Extraoral Defects Research Articles

Dumbbell Shaped Bi-Paddled Pectoralis Major Myocutaneous Flap (PMMF) for Composite Commissural Defects: A Defect Driven Modification

Pectoralis major myocutaneous flap (PMMF) has been a workhorse in orofacial reconstruction. Although microvascular tissue transfer has gained popularity in major tertiary centres, several infrastructural factors limit its use in many facilities, particularly in developing countries with high caseloads. Numerous modifications have been made to the PMMF since its inception. Here, we present a novel technique for reconstructing composite commissural defects with PMMF by modifying the skin paddle design to a dumbbell shape. Both ends of the paddle are used to line intraoral and extraoral defects, while the constricted middle portion recreates the commissure. We report the outcomes of a cohort of seven patients treated at our institution, describing the modified PMMF design, harvesting, and in-setting techniques used in oral carcinoma cases involving the commissure. We have detailed the study outcomes for each patient, including the various complications related to the flap, donor, and recipient sites.

Precise maxillofacial soft tissue reconstruction: A combination of cone beam computed tomography and 3dMD photogrammetry system

IntroductionThe reconstruction of both extra- and intra-oral soft tissue defects, particularly in restoring the morphology of the lip and the corners of the mouth, has posed a significant challenge for surgeons. Inappropriate methods often lead to maxillofacial deformity which then causes psychological and functional problems. This study aimed to address the challenge of reconstructing extensive and complex maxillofacial soft tissue defects, mainly focusing on the lip, the corners of the mouth, and the surrounding areas. Materials and methodsWe developed a reconstruction approach by combining the 3dMDface System (3dMD) with the cone beam computed tomography (CBCT). Firstly, with the extra-oral incision line, we evaluated the shape and the size of the extra-oral defect with 3dMD digitally. Then we used the corresponding maxillary and mandible tooth positions to record the intra-oral defect, which was then converted to digital images by combining 3dMD and CBCT. The islands of the anterolateral thigh perforator flap were then designed after the locations of the perforators were detected with Doppler ultrasonography. ResultsA clinical case diagnosed as dermatofibrosarcoma protuberans was presented to illustrate the approach. The patient's tumor resection and the size of multiple defects were measured and simulated via the virtual surgery system. A three-island perforator flap from the descending branch of the lateral femoral circumflex artery was designed accurately. Two weeks postoperatively, the flap was healed as anticipated and the patient was satisfied with the profile. ConclusionThe combination of the 3dMD and CBCT technologies improves the accuracy and fitness of extra- and intra-oral soft tissue reconstruction.

Nunchaku-like Free Fibula Osteocutaneous Flap in Through-and-through Composite Oromandibular Defect Reconstruction.

The free fibula osteocutaneous flap (FFOCF) has been used for oromandibular reconstruction over several decades. However, when facing through-and-through composite oromandibular defects (COMDs), significant challenges still arise. The complexity of COMD necessitates the reconstruction of bone, intraoral mucosa, and extraoral skin. Additional flaps are often needed, which extend surgical durations and heighten associated risks. This report presents a 62-year-old man with squamous cell carcinoma of the left lower gingiva. After ablative surgery, successful reconstruction of a through-and-through COMD was achieved with a single FFOCF through innovative design. The flap was osteotomized into 2 segments with attached skin islands while preserving the vascular pedicle. Rotation of 1 segment created 2 skin islands on opposing sides, simultaneously repairing intraoral and extraoral defects. Postoperative outcomes at the 1-month follow-up were encouraging. Although technically challenging, the "Nunchaku-like FFOCF" offers a safe and effective approach for the comprehensive reconstruction of through-and-through COMD.

