Maxillary reconstruction: functional and aesthetic considerations

Management of a Rare Case of Central Nasal Dermoid Cyst Deformity in an Adult Patient

Congenital nasal dermoid and sinus cysts (NDSCs) are rare congenital deformities with a prevalence rate of 0.005% to 0.0025%. Early diagnosis is usually made during the first three years of life, but in some cases, the diagnosis may be delayed. The present case study elaborates the treatment course of a 22-year-old adult with a rare congenital nasal midline dermoid cyst. The patient had no family history of the deformity, and intracranial extensions were also ruled out before surgery. Open rhinoplasty technique was used along with osteotomies during the surgical process. The cyst was removed in entirety. The total operating time was six hours, and no complications were observed during the intra-operative or post-operative period. In conclusion, the case presentation focuses on various techniques and methods that can be used during surgery that have not been practiced before to correct the deformity while achieving a good aesthetic result as well.

Immediate Dental Implant Placement in the Oncologic Setting: A Conceptual Framework

Historically, immediate dental implants have been reserved for patients with benign disease, with full dental rehabilitation rarely being accomplished in the oncologic setting due to concerns related to implant survival, flap compromise, and delay in initiation of adjuvant therapy. Recent developments in technology have made immediate dental implants using virtual surgical planning safe and reliable. At Memorial Sloan Kettering Cancer Center, we have implemented a workflow for immediate dental implant placement in the oncologic patient population that has become a routine part of maxillary and mandibular reconstruction. This approach begins with a multidisciplinary virtual surgical planning session and custom dental splints to be used for cutting and inset guides. Dental implants are placed intraoperatively at the time of tumor resection and reconstruction with the fibula flap. A temporary prosthesis, which can be worn during radiation therapy, is placed following a vestibuloplasty, approximately 4–6 weeks after the initial reconstruction. After the completion of radiation therapy and the resolution of edema, a permanent prosthesis is placed. When critically evaluating our experience, we have found that patients undergoing immediate dental implant placement have higher rates of implant survival and no delay in adjuvant therapy. The protocol described here in detail has successfully expanded the indications for immediate dental rehabilitation in the oncologic patient population.

Virtual Surgical Planning of Deep Circumflex Iliac Artery Flap for Midface Reconstruction

Objective

Midface reconstruction is challenging for functional and esthetic reasons. The present study analyzed the effect of virtual surgical planning (VSP) of the deep circumflex iliac artery (DCIA) flap for midface reconstruction.

Patients and Methods

Thirty-four patients who underwent midface reconstruction with the DCIA flap were included in this retrospective study. Of the 34 patients, 16 underwent preoperative VSP, which used a three-dimensionally printed surgical guide, computer-assisted navigation system, and pre-bent titanium implants to transfer VSP into real-world surgery. The other 18 patients underwent traditional midface reconstruction. The following were compared between the two groups: bony contact rate in the buttress region (BCR), dental arch reconstruction rate (DAR), surgical approach, position of vascular anastomosis, and dental implantation rate. The independent-samples t-test and Fisher's exact test were used for analysis. P < 0.05 was considered statistically significant.

Results

In total, 12 males and 22 females were included in this study. All patients underwent midface reconstruction using the DCIA flap at the same institution. The median age of patients was 33 years (range: 16-68 years). The average BCR and DAR values in the VSP group were 59.4% ± 27.9% and 87.5% ± 18.9%, respectively, which were significantly higher compared with the non-VSP group (P = 0.049 and P = 0.004, respectively). The dental implantation rate in the VSP group (50.0%) was significantly higher compared with the non-VSP group (11.1%; P = 0.023). The intraoral approach for tumor ablation and vascular anastomosis was the most frequent choice in both groups. There was no significant difference between the two groups. All patients were satisfied with facial symmetry postoperatively.

Conclusions

VSP could effectively augment the effect of midface reconstruction with the DCIA flap. Stronger bone contact in the buttress region and higher DAR provide more opportunity for dental implantation, which might be the best solution to improve masticatory function in patients with midface defects.

