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Following maxillectomy for an odontogenic tumOUR options for ReCONSTRUCTION of Defect by Dr.Athar
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FOLLOWING MAXILLECTOMY FOR AN ODONTOGENIC TUMOUR OPTIONS OF RECONSTRUCTION
By Dr.M.Athar khan
PGR OMFS NID,Multan.
PROBLEMS AFTER MAXILLECTOMY
Airway problem
Oronasal communication
Facial disfigurement
Masticatory & feeding problem
Deviation of the mandible
CLASSIFICATION OF DEFECTS AFTER MAXILLECTOMY
A. SURGICAL
COMPONENT(VERTICAL)
B. DENTAL
COMPONENT(HORIZONTAL)
A. SURGICAL COMPONENT(VERTICAL)
CLASS 1
Minimal loss of alveolar bone without
an oroantral fistula
Loss of hard palate only with no breach
of oral cavity or lose of the alveolus.
CLASS 2
It includes the alveolus and
antral walls, but not extending to
the orbital rim and adnexae
CLASS 3
Similar to class 2 but including
the orbital floor or medial wall.
CLASS 4
maxillectomy with orbital
exenteration
B. DENTAL COMPONENT (HORIZONTAL)
CLASS a
less than or equal to half the dental
alveolus.
CLASS b
more than half the dental alveolus or
crossing the mid line.
CLASS c
the entire maxillary alveolus
RECONSTRUCTION OF CLASS 1 (A TO C)
Can be simply treated with obturator or a
soft
tissue flap
Can even be left without obturation to be
healed
by secondary intention
ADVANTAGES
Simple & quick procedure
Donor site is not required
Immediate facial & dental restoration
Inspection of the cavity & check for
recurrence
is available
DISADVANTAGES
Difficult obturator fit & high risk of failure in
class 3 and 4.
Oro nasal reflux can be a problem
Reconstruction remains an option in the
longer
term
Pedicled
Flaps
o Temporalis Flap
o Buccal fat pad
o
Temporoparietal
Fascia Flap
RECONSTRUCTION OF CLASS 2A
o Submental
island flap
o Uvula flap
oTongue flap
oMasseter flap
oNasolabial flap
FREE TISSUE TRANSFER
Composite Fibula Flap
Radial Forearm Flap
TEMPORALIS FLAP
Originates along the lateral skull at the
temporal
line and inserts on the coronoid process of
the
mandible.
It is a powerful elevator of the mandible
Blood supply is from anterior deep temporal
and the
posterior deep temporal arteries.
ADVANTAGES
Ease of Elevation
Reliable blood supply
Proximity to the maxillofacial structures
Camouflage of the incision with in the
hair line
DISADVANTAGES
Sensory Disturbances
Potential facial nerve Injury
Temporal Hollowing
Limited arc of rotation
BUCCAL FAT PAD
First reported to be used in 1977 for closure of
oroantral or oronasal
communication
In 1983 Neder used fat pad as a free graft in the oral
cavity
Buccal fat pad epithelializes within two to three
weeks when used as a
Pedicled flap.
Blood supply is from buccal and deep temporal
branches of maxillary
artery.
ADVANTAGES
Can be used in conjunction with free bone
grafting
Provides increased soft tissue bulk over
reconstruction bars.
Donor site complications are rare.