Retention systems in extraoral prosthesis

Abstract Prosthodontist plays a very important part in the reconstruction of extraoral defects. Prosthetic rehabilitation of huge maxillofacial defects will be a crucial process for a prosthodontist. The rehabilitation depends on multiple factors such as size, site, etiology, extension of the defect, age of the patient, patient’s comfort, patient’s satisfaction, and treatment cost. The experience, skill, and knowledge of both a surgeon and a prosthodontist help to decide the foremost mode of retention possible for the rehabilitation of maxillofacial prosthesis. Achieving adequate retention for maxillofacial prosthesis is a great challenge. Various conventional methods are there for retention of maxillofacial prosthesis but treatment modalities became advanced with the rise of osseointegrated implants. Periodic evaluation of prosthesis must be carried to determine the retention, stability, function as well as esthetics of the extraoral prosthesis which enhances the well-being and satisfaction of patients. In this review, we collected the articles from PubMed as well as Scopus-indexed journals and limited to research articles published from 1976 to 2020.

Three-dimensionally printed facial prosthesis with a silicone veneer technique: A clinical report.

Digital technology has revolutionized the acquisition of patient data and the fabrication ofprosthetic replacements for extraoral defects. This clinical report illustrates the use of a newtechnique which allows the digital creation of an acrylic resin framework which is then veneered with silicone to create an esthetic prosthesis in less time and with less patient discomfort.

An Inclusion Epidermoid Cyst, a Rare Complication of Versatile Naso-Labial Flap

We are reporting a case of 47 years old gentleman who was diagnosed with left lower alveolus carcinoma and later on he presented with epidermal inclusion cyst post oncological resection with nasolabial flap reconstruction. Compared to microsurgical free flaps, nasolabial flaps are simple, easy to learn, one staged procedure and provides good cosmetic results. It can be used bilaterally for coverage of both, intra-oral and extra-oral defects. It is highly vascular flap with blood supply from the facial, transverse facial, angular, infraorbital, infratrochlear artery and the free anastomosis between the terminal branches overlying the nasolabial skin. The important thing in harvesting this flap is to avoid implantation of epidermal tissue like hair follicles, sebaceous glands and sweat glands into the deep tissues. Inadequate de-epitheliaslisation results in formation of inclusion cyst during transposition of flap through trans-buccal tunnel into the oral cavity. Formation of inclusion epidermoid cyst is a rarely encountered phenomenon in head and neck cancers.

A practical approach to orofacial rehabilitation in a patient after inferior maxillectomy and rhinectomy with mono framework construction supported on a zygomatic implant placed in the glabella: a case report

BackgroundIn the field of craniofacial tumor surgery, an adequately performed excision, despite being a life-saving procedure, is only a first step to successful treatment. During such a procedure, the main goal is to completely remove the lesion, paying less attention to factors contributing to future rehabilitation possibilities. One ty 2of the possibilities for prosthetic rehabilitation of such cases is utilizing one-piece implants with bicortical anchorage.Case presentationThis case report presents a case of a 48-year-old patient with oral squamous cell carcinoma (OSCC). The treatment protocol consisted of radical surgery to remove the tumor, and intraoral and extraoral rehabilitation with a single framework prosthesis anchored with one-piece implants. Moreover, the intraoral stomatognathic deformity was corrected with a fixed implant-retained prosthesis, and the extraoral defect was covered with a removable epithesis.ConclusionsThe use of one-piece implants with bicortical anchorage may be an additional tool in reconstructing maxillofacial defects. Properly executed treatment may improve the esthetics, speech, masticatory function, muscle support, and the overall quality of life of patients with extensive defects in the maxillofacial region.

Development of a psychosocial perception scale and comparison of psychosocial perception of patients with extra oral defects before and after facial prosthesis