Accuracy of Computer-Assisted Surgery in Maxillary Reconstruction: A Systematic Review

Computer-assisted surgery (CAS) in maxillary reconstruction has proven its value regarding more predictable postoperative results. However, the accuracy evaluation methods differ between studies, and no meta-analysis has been performed yet. A systematic review was performed in the PubMed, Embase, and Cochrane Library databases, using a Patient, Intervention, Comparison and Outcome (PICO) method: (P) patients in need of maxillary reconstruction using free osteocutaneous tissue transfer, (I) reconstructed according to a virtual plan in CAS software, (C) compared to the actual postoperative result, and (O) postoperatively measured by a quantitative accuracy assessment) search strategy, and was reported according to the PRISMA statement. We reviewed all of the studies that quantitatively assessed the accuracy of maxillary reconstructions using CAS. Twelve studies matched the inclusion criteria, reporting 67 maxillary reconstructions. All of the included studies compared postoperative 3D models to preoperative 3D models (revised to the virtual plan). The postoperative accuracy measurements mainly focused on the position of the fibular bony segments. Only approximate comparisons of postoperative accuracy between studies were feasible because of small differences in the postoperative measurement methods; the accuracy of the bony segment positioning ranged between 0.44 mm and 7.8 mm, and between 2.90° and 6.96°. A postoperative evaluation guideline to create uniformity in evaluation methods needs to be considered so as to allow for valid comparisons of postoperative results and to facilitate meta-analyses in the future. With the proper validation of the postoperative results, future research might explore more definitive evidence regarding the management and superiority of CAS in maxillary and midface reconstruction.

Premaxillary Deficiency: Techniques in Augmentation and Reconstruction

Progressive premaxillary retrusion is a common sequela of the facial aging process. In most cases, this manifests with central maxillary recession. Central maxillary insufficiency is also commonly encountered within certain ethnic communities, or in cleft lip nasal deformity, and may represent a challenge for the plastic and reconstructive surgeon attempting correction in the setting of facial contouring, rhinoplasty, or reconstruction following oncologic resection or trauma. Aesthetically, premaxillary retrusion may be coincident with an acute nasolabial angle and ptotic nasal tip. Minor deformities may be addressed with use of either alloplastic implants, autogenous tissue, lipotransfer, or injectable filler. Larger composite defects may require reconstruction with implementation of free tissue transfer. Herein, we describe techniques that aim to augment, or reconstruct, the premaxillary region in the context of nasal deformity, osseous resorption, or composite maxillofacial defects.

[Intraoral anastomosis for maxillary reconstruction with medial femoral condyle periosteal flap: a case report]

Maxillary defects result in esthetic and functional defects in patients. Several techniques are available for ma-xillary reconstruction. Herein, we present a case of maxillary reconstruction with medial femoral condyle periosteal flap by intraoral anastomosis. The characteristics of medial femoral condyle periosteal flap and the advantages of intraoral anasto-mosis are introduced.

Repair of Orbital Post-Traumatic Wall Defects by Custom-Made TiNi Mesh Endografts

Repairs of orbital post-traumatic and extensive malignant defects remain a major surgical challenge, in view of follow-up outcomes. Incorrect surgical management of injured facial structures results in cosmetic, ophthalmic, and social aftereffects. A custom-made knitted TiNi-based mesh (KTNM) endograft was employed to overcome post-surgical complications and post-resected lesions of the orbital area. Preoperative high-resolution computed tomography (CT) imaging and CAD modelling were used to design the customized KTNM in each case. Twenty-five patients underwent surgery utilizing the suggested technique, from 2014 to 2019. In all documented cases, resolution of the ophthalmic malfunction was noted in the early period. Follow-up observation evidenced no relapsed enophthalmos, hypoglobus, or diplopia as late complications. The findings emanating from our clinical observations allow us to claim that the KTNM indicated a high level of biocompatibility. It is simply modified intraoperatively to attach any desired shape/size for implantation and can also be screw-fixed, providing a good supporting ability. The KTNM precisely renders orbitozygomatic outlines and orbital floor, thus recovering the anatomical structure, and is regarded as an attractive alternative to Ti-based meshes and plates. Additionally, we report one of the studied cases, where good functional and cosmetic outcomes have been achieved.

Flap selection for reconstruction of wide palatal defect after cancer surgery

BACKGROUND

The resection of head and neck cancer can result in postoperative defect. Many patients have difficulty swallowing and masticating, and some have difficulty speaking. Various types of flaps are used for palatal reconstruction, but flap selection remains controversial. Therefore, our study will suggest which flap to choose during palatal reconstruction.

