providing the reconstructive surgeon with innovative options for reconstruction with minimal morbidity to the patient. As the technology around the design and creation of the custom implants continues to improve, the role of computer assistance in reconstruction will become more prominent.

Three-Dimensional Printing: Custom-Made Implants for Craniomaxillofacial Reconstructive Surgery

Craniomaxillofacial reconstructive surgery is a challenging field. First it aims to restore primary functions and second to preserve craniofacial anatomical features like symmetry and harmony. Three-dimensional (3D) printed biomodels have been widely adopted in medical fields by providing tactile feedback and a superior appreciation of visuospatial relationship between anatomical structures. Craniomaxillofacial reconstructive surgery was one of the first areas to implement 3D printing technology in their practice. Biomodeling has been used in craniofacial reconstruction of traumatic injuries, congenital disorders, tumor removal, iatrogenic injuries (e.g., decompressive craniectomies), orthognathic surgery, and implantology. 3D printing has proven to improve and enable an optimization of preoperative planning, develop intraoperative guidance tools, reduce operative time, and significantly improve the biofunctional and the aesthetic outcome. This technology has also shown great potential in enriching the teaching of medical students and surgical residents. The aim of this review is to present the current status of 3D printing technology and its practical and innovative applications, specifically in craniomaxillofacial reconstructive surgery, illustrated with two clinical cases where the 3D printing technology was successfully used.