Statement of problemLoss of facial organs and subsequent rehabilitation affects a patient’s psychological status. Understanding the perceived psychosocial aspects of quality of life among patients with missing organs and after prosthetic rehabilitation is essential, but studies that quantify this aspect are lacking. PurposeThe purpose of this clinical study was to develop and validate a psychosocial perception scale and compare psychosocial perception before and after the prosthetic rehabilitation of a missing facial part. Material and methodsA psychosocial perception scale was developed to quantitatively measure the perceived psychosocial aspects of quality of life among patients with extraoral defects. The instrument was translated in the Hindi and Marathi Indian languages by using a forward and backward translation method. Depending on the responses obtained from the patients in the interview about the interpretation and ease of understanding, the questionnaire was modified and further pilot testing conducted. In the first phase, validation of the questionnaire was carried out with internal consistency, interdomain correlation, and intraclass correlation assessed by using the Cronbach α, Pearson correlation, and test retest reliability. Construct validity was established by the exploratory factor analysis. In the second phase, 32 participants were evaluated for their psychosocial response before and 3 months after prosthetic rehabilitation. Responsiveness and change in the domains scores of the psychosocial perception scale were studied by using the Wilcoxon signed-rank sum test (α=.05). ResultsThe Cronbach α for internal consistency of overall psychosocial perception was .855 and .809 in the pretreatment and post-treatment visits consecutively. Most of the domains in the psychosocial perception scale had a Pearson correlation (r)>0.40. The domain of esthetics had r=0.84(confidence interval: .43-0.95), indicating good intraclass correlation. The domains of esthetics (P<.005), function (P<.005), positive emotions (P<.005), negative emotions (P=.011), and social and personal relationship P=.003) of the psychosocial perception scale showed statistically significant improvement in the scores after prosthetic intervention and had excellent (r>0.90) intraclass correlation. ConclusionsThe psychosocial perception scale was a reliable tool to assess the patient response toward the prosthetic rehabilitation of extraoral defects. Positive improvements in the domains score (esthetics, function, positive emotions, and social and personal relationship) contributed to better perception after prosthetic rehabilitation.

Osseointegration of Hafnium when Compared to Titanium - A Structured Review

Aim: This systematic review was conducted to analyse osseointegration of hafnium over conventional titanium. Materials and Methods: Search methodology was comprehended using PICO analysis and a comprehensive search was initiated in PubMed Central, Medline, Cochrane, Ovid, Science Direct, Copernicus and Google Scholar databases to identify the related literature. Randomised control trials, clinical studies, case control studies and animal studies were searched for osseointegration of hafnium coated titanium implants versus conventional titanium implants. Timeline was set to include all the manuscripts published till December 2018 in this review. Clinical Significance: Hafnium is a very promising surface coating intervention that can augment osseointegration in titanium implants. If research could be widened, including in vivo studies on hafnium as a metal for coating over dental implants or as a dental implant material itself to enhance better osseointegration, it could explore possibilities of this metal in the rehabilitation of both intra and extra oral defects and in medically compromised patients with poor quality of bone. Results: Out of the 25 articles obtained from the PICO based keyword search, 5 studies were excluded based on title and abstract. Out of the remaining 20 studies, 16 were excluded based on the inclusion and exclusion criteria of our interest and finally, 4 were included on the basis of core data. Conclusion: This systematic review observed hafnium metal exhibited superior osseointegration than titanium. Owing to its biocompatibility, hafnium could be an alternative to titanium, in the near future.

English

Combined intra and extra oral defects can be stated as those facial defects which have an intraoral communicating route. Midfacial defects are aptly classified into 2 major categories by Marunick et al. 1 as midline midfacial defects in which the nose and / or upper lip defects are included; and the second major group was lateral defects in which the cheek and orbital defects are categorized. However, defects which include combinations of the above-mentioned defects are in existence. Midfacial defects which are acquired, present themselves often with severe disfigurement of structures and hence show impaired function. It is a meticulous task to rehabilitate the defects which are caused as a result of cancerous lesion resection as they are huge. Such post resection lesions frequently are rehabilitated by a facial prosthesis to maintain function as well as the appearance in the normal form. In adjunction to the facial prosthesis, an intraoral prosthesis which constitutes of an obturator is also required to regain the natural speech and pattern of swallowing. Fabrication of such facial prosthesis not only requires the artistic capability but also excellent clinical decision making of the prosthodontist. Mode of retention of the combined prosthesis should also be kept in mind while fabricating as it is also a difficult task to retain them because of the size and weight of the same. Moreover the prosthesis should also be secured in its place with these aids which can also prove as a challenge. This case report states rehabilitating a large surgically resected midfacial defect with the assistance of a “3-piece prosthesis” which constitutes a sectional intraoral obturator along with maxillary and mandibular extraoral facial prosthesis.