METHODS

Thirteen patients who underwent palatal reconstruction from 30 January, 1989 to 4 October, 2016 at our institution. Size was classified as small when the width was < 4 cm², medium when it was 4-6 cm², and large when it was ≥ 6 cm². Based on speech evaluation, the subjects were divided into a normal group and an easily understood group. After surgery, we assessed whether flap selection was appropriate through the evaluation of flap success, complications, and speech evaluation.

RESULTS

Defect size ranged from 1.5× 2.0 cm to 5.0× 6.0 cm. In four cases, the defect was in the anterior third of the palate, in eight cases it was in the middle, and there was one case of whole palatal defect. There were three small defects, two medium-sized defects, and eight large defects. Latissimus dorsi free flaps were used in six of the eight large defects in the study.

CONCLUSION

The key to successful reconstructive surgery is appropriate selection of the flap with reference to the characteristics of the defect. Depending on the size and location of the defect, the profiles of different flaps should be matched with the recipient from the outset.

Management of High-energy Avulsive Ballistic Facial Injury: A Review of the Literature and Algorithmic Approach

Background:

High-energy avulsive ballistic facial injuries pose one of the most significant reconstructive challenges. We conducted a systematic review of the literature to evaluate management trends and outcomes for the treatment of devastating ballistic facial trauma. Furthermore, we describe the senior author’s early and definitive staged reconstructive approach to these challenging patients.

Methods:

A Medline search was conducted to include studies that described timing of treatment, interventions, complications, and/or aesthetic outcomes.

Results:

Initial query revealed 41 articles, of which 17 articles met inclusion criteria. A single comparative study revealed that early versus delayed management resulted in a decreased incidence of soft-tissue contracture, required fewer total procedures, and resulted in shorter hospitalizations (level 3 evidence). Seven of the 9 studies (78%) that advocated delayed reconstruction were from the Middle East, whereas 5 of the 6 studies (83%) advocating immediate or early definitive reconstruction were from the United States. No study compared debridement timing directly in a head-to-head fashion, nor described flap selection based on defect characteristics.

Conclusions:

Existing literature suggests that early and aggressive intervention improves outcomes following avulsive ballistic injuries. Further comparative studies are needed; however, although evidence is limited, the senior author presents a 3-stage reconstructive algorithm advocating early and definitive reconstruction with aesthetic free tissue transfer in an attempt to optimize reconstructive outcomes of these complex injuries.

Radial Forearm Osteocutaneous Free Flap for Reconstruction of Hard Palate With Alveolar Defect

The radial forearm free flap is beneficial for reconstruction of large palatal defect with oronasal fistula.A 51-year-old male patient who had anterior palate defect including alveolus after the radiation therapy of malignant cancer on the nasopharyngeal area undertook the radial forearm osteocutaneous free flap to close the oronasal fisula and restore the alveolar arch. The small radial bone segment was fixed in the alveolar defect and vascular anastomoses were performed with facial vessels in neck. The donor site was closed with split thickness skin graft. All suture wounds in the oral and nasal side had healed primarily with no complication within 1 month. The patient was able to swallow soluble foods in the 3 weeks postoperatively without the leakage phenomena in the nose and decreased hypernasality nature in his speech. Grafted bone union at alveolus was confirmed by follow-up computed tomography scan. There was no complication at left forearm donor site with intact musculoskeletal function.Radial forearm osteocutaneous free flap is a versatile option for its capability of reconstruction in complicated defect of soft and hard plate with alveolar defect.

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.

Reconstruction of Maxilla with Titanium Mesh and Fascia Lata - A Case Report

Maxillary defect reconstruction has been a grave challenge which unfortunately has stopped many ENT surgeons from attempting maxillectomy due to the fear of reconstruction. With our technique of reconstructing the maxillary defect with titanium mesh and fascia lata, the need for microvascular assistance is obviated. Here we describe a revision case of ameloblastoma of maxilla in a 33-year-old female for which total maxillectomy with reconstruction was done without the aid of microvascular tissue transfer. The aim of this article is to encourage and alleviate the fear among the ENT surgeons, in attempting maxillectomy and its reconstruction for delivering an equally good aesthetic and functional outcome especially at the centres where the facility of plastic assistance is not readily available.

Jaw in a Day: State of the Art in Maxillary Reconstruction

BACKGROUND

Reconstruction of maxillary defects following tumor extirpation is challenging because of combined aesthetic and functional roles of the maxilla. One-stage reconstruction combining osseous free flaps with immediate osseointegrated implants are becoming the standard for mandibular defects, and have similar potential for maxillary reconstruction.