NASOLABIAL FLAP
Blood supply is from perforators of the facial and
angular arteries
The superiorly based flap is used for the closure of
oroantral
fistula
Limited donor tissue, facial scaring and limited arc
of rotation are
the main disadvantages
`flap is extremely difficult to use in dentate patients
UVULA FLAP
In patients who have a long redundant uvula and have undergone a
resection of
the posterior hard palate or part of the soft palate, the uvula provides an
easily
harvested source of muscle & mucosa
Blood supply is from random perforators from local palatal vessels
Can be used to provide mucosa for the oral and nasal surface of the hard
palate
Flap is not available in total palatal resections
Its dimensions are inadequate for larger defects
TONGUE FLAP
May be based anteriorly, dorsally, posteriorly, or
bipedicled dorsally
Dorsally based flap is used for closure of hard palate
Blood supply is from lingual artery
The mobility of the pedicles caused by normal tongue
movement can
cause the flap to pull away from the defects
Alteration of the natural tongue contour & bulk at the
tip can alter
speech
MASSETER FLAPHas been used for many years in the reanimation of
paralyzed face
Langdon modifies the procedure by resecting the
anterior portion of
the vertical ramus & coronoid process to allow
transfer of the flap to
defects of the palate
Blood supply is from the masseteric artery, a branch of
the transverse
facial artery
Major disadvantage is the potential for trismus and
limited volume of tissue
TEMPOROPARIETAL FASCIA
Provides a rapidly re-epetheliazed coverage
in oral cavity
Can be elevated, grafted with skin or
cartilage, or both
Flap receives its blood supply from the
superficial
temporal artery
ADVANTAGES
Robust Blood Supply
Ease of Elevation
Lack of hair
Well camouflaged donor site
Vascular anatomy is constant & reliable
Surface of the fascia readily accepts grafts
DISADVANTAGES
Numbness of the donor site
Alopecia
Lack of skin paddle for flap
monitoring.
SUBMENTAL ISLAND FLAP
Blood supply is from the submental artery, a branch
of facial artery.
Appropriate for cases in which no prior neck surgery
has obliterated
the vascular pedicles
Provides abundant regional tissue with a reliable
blood supply
Flap may be used without skin as a fascio-
subcutaneous flap for the
augmentation of contour defects
Also used for reconstruction of most anterior oral
cavity defects
ADVANTAGES
Excellent color match
Excellent aesthetics
Transfer of tissues with like
thickness & texture
Reliable vascular anatomy
The only disadvantage is the
incisional scar.
FREE TISSUE TRANSFER
1. COMPOSITE FIBULA FLAP
only long & straight bone that is not indispensable
The common peroneal nerve runs around the fibular head
damage to the nerve & the knee joint can be prevented by leaving
approximately 8cm of proximal fibular end in the leg
Also distally 8cm are left in order to maintain the ankle joint fork
A fibula 40cm long can provide 26cm for the transplantation,this makes
the fibular graft the longest transplantable bone segmant in human
beings
Blood supply to the fibula is from peroneal artery
ADVANTAGES
Constant anatomical topography
Long bone & high stability
Minor donor site morbidity
Disadvantage is the short vascular pedicle
When used for the reconstruction of
maxilla , one must
use a vessel interponate because of
shortness of vascular pedicle.
RADIAL FOREARM FLAP
This flap is based on ascending & descending radicles from the
radial artery
Different variants like fascial flaps, double paddle fasciocutaneous
flaps, and
osteocutaneous flaps can be harvested
Maxillectomy defects are adequately reconstructed with a radial
forearm
fasciocutaneous flap
In osteocutaneous flap up to 16cm of bone may be harvested
ADVANTAGES
Thin, elastic, pliable skin paddle
Hairless
Drapes conveniently over the complex
shapes within the
oral cavity
Flap has relatively minimal bulk hence
provides little
resistance to tongue movements
DISADVANTAGES
Exposure of tendons at donor site
Poor aesthetics
Radius fracture
RECONSTRUCTION OF CLASS 2(B-C)
AIMS OF RECONSTRUCTION:
When the class 2 defect crosses the midline or involves
the entire dental alveolus, a composite flap is essential
to:
Restore the loss of bone including the anterior alveolus
Support the alar region & nasal columella
Provide adequate bony basis for implants
RECONSTRUCTION
Flaps for reconstruction depend on amount of bone
lost in the in
anterior maxilla and nasal septum
If loss of bone includes only the dental alveolus, then
a fibula flap is
the ideal choice
If, however, loss of bone includes a significant part of
nasal piriform ,
nasal septum and extending towards the nasal bone
(>2cm), then iliac
crest with internal oblique is the ideal flap.