Rehabilitation of oncological nasal defect with effective maxillofacial prosthesis material

Acquired maxillofacial defects usually result from surgical removal of tumors, infectious diseases, or traumatic injuries and affect the function, esthetics, and psychology of the patient. These extraoral defects can be effectively rehabilitated through surgical reconstruction and/or prosthetic rehabilitation to bring back a near-normal life. This clinical report describes a nasal defect due to squamous cell carcinoma which was successfully managed with an effective prosthesis, and for which, the retention was obtained mechanically using spectacles which is not only cost-effective but also easy to fabricate.

Utility and relevance of modified lateral trapezius myocutaneous flap as a locoregional reconstructive option for medium-sized ablative defects in head and neck cancer-our experience.

Lateral trapezius myocutaneous (LTMC) flap has been used less frequently for defects pertaining to head and neck cancer ablative surgical defects. This study is to assess the utility of LTMC flap with a new modification of the flap design. This is a retrospective study using LTMC flap with modifications as a reconstructive option for intraoral & extraoral skin defects in head and neck cancer patients following ablative surgery, from August 2014 to October 2019 in a tertiary care hospital. The original technique of LTMC flap was modified for better results and outcomes. Thirty-five patients underwent lateral trapezius flap reconstruction for ablative defects of oral cavity, laryngopharynx, neck and parotid. Twenty-three patients (65.71%) underwent adjuvant radiation/radiation-chemotherapy while one patient defaulted. Two patients (5.71%) had major flap failure. After the loss of flap in these patients, the operative technique was further modified for better results. However, the disadvantage of using this flap is shoulder disability. Nonetheless in the present study, the disability was reduced after modifying the operating technique by preserving the spinal accessory nerve. The present study demonstrated minimal functional loss, low morbidity with satisfactory results, thus also reducing treatment cost. Thus, LTMC is a reliable reconstructive option in head and neck cancer patients for medium-sized defects.

RESTORATION OF A POST-SURGICAL DEFECT BY MAGNETIC MAXILLOFACIAL PROSTHESIS: A CASE REPORT

ABSTRACT:Edentulous patient with an intra-oral and extra-oral defect suffers from both functional loss and psychological distress. Magnets give a successful approach to rehabilitate the oral functions and improve the quality of life. This case report describes a simple method of fabricating a two part magnetic maxillofacial prosthesis.

Principles of Implant Implementations for Restorations of Extra-Oral Defects

Principles of Implant Implementations for Restorations of Extra-Oral Defects

Prelamination of the latissimus dorsi flap for reconstruction in head and neck surgery

Free microsurgical tissue transfer of the latissimus dorsi flap may be indicated for the restoration of intra- and extraoral defects, especially when a large-sized skin island flap is required. In many cases, use of the latissimus dorsi flap for coverage of large-sized intraoral defects results in bulkiness due to the proportion of subcutaneous fat. Prelamination of free flaps appears to be a promising technique to overcome this flap bulkiness. This modification in flap design could improve the postoperative functional outcome, as well as reduce donor site morbidity. This article presents four novel clinical cases, in which the patients underwent prelamination of the latissimus dorsi flap with local skin grafts during oral cancer treatment in order to reduce the thickness of the free flap and allow tension-free primary closure of the donor site. These attempts successfully covered large-sized intraoral defects, achieving good functional outcomes with minimal donor site morbidity.

Tripaddled Anterolateral Thigh Flap for the Reconstruction of Extensively Full-Thickness Cheek Defects by Stacking Two Skin Paddles as Kiss Pattern.