METHODS

A woman with maxillary Ewing sarcoma successfully treated at age 9 with neoadjuvant chemotherapy, right hemimaxillectomy, and obturator prosthetic reconstruction presented for definitive reconstruction, complaining of poor obturator fit, and hypernasality. Her reconstruction was computer-simulated by a multidisciplinary team, consisting of left hemi-Lefort I advancement and right maxillary reconstruction with a free fibula flap with immediate osseointegrated implants and dental prosthesis.

RESULTS

Full dental restoration, midface projection, and oral fistula corrections were achieved in 1 operative stage using this approach.

CONCLUSIONS

This patient demonstrates a successful approach for maxillary reconstruction using computer-planned orthognathic surgery with free fibula reconstruction and immediate osseointegrated implants with dental prosthesis.

Reconstruction of Midface and Orbital Wall Defects After Maxillectomy and Orbital Content Preservation With Titanium Mesh and Fascia Lata: 3-Year Follow-Up

PURPOSE

To describe the authors' experience in the reconstruction of patients after total maxillectomy with preservation of orbital contents for maxillary tumors using titanium mesh and autogenous fascia lata, where no setting for free flap reconstruction is available.

PATIENTS AND METHODS

Twelve consecutive patients with paranasal sinus tumors underwent total maxillectomy without orbital exenterations and primary reconstruction. The defects were reconstructed by titanium mesh in combination with autogenous fascia lata in the orbital floor performed by 1 surgical team. Titanium mesh (0.2 mm thick) was contoured and fixed to reconstruct the orbital floor and obtain midface projection. Fascia lata was used to cover the titanium mesh along the orbital floor to prevent fat entrapment in the mesh holes.

RESULTS

The most common pathology was squamous cell carcinoma (50%). Patients' mean age was 45.66 years (33 to 74 yr). The mean follow-up period was 35.2 months (30 to 49 months). During follow-up, no infection or foreign body reaction was encountered. Extrusion of titanium mesh occurred in 4 patients who underwent postoperative radiotherapy. Two cases of mild diplopia at extreme gaze occurred early during the postoperative period that resolved after a few months.

CONCLUSION

Placing fascia lata between the titanium mesh surface of the orbital implant and the orbital contents was successful in preventing long-term diplopia or dystopia. Nevertheless, exposure of the titanium implant through the skin surface represented a complication of this technique in 25% of patients. Further studies are required with head-to-head comparisons of artificial materials and free flaps for reconstruction of maxillectomy defects.

Use of Orbital Conformer to Improve Speech in Patients with Confluent Maxillectomy and Orbital Defects

The basic objective in prosthetic restoration of confluent maxillary and orbital defects is to achieve a comfortable, cosmetically acceptable prosthesis that restores speech, deglutition, and mastication. It is a challenging task complicated by the size and shape of the defects. The maxillary obturator prosthesis often satisfies the objective of adequate deglutition; however, orbital defects that are not obturated in the medial, septal, or posterior walls allow air to escape, negatively impacting phonation. This article describes a technique to achieve favorable prosthetic rehabilitation in a patient with a maxillectomy and ipsilateral orbital exenteration. The prosthetic components include maxillary obturator, orbital conformer, and orbital prosthesis connected using rigid magnetic attachments.

Pedicled buccal fat pad flap as a reliable surgical strategy for the treatment of medication-related osteonecrosis of the jaw

PURPOSE

The purpose of this study was to evaluate the coverage of the pedicled buccal fat pad flap (PBFP) and the long-term results of this treatment in patients with medication-related osteonecrosis of the jaw (MRONJ).

PATIENTS AND METHODS

Ten patients (2 men and 8 women; average age, 72.9 yr old) diagnosed with MRONJ were selected. Patients were treated with a PBFP. Data from patients regarding MRONJ stage, defect size, bone exposure after surgery, operation time, admission period, duration of antibiotic therapy, recurrence of disease, and postoperative complications were analyzed retrospectively.

RESULTS

Six patients were diagnosed with MRONJ stage 2, and 4 patients were diagnosed with MRONJ stage 3. The maximum defect in the study was 62 × 18 mm. Among the 10 patients, there was only 1 bony exposure, which occurred on postoperative day 2 after receiving the PBFP. This exposure might have been due to an incomplete resection of the affected bone. There were no severe donor site morbidities, and all patients showed satisfactory healing without incident.

