Maxillary Reconstruction

BY: ANTENEH GEBRU(MD,PSR 4,AAU,ALERT Center)

Feburary,2020

MAXILLARY RECONSTRUCTION BY ANTENEH GEBRU

anteshgo@[Link]
 CONTENTS
• INTRODUCTION
• RELAVENT SURGICAL ANATOMY OF MAXILLA
• RECONSTRUCTION -MAXILLARY DEFECTS
• SUMMARY
• REFERENCES

MAXILLARY RECONSTRUCTION BY ANTENEH GEBRU

 INTRODUCTION:
Maxilla

• an essential component of the midface

• has both functional and aesthetic roles
• contributes to facial appearance
• determines midfacial width and height
• serves as support for the orbit, cheek, nose, and upper lip
• supports critical functions such as mastication, speech,
and deglutition

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
History
Maxillary reconstruction
• numerous recent advancements.
• In the 1980s-biocompatible, versatile, rigid internal
fixation hardware replaced wire fixation
• In the 1990s-osteocutaneous free tissue transfer
• Most recently-advanced prosthetic obturators
• vascularized composite allotransplantation (ie, facial
transplantation)

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 RELAVENT SURGICAL ANATOMY OF MAXILLA
• a clear understanding of the complex 3D anatomy of the maxilla
• six-walled geometric box
• maxillary antrum -contained within the central portion of the
maxilla.
• two horizontal and three vertical buttresses
– produce facial width, height, and projection.
• overlying soft tissues, including the muscles of facial expression
and mastication,
– insert on the maxilla
– responsible for individual facial appearance and function.
MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
ANATOMY-MAXILLA

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 ANATOMY-MAXILLA
• orbit-superiorly,
• palate and oral cavity-inferiorly,
• nasal airway -medially
• infratemporal fossa and cranial base
posteriorly
• anteriorly and laterally-forms the
contour of the cheek

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 Causes of Maxillary Defects
• Tumors(benign or malignant)
– Maxilla
– adjacent structures
• Trumatic injuries
– sharp/gun shot injuries
– blunt injuries
• Extensive fungal/granulomatous
infections

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
RECONSTRUCTION -MAXILLARY DEFECTS

• Visualizing the maxilla as a six-sided box

– helpful in determining which walls are missing
• The three walls that require reconstruction:
– the superior (orbital floor),
– floor (palatal), and
– anterior (cheek) walls

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 RECONSTRUCTION -MAXILLARY DEFECTS
The GOALS of maxillary reconstruction:

1. Reconstruct the orbital floor or fill the orbital cavity

2. Reconstruct linings( intraoral, cheek, palatal, and nasal)
3. Separate the oral and nasal cavity from the skull base & orbit
4. Restore external skin and 3D facial contour
5. Obliterate the maxillectomy defect

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 RECONSTRUCTION -MAXILLARY DEFECTS -APPROACH
• Clinical assesement
–define the maxillary defect in terms of bony and soft-tissue components.
–assess djacent critical structures-the eye, nose, and lips
–a history of radiotherapy or previous neck dissection
–asess length of the vascular pedicle and donor-site morbidity
–the amount, location, and quality of residual bone, dentition, and
denture-bearing alveolar arch
 determine whether a bone-containing flap is necessary
• CT Scan with 3D recon
• Detrmine repair options
• Plan treatment strategy

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 Classification Of Mid-face Defects
• Ohngren 1933
• Aramany 1978
• Brown 1996
• Spiro 1997
• Cordeiro and Santamaria 2000
• Brown 2010

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
Cordeiro & Santamaria (Memorial Sloan-kettering Cancer Center,New York)
Classification

• Type I (Limited maxillectomy) • Type III(Total maxillectomy)

-one or two walls, -all six walls resected
-palate preserved -IIIa-orbital preservation
• Type II(Subtotal maxillectomy) -IIIb-orbital content
-lower 5 walls, exentration
-orbital floor preserved • Type IV(Orbitomaxillary)
-IIa-<50% palate resected -Upper 5 walls
-IIb->50% palate resected -palate preserved

MAXILLARY RECONSTRUCTION BY ANTENEH GEBRU

Brown's Classification
• Brown class I-two types of defects
– Alveolar defect without oro-nasal or oro-antral fistulae
– Palatal bone defect without alveolar defect
• Brown class II
– Alveolar & antral wall defect,not including orbital floor and rim
– Unilateral,Bilateral(incomplete) & Complete

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 Brown Classification
• Brown class III
– Alveolar and antral wall defect including the orbital floor
– periorbita and skull base may/may not be involved
– Unilateral,Bilateral(incomplete),Complete
• Brown class IV
– Alveolar and antral wall defect including the orbital floor and
content
– Skull base may/may not be involved
– Unilateral,Bilateral(incomplete),Complete

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
Brown Classification

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
Reconstructive Options For Maxillary Reconstruction

• Prosthetic Obturation
• Autogenous flaps
– Pedicled flaps
• Local
• Regional
– Free flaps
– Vascularized/Non vascularized bone grafts
– Combination procedure

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 Reconstructive Options For Maxillary
Reconstruction
• Prosthetic Obturation

– Advantages – Disadvantages
shortens operative time & post op hypernasal speech
hospital stay regurgitation of food & fluids
better visualization for survillance into nasal cavity
helps in speech & swallowing difficulty maintaining hygiene
restores aesthetics need for repeated
adjustments

