Following maxillectomy for an odontogenic tumOUR options for ReCONSTRUCTION of Defect by Dr.Athar

2. FOLLOWING
MAXILLECTOMY FOR AN
ODONTOGENIC
TUMOUR OPTIONS OF
RECONSTRUCTION
By Dr.M.Athar khan
PGR OMFS NID,Multan.

3. PROBLEMS AFTER
MAXILLECTOMY
 Airway problem
 Oronasal communication
 Facial disfigurement
 Masticatory & feeding problem
 Deviation of the mandible

4. CLASSIFICATION OF
DEFECTS AFTER
MAXILLECTOMY
A. SURGICAL COMPONENT(VERTICAL)
B. DENTAL COMPONENT(HORIZONTAL)

5. 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.

6.  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

9. 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

11. 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

12. ADVANTAGES
 Simple & quick procedure
 Donor site is not required
 Immediate facial & dental restoration
 Inspection of the cavity & check for recurrence
is available

13. 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

16.  Pedicled Flaps
o Temporalis Flap
o Buccal fat pad
o Temporoparietal
Fascia Flap
RECONSTRUCTION OF
CLASS 2A
o Submental island flap
o Uvula flap
o Tongue flap
o Masseter flap
o Nasolabial flap

17. FREE TISSUE TRANSFER
 Composite Fibula Flap
 Radial Forearm Flap

18. 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.

20. ADVANTAGES
 Ease of Elevation
 Reliable blood supply
 Proximity to the maxillofacial structures
 Camouflage of the incision with in the hair line

21. DISADVANTAGES
 Sensory Disturbances
 Potential facial nerve Injury
 Temporal Hollowing
Limited arc of rotation

24. 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.

27. ADVANTAGES
 Can be used in conjunction with free bone
grafting
 Provides increased soft tissue bulk over
reconstruction bars.
 Donor site complications are rare.

28. 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

29. 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

30. 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

31. MASSETER FLAP
 Has 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

32. 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

34. 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

35. DISADVANTAGES
Numbness of the donor site
Alopecia
Lack of skin paddle for flap monitoring.

36. 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

38. ADVANTAGES
 Excellent color match
 Excellent aesthetics
 Transfer of tissues with like thickness & texture
 Reliable vascular anatomy
 The only disadvantage is the incisional scar.

39. 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

41. 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.

46. 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

49. 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

50. DISADVANTAGES
Exposure of tendons at donor site
Poor aesthetics
Radius fracture

52. 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

53. 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.

54. 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

55. 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.

57. 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

58. DISADVANTAGES
 Skin necrosis
 Hernia
 Hypertrophic scar
 Local pain & pain on ambulation
 Gait disturbances
 Femoral neuropathy
 Contour deformities.

62. 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.

63. 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

64. 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

65. DISADVANTAGES
 Does not provide adequate thickness of bone to
retain dental implants
 Skin paddles may be too bulky for intra oral use

66. 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.

67. 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

69. 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

74. 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.