CONCLUSIONS

According to this evaluation, the PBFP effectively covered a relatively large surgical defect. Complications were minimal, and there was no recurrence of bony exposure during follow-up. In conclusion, using the PBFP was a reliable treatment option for the management of denuded bone in patients with MRONJ.

Rehabilitation of hemimaxillectomy with foldable obturator in restricted mouth opening: a case report

Acquired defects of the head and neck region as in case of hemimaxillectomy can be devastating to the patients and presents considerable reconstructive challenge for the Prosthodontists. The defects created by the surgery results in damaging effects on functional, cosmetic, and psychological aspects of the patient. The purpose of this clinical report is to discuss the method of fabricating a foldable obturator for rehabilitation of a patient of hemimaxillectomy with restricted mouth opening.

Midface reconstruction

In the midface, two polyhedron-shaped maxillary units are separated by the central midportion, which includes the nasal area. The midface includes such facial features as the nose, cheek, and upper lip, and posteriorly it extends to the anterior skull base. In the superoinferior direction, the midface includes the soft and bony tissue from the orbital cavity to the oral cavity. Laterally, the midface extends to the temporal bone. Although most superficial skin defects of the midface can be covered by various standard reconstructive modalities, because of the need to evaluate the nature of the tissues involved and because of structural and also functional considerations, the management of large, full-thickness defects is a challenge for reconstructive surgeons. Advances in microsurgical techniques have permitted reliable wound closure and a substantial decrease in patient morbidity with low complication rates while allowing a variety of reconstructive flap options in a single stage. To create a reconstructive algorithm, several classification systems have been proposed, mostly relating to the extension, location, and tissue involvement of the defect. Defects can be classified as simple soft tissue defects and complex defects. The complex three-dimensional defect is classified under four types: types I to IV. Although maxillary prostheses are nonliving tissues and may cause discomfort for the patient, in special situations they can be reconstructive options requiring special experience. Essentially, the method of reconstruction should be selected on an individual basis, bearing in mind the medical situation; the age and prognosis of the patient; the size, extension, and composition of the defect; and the availability of local or distant tissues.

Sinus lift access in partial maxillectomies

Maxillectomies often result in anatomical defects that need to be reconstructed. In partial maxillectomies, the most significant defect is the formation of an oronasal or oral-antral fistula. This creates discomfort and needs to be addressed secondarily with local or regional flaps. Here, we describe a technique adopted in 8 patients in which limited maxillectomies are carried out in a way that preserves the nasal and sinus mucosa, preventing the formation of fistulas and allowing the use of flaps that would normally carry a high risk of fistula formation. Contemporary bone reconstruction with grafts was used in 2 patients. Sparing the sinus and nasal mucosa during maxillectomies is an easy, safe procedure that can prevent a number of complications and can be recommended in selected cases.

Maxillary tuberosity reconstruction with transport distraction osteogenesis

Severe bone loss due to pathology in the maxillary tuberosity region is a challenging problem both surgically and prosthetically. Large bone grafts have a poor survival rate due to the delicate bony architecture in this area and presence of the maxillary sinus. Our case presentation describes a new technique for reconstructing severe bony defect in the maxillary tuberosity with horizontal distraction osteogenesis in a 45-year-old man. A 4 × 6 × 3 cm cyst was discovered in the left maxillary molar region and enucleated. Three months postoperatively, the area had a severe bone defect extending to the zygomatic buttress superiorly and hamular notch posteriorly. Three months later, a bone segment including the right upper second premolar was osteotomised and distracted horizontally. The bone segment was distracted 15 mm distally. After consolidation, implants were placed when the distractor was removed. A fixed denture was loaded over the implants after 3 months. Complete alveolar bone loss extending to the cranial base can be reconstructed with transport distraction osteogenesis. Distalisation of the alveolar bone segment adjacent to the bony defect is an easy method for reconstructing such severe defects.

[Reconstruction of complex midfacial defects with individualized titanium implants]

BACKGROUND

Loss of hard and soft tissue structures of the midface due to resection or trauma is associated with substancial functional and aesthetic deficits. Besides reconstruction of bony contours for preservation of orbit position and facial symmetry, reconstruction often requires simultaneous transplantation of soft tissue flaps for separation of nasal and oral cavities and refilling of soft tissue volume deficits.

PATIENTS AND METHODS

A well-established procedure of our institution will be demonstrated in 10 exemplary patients, in which titanium meshes are customized for individual defect situations using computer-assisted techniques in combination with soft tissue transfer if required.