ILIAC CREST This flap is based on the deep circumflex
iliac
artery(DCIA) & deep circumflex iliac vein
DCIA is a branch of the external iliac artery.
DCIA sends
some perforators into the bone & the muscle
attached to it
The skin component of the iliac crest
derives some of its
blood supply from these perforators
USE OF FLAP IN MAXILLECTOMY
Using the internal oblique muscle flap based
on the
ascending branch of DCIA, a well
vascularized piece of
soft tissue can be obtained on the same
pedicle as the iliac
crest
Reconstruction of the orbital floor & rim
may be achieved
using the inner table of iliac crest & the
attached soft tissue.
ADVANTAGES
Offers o large, curved piece of mainly cancellous bone,6 to 16cm
in length
Composite flap carries a significant soft tissue bulk, can be
useful in filling extensive resection defects
Skin paddle is reliable & may be as large as 16 x 20cm or
greater
Iliac crest is mainly cancellous bone, hence provides primary
bone union
size & depth of bone allows it to accommodate osteointegrated
dental implant
Cosmetically acceptable, as the scar is hidden in groin crease
Contour irregularity can be overcome by taking only the inner
cortex
DISADVANTAGES
Skin necrosis
Hernia
Hypertrophic scar
Local pain & pain on ambulation
Gait disturbances
Femoral neuropathy
Contour deformities.
RECONSTRUCTION OF CLASS 3(A-C)
AIMS
To close the oroantral fistula
Restore the functioning dental alveolus
Support for facial skin
Support the orbit & eyelids
Iliac crest with internal oblique is the ideal option to
meet these goals.
ILIAC CREST WITH INTERNAL OBLIQUE
It provides sufficient bone for the implant retained
dental prosthesis
Provides a platform for the reconstruction of the
orbital floor with titanium mesh
The muscle will close the oral defect & provide an
epethelialized lining for the lateral nose
Facial vessels overlying the body of mandible are
used for anastomosis
THE SCAPULA
Blood supply is from subscapular artery, a branch of the axillary artery
This flap is easy to elevate & the donor site defect is only moderate
For complex three dimensional reconstruction, two skin paddles can
be moved independently of each other
Angle of the scapula based on the angular artery & incorporating a
portion of latissimus dorsi , is used for orbital floor & maxillectomy
reconstruction
DISADVANTAGES
Does not provide adequate thickness
of bone to
retain dental implants
Skin paddles may be too bulky for
intra oral use
RECONSTRUCTION OF CLASS 4A
When the orbital contents have been exenterated, problems of diplopia,
enophthalmos, and ectropion are obviated by removal of the eye.
Provision of the prosthetic eye can mask some of the deformity
Again, iliac crest with internal oblique is the first choice in class 4A
reconstruction
The best compromised reconstruction is a large soft tissue flap such as the
rectus abdominis to obturate whole of the defect from roof of the orbit to
the
dental alveolus.
RECTUS ABDOMINIS
It is a strap like muscle, that spans the length of
the anterior
abdominal wall
Enclosed in rectal sheath, originates from the
cartilages of fifth,
sixth, and seventh ribs and front of the xiphoid
process
Lower tendinous attachment to the body and
symphysis of pubis
Blood supply is from superior & inferior
epigastric artery
USE OF FLAP IN MAXILLECTOMY
Used for larger defects
Ease of dissection of the vascular pedicle
Disadvantages are lack of uniform thickness
and
more tedious dissection in obese persons
No chance of dental rehabilitation
RECONSTRUCTION OF CLASS 4(B-C)
When the defect crosses the midline or involves
the nasal bone, iliac crest with internal oblique is
the only choice that can provide sufficient bone
to support the facial and nasal bone as well as
providing a choice for dental rehabilitation.
THANK YOU