MAXILLARY RECONSTRUCTION BY
Reconstructive Options For Maxillary
Reconstruction
• Autologous Tissues
– small defects-local/regional flaps with/out bone graft
– large defects-pedicled/free flaps
– hexahedral box-anterior wall,floor & roof
– bone replacement
– palate repair
– maxillary sinus
– nasal & oral cavity lining
– external cheek skin
MAXILLARY RECONSTRUCTION BY ANTENEH GEBRU
 Reconstructive Options For Maxillary
Reconstruction
• Bone Replacement
– Autologous bone grafts
• non vascularized bone graft with coverage(orbital rim)
• vascularized bone graft with soft tissue(maxillar arch & vertical buttress)
– Alloplastic materials(Titanium Mesh)
• bone grafts not available or disallowed
• in comination with bone grafts or hydroxyapatite cement
• biocompatible
• readily available
• no donor morbidity
• contraindicated in radiotherapy
MAXILLARY RECONSTRUCTION BY ANTENEH GEBRU
 LOCAL & REGIONAL FLAPS
• Pectoralis majior flap
• Supraclavicular flap
• Submental flap
• Deltopectoral flap
• Latismus Dorsi flap
• Temporoparital flap

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
RECONSTRUCTION by Defect Type

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 Type I (limited maxillary) defects
• one or two walls of the maxilla resected,
excluding the palate
– anterior and medial walls of the maxilla
– occasionally the orbital rim,
• soft tissues and skin of the face
• the defect has a high surface-area:volume ratio
• radial forearm flap -an ideal flap
• split-calvarial or rib bone grafts-orbital rim or
orbital floor
• scapular,
• parascapular, and
• anterolateral thigh fasciocutaneous flaps
MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
Type II (subtotal maxillectomy) Defects

• maxillary arch, palate, and anterior and

lateral walls resectd
• orbital floor preserved
• type IIA defects -<50% of the palate
• type IIB defects ->50% of the palate
• moderate-volume deficiencies with
large surface area requirements, which
usually require two skin islands

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 Type II (subtotal maxillectomy) Defects
• For type IIA defects • For type IIB Defects
– a free flap or – An osteocutaneous radial forearm
– a combination of a skin flap folded into a “sandwich”
• provides anterior projection and
graft and an obturator, vascularized bone for dental implant
– dentures or osseointegration
• provides support for the upper lip
osseointegrated dental • The folded skin surfaces restore the
implants palatal mucosal lining and nasal floor lining
– a temporalis muscle flap – scapula and fibula osseocutaneous
flaps

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
Type II (subtotal maxillectomy)
Defects

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
MAXILLARY RECONSTRUCTION BY ANTENEH GEBRU
Type III (total maxillectomy)

• all six walls resected

• type IIIA
• preserved the orbital
contents
• orbital floor -resected
• type IIIB
• a total maxillary defect
combined with orbital
exenteration
MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 Type IIIA defects
• medium-large volume and medium-large surface area requirements.
• orbital floor reconstruction
– nonvascularized bone graft (must be supported by a well-vascularized flap)
• Rectus abdominis flap
• Temporalis muscle flap
• Fibula flap

MAXILLARY RECONSTRUCTION BY ANTENEH GEBRU

Type III-A right maxillary defect following total maxillectomy with orbital
preservation reconstructed a vertical rectus abdominis myocutaneous flap
based on the inferior epigastric vessels

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 Type IIIB defects
• extensive and a large volume and large surface area requirement.
• palate and nasal lining -require closure to obviate oronasal fistulae.
• the anterior skull base -often exposed
• Rectus abdominis flap -the flap of choice
– the skin island of the rectus flap - to close the palate.
– a second skin paddle -to reconstruct the lateral nasal wall.
– a third skin island used to restore the external skin.
• Vastus lateralis fascio cutaneous/myocutaneous flap
• LD flap
• Gracilis flap MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 Type IV (orbitomaxillary) defects
• resection of the orbital contents and the
upper five walls of the maxilla, sparing the
palate
• The goal-
• filling the dead space &
• resurfacing the external skin
• Rectus abdominis flap - the ideal flap

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
Critical Soft Tissue Component of the Face
• Upper Lip and Oral Commissure
– Reconstruction of the oral sphincter
– no satisfactory method to recreate the oral sphincter mechanism using tissues
other than the lip itself
– Microstomia -less disturbing than the sequelae of oral incompetence
• Eyelids
– can be involved in type I, type III, or type IV defects
– type III-B and type IV defects-to cover a prosthesis
• Nose
– a prosthesis or alternative surgical procedures-delayed fashion

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 COMPLICATIONS
■ Free flap loss will usually require a secondary free flap.
■ Ectropion
■ Ocular dystopia
■ Enophthalmos
■ Velopharyngeal dysfunction
■ Unintelligible speech
■ Nasal regurgitation of fluid
■ Drooling
■ Microstomia
■ Color and texture mismatch of external skin
■ Bulky reconstruction
MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 SUMMARY
• Maxilla-majior component of midface
• 3D structure with 6 walls
• free tissue transfer-revolutionized maxillary(midface)
reconstruction
• defect analysis-the initial step
• algorthmic approach-4 defect types based on bony defect
• bony defect 1st,soft tissue then other tissue components of
face

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
Refernces
• Grab & Smith 8th ed.
• Neligan
• Operative plastic surgery
• Internet

MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU
 U !
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MAXILLARY RECONSTRUCTION BY
ANTENEH GEBRU