RESULTS

According to our experience, this procedure provides satisfactory results in functional as well as in aesthetic respects. Especially in patients with loss of bony structures of the orbit and preservation of orbital contents, this procedure forms optimal preconditions for prevention of enophthalmos and diplopia by preservation of the original orbital volume.

CONCLUSION

Individualized titanium implants should be used more frequently in clinical routine for reconstruction of complex midfacial defects.

Early partial monolateral zygomatic arch defect leads to unilateral craniofacial malformation

OBJECTIVE

This study used reconstructed three-dimensional imaging to examine the influence of early partial monolateral zygomatic arch defect on the craniofacial development in a minipig model.

METHODS

Five 7-week-old Chinese minipigs were used in this study. Each of them underwent skull radiography, three-dimensional computed tomography (CT), and surgery at 8 weeks of age. Bilateral zygomatic arches were randomized and divided into the experimental side and the control side. A standard 2-cm-long zygomatic arch defect was made by an electric drill on the experimental side. The contralateral side was left intact. One of them underwent skull radiography and three-dimensional CT 2, 4, 8, and 12 weeks after surgery. The other 3 minipigs underwent scanning 4, 8, and 12 weeks after surgery. The bone defect was observed by radiography and three-dimensional CT. All three-dimensional CT data were examined by Mimics 10.01 software, and three-dimensional images were reconstructed. The length of both zygomatic arches, the length and width of the skull, and the hemicranial angles of both sides were measured and compared.

RESULTS

The zygomatic arch developed to a summit at approximately 20 weeks of age. The zygomatic arch length of the experimental side is longer than that of the control side at each time point after surgery. The hemicranial angle of the experimental side is less than that of the control side at each time point after surgery.

CONCLUSIONS

Early partial monolateral zygomatic arch defect accelerates its growth in the sagittal plane and impedes the hemicranial growth in the coronal plane. Early reconstruction of zygomatic arch defect may be essential to minimize the developmental craniofacial malformation in children.

Resection of a primary oral malignant melanoma and rehabilitative management using nasolabial flap: a case report

BACKGROUND

The primary malignant melanoma is a rare neoplasm of melanocytic origin in the oral cavity. Only about 1% of all melanomas arise in the oral mucosa and these account for 0.5% of all oral malignancies

CASE REPORT

This report describes an oral malignant melanoma occurring in the right maxilla of a 73-year-old patient. The interdisciplinary management using a nasolabial flap and prosthetic oral rehabilitation procedure is described.

DISCUSSION

The nasolabial flap technique offers the possibility of an immediate reconstruction of the maxillary defect and obviated problems with speech, swallowing, and permitted oral intake. As a supplementary benefit, the resection area can support the prosthetic rehabilitation.

One-stage reconstruction for midfacial defect after radical tumor resection

A serious midface defect involving resection of squamous cell carcinoma originating from the hard palate was treated by an unusual reconstructive strategy. After tumor resection, surgical reconstruction was accomplished in one stage using one free flap with one distant and local flap: a radial forearm flap to reconstruct the upper lip, a forehead flap to reconstruct the external nose, a cantilever calvarial bone graft to replace the nasal skeleton and a nasolabial flap and split thickness skin graft to cover the internal nasal lining. The rationale for this one-stage reconstruction and the problems associated with midfacial reconstruction after wide tumor excision are discussed.

Maxillary reconstruction using microvascular free flaps

OBJECTIVE

Loss of all or part of the maxilla as a result of tumor ablation has both functional and aesthetic consequences. Reconstruction of the maxilla remains a challenge despite the availability of several flaps and the skills of the prosthodontist. We have analyzed a series of maxillary resections that underwent flap reconstruction to guide planning of the rehabilitation of patients with such defects.

STUDY DESIGN

The authors present 83 patients with various types of maxillary defects that were reconstructed with different microvascular free flaps. All clinical data, including data on the functional and aesthetic outcome, are analyzed.

RESULTS

Flap transfer was successful in 80 of 83 patients who underwent maxillary reconstruction. Separation of the oral and nasal cavities was achieved in all cases. Flap compromise occurred in 6 cases, which made revision necessary. Three of these flaps were salvaged and 3 flaps failed. In 10 of 28 patients with transferred bone, osseointegrated implants were inserted and dentally rehabilitated with excellent functional and aesthetic results.

CONCLUSION

Various types of maxillary defects can be reconstructed successfully using different microvascular free flaps. This procedure is challenging because of the anatomical site of reconstruction creating a steep learning curve. If the reconstruction is successful, both facial appearance and oral function can be improved. Microvascular flaps containing bone of the fibula, scapula, or iliac crest facilitate complete dental rehabilitation.

Evaluation of a new semiburied curvilinear distraction device in dogs

We developed a semiburied, curvilinear distraction device for use in osteogenesis in the reconstruction of maxillofacial defects. The device was tested in two dogs, which had segmental defects made in the maxilla and zygoma. The residual zygoma was distracted with the device. The bony transport discs were distracted about 12mm around an arc, and the new bone formed well in the distracted gap. The semiburied curvilinear distraction device has proved to be reliable for internal curvilinear distraction. Its clinical applicability needs to be studied further.

Reconstruction of a palatomaxillary defect with vascularized iliac bone combined with a superficial inferior epigastric artery flap and zygomatic implants as anchorage

Here is described a modified technique of palatomaxillary reconstruction that combines the use of a free vascularized bone graft by osteotomy, soft-tissue flap, zygomatic implant as an anchorage and two standard implants simultaneously. The patient presented with deformity in the left face after subtotal maxillectomy (Brown 2b classification). Preoperative work up was performed by a rapid prototyping model using computer-aided manufacturing technology. The purpose of this model is to provide accurate measurements of the defect. The palatomaxillary three-dimensional buttress system can be managed by orienting the bone graft vertically and horizontally. Reconstruction of the palatomaxillary defect was successfully accomplished in a single surgical procedure. Dental implant restoration achieved good osseointegration without any significant resorption. This new modification represents a significant contribution to palatomaxillary reconstruction using zygomatic implants as anchorage.

Free flap reconstruction in the treatment of tumors involving the hard palate

AIM

To report our experience in free flap reconstruction of the hard palate after malignant tumor resection, in terms of reconstruction method, immediate post-operative course and subjective functional results.

PATIENTS AND METHODS

Files from 1988 to 1999 were reviewed for patients having undergone microvascular reconstruction of the hard palate. The immediate post-operative course (during the first month) was reviewed to determine the occurrence of complications. The surgeon's evaluation 1 year post-operatively was used to determine the intelligibility of speech, type of diet and the quality of nasal permeability.

RESULTS

Thirty eight patients (28 men and 10 women) with malignant tumors involving the hard palate had undergone surgical reconstruction using microvascular free flap techniques: free radial forearm flap (13 cases), scapular flap (24 cases) or fibular flap (five cases). Two different flaps were employed in two cases (scapula plus fibula). A second flap was used with success in two cases of failure of the first flap, for a total of 42 free flaps for 38 patients. Complications occurred in seven cases, with two cases of flap necrosis. At 1 year, 33 patients achieved a normal diet and 35 normal or easily intelligible speech.

CONCLUSIONS

Microsurgical reconstruction using free tissue transfer allows reconstruction of large defects of the hard palate, with low morbidity and an excellent functional outcome. We propose criteria for free flap reconstruction and choice of flap.

Developments in reconstruction of midface and maxilla

Loss of the maxilla and midfacial structures after tumour removal has substantial functional and aesthetic consequences. The variable loss of soft tissue, bone, or both, leading to collapse of the lip, cheek, periorbital soft tissues, and palatal competence present a challenging dilemma for reconstructive surgeons. Efforts have been made to classify these midfacial defects and provide appropriate algorithms for optimum reconstruction. Not only does the cavity need to be obliterated and midfacial contours recreated, but swallowing function, phonation, and mastication need to be restored for an ideal result. Traditionally, these defects would have been repaired by a maxillofacial prosthesis but advances in tissue transfers, particularly of microvascular free flaps, have greatly increased reconstructive options. The wide variety of free flaps that contain both soft tissue and bone offer unique properties that could be applicable depending on the defect. Combinations of free tissue transfer, local flaps, and maxillofacial prostheses might achieve a more ideal result than one technique alone. Advances in osseointegration have also enhanced the ability to achieve the best function and form. No one flap or technique is sufficient to reconstruct midface defects in all patients. The choices should be tailored to the bony and soft-tissue needs of each specific defect, denture-bearing potential of the original tissues, and available prosthodontic support. Use of a multidisciplinary approach to reconstruct these defects can yield excellent results. The complexity of the techniques should match the desired goals and needs of each individual patient.

Surgical reconstruction of maxilla and midface: Clinical outcome and factors relating to postoperative complications

AIM

The aim of this study was to evaluate the success rate of different techniques of repairing maxillary and midfacial defects according to their extent.

PATIENTS AND METHODS

In this retrospective study, 47 maxillary reconstructions in 41 patients were reviewed. Evaluation took place an average of 4.5 years postoperatively. The cases were divided into three groups according to the classification of Brown et al. (Br J Oral Maxillofac Surg 40: 183-190, 2002): Group 1: maxillary defects limited to one side (Class 2a); Group 2: bimaxillary defects (Classes 2b and 2c); Group 3: maxillary/midfacial defects (Classes 3 and 4). Most reconstructions were performed with non-vascularized bone grafts in the first patient group, whilst microvascular soft tissue flaps combined with free bone grafts were used in the second group, and re-vascularized osteocutaneous flaps in the third group.

RESULTS

Overall flap survival was 79%. Dental reconstruction was successfully completed in 31 cases (66%). Postoperative infection leading to transplant loss was the main reason for failure. This complication was specifically associated with temporal osteomuscular flaps (50%) and free iliac crest grafts (61%) and was related to the extent of the defect. In the reconstructive methods evaluated here, associated radiotherapy had a minor influence on the occurrence of complications.

CONCLUSION

Non-vascularized iliac bone grafts should be used sparingly in Class 2b, even in combination with microvascular flaps. There is a very limited indication for these grafts in Classes 3 and 4. Temporal osteomuscular flaps do not seem to be suitable for maxillary reconstruction.

Vascular Iliac Crest With Inner Table of the Ilium as an Option in Maxillary Reconstruction

Reconstruction of large maxillary defects has been a long-standing challenge to the reconstructive surgeon. Total maxillary reconstruction is desirable but often not possible; ideally, this would provide all the anatomical structural support, function, and esthetics missing because of the defect. A case is presented in which all the criteria for total maxillary reconstruction have been fulfilled. The patient is a 60-year-old man who had wide excision of his maxilla for ameloblastoma, followed by temporal bone flap reconstruction, which failed. He presented to our institution for further evaluation and possible treatment options; these were discussed with the patient and the multidisciplinary team that deals with congenital and acquired deformities in the head and neck area. An iliac crest free flap that included the inner table of the ilium based on the deep circumflex iliac artery was used for the reconstruction. The procedure is described, including restoration of a nasal lining. Osseointegrated implants were used for dental rehabilitation. Ameloblastoma is briefly discussed. The goals of maxillary rehabilitation and obstacles to obtaining those goals are presented. Options available for maxillary reconstruction are discussed, along with some of their advantages and disadvantages, as is the reason why the iliac crest free flap with the inner table of the ilium was chosen. An iliac crest free flap with microvascular anastomosis to facial vessels was used to reconstruct a large maxillary defect. Osseointegrated implants were used to facilitate dental rehabilitation. Our patient has excellent restoration of oronasal function with a satisfactory esthetic result.

The evolution of the obturator framework design

This brief overview of the progress and evolution of philosophies of obturator framework designs was accomplished by hand, as well as via Medline. It begins in 1530 ad with Ambrose Paré who described the first button-shaped sponge and metal obturator, and continues through the formation of the American Academy of Maxillofacial Prosthetics and the development of the specialty. It concludes with a simplified discussion of complex surgical-prosthetic coordination and the use of vascularized free flaps with osseointegrated dental implants.

Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects

Surgical reconstruction of maxillectomy defects has been described as an alternative to prosthetic rehabilitation to close the oral cavity. Advancements in microvascular surgical techniques require comprehensive treatment planning guidelines for functional rehabilitation. This retrospective study evaluated acquired maxillectomy defects after surgical reconstruction and/or prosthodontic rehabilitation in an attempt to establish surgical and prosthodontic guidelines that could be organized into a classification system. Forty-seven consecutive patient treatments of palatomaxillary reconstruction at a single facility, The Mount Sinai Medical Center (New York, N.Y.), were reviewed. All patients were rehabilitated with a tissue-borne obturator, a local advancement flap, a fasciocutaneous free flap, or a vascularized bone-containing free flap. Palatomaxillary defects were divided into 3 major classes and 2 subclasses. The aim of this defect-oriented classification system was to organize and define the complex nature of the restorative decision-making process for the maxillectomy patient.