Extended anterolateral thigh (ALT) flap can provide a large amount of skin to reconstruct the extensively full-thickness defects of cheek. However when the width of 1 skin paddle exceeds 8 cm, it always results in that the donor site cannot be closed primarily and need to be covered by split-thickness skin grafting, which delivers lots of impacts on the functional and cosmetic outcome of the thigh. The aim of this study was to introduce the authors' modification of stacking 2 skin paddles of the tripaddled ALT flap to reconstruct the extensive full-thickness defects in the cheek after the radical ablasion of advanced buccal squamous cell carcinoma. Ten patients of advanced buccal squamous cell carcinoma between March 2014 and December 2016 were enrolled in the authors' hospital. All the patients were received the soft-tissue reconstructions for the extensively full-thickness cheek defects by using the tripaddled ALT chimeric flaps. Among 3 skin paddles, the distal paddle was used to reconstruct the inner mucosa defect, and the other 2 large skin paddles were stacked side by side for outer mega cheek defect. The mean area of the intraoral defect was 32.2 cm and the mean area of the extraoral defect was 106.34 cm. The mean width of the outer skin defect was 9.5 cm. All the flaps survived and all the donor sites were closed primarily. So, stacking 2 skin paddles of a tripaddled ALT flap as a kiss pattern is a novel modification on conventional flap design to provide customized coverage for extensive and full-thickness buccal defects while minimizing donor-site morbidity.

Application of Digital Technologies in Maxillofacial Prosthetics Literature: A 10-Year Observation of Five Selected Prosthodontics Journals.

To identify trends in the application of various types of digital technologies in maxillofacial prosthetics by identifying these digital technologies and their characteristics and reviewing the prevalence of applied digital technologies and their recent trends in the maxillofacial prosthetics literature. Five leading peer-reviewed prosthodontics journals were manually searched for maxillofacial prosthetics articles on the use of digital technologies published from January 2008 to December 2017. Descriptive statistics were used to analyze data collected on productivity, type of digital technology used, type of article, type of defect, number of authors, and geographic distribution. Of the 336 maxillofacial prosthetics articles screened, 87 (26%) were selected for analysis. A remarkable increase was found in article productivity in the last 5 years (63%) compared to the first 5 years (37%). There was also a notable increase over the last 10 years in all digital technologies used except for evaluation technologies, which remained almost constant. Case reports most frequently mentioned use of digitization technologies (61%), design technologies (66%), and rapid prototyping technologies (66%). Original research articles most frequently mentioned use of evaluation technologies (89%); 39% of these technologies were used for intraoral defects and 27% for extraoral defects. Most often, articles had four to five authors (54%). Most published articles were from the Asia-Pacific region (44%), followed by North America (22%) and Europe (20%). Although the application of digital technologies reported in the maxillofacial prosthetics literature has increased notably in leading prosthodontics journals over the last 10 years, total article productivity has remained relatively small.

Donor site morbidity of the anterolateral thigh flap

IntroductionThe purpose of this study was to investigate donor site morbidity after reconstruction of defects in the head and neck region with an anterolateral thigh (ALT) flap. MethodsFrom 07/2006 to 12/2015 the anterolateral thigh flap was used for reconstruction of large intra- or extraoral defects in 138 patients. The donor sites were available to examine for morbidity in 51 patients (36.7%). All patients completed a standardized questionnaire, received a physical examination, and underwent isokinetic muscle exercises of the lower extremity with a Dynamometer. ResultsThe average postoperative follow-up was 29 months and showed significant donor site morbidity in the form of sensory disturbance as well as revealing significant differences in extension and flexion between donor and normal thighs in the isokinetic power test. Range of motion at the hip and knee was moderately compromised. ConclusionThe results of this study suggest that dissection of the musculocutaneous perforators can compromise the function of vastus lateralis, which is the largest compartment of the quadriceps group. This could also affect the antagonistic muscles such as the semitendinosus, semimembranosus and biceps femoris. Because of its versatility, adequate tissue stock, possibility of simultaneous two-team approach large and long pedicle and minimal donor site morbidity, the ALT flap has become one of the most preferred transplants for soft tissue reconstruction in the head and neck region. Most authors described the donor site morbidity as minimal (Song et al. 1984; Wolff et al., 2006; Xu et al., 1988; Kimata et al., 1997; Kuo et al., 2001; Collins et al., 2012). In summary, the study shows that functional impairment of the donor thigh can occur but does not affect the patients in their daily life.

Double-paddle peroneal flap for extensive lip defect reconstruction.

Today, reconstructive surgeons offer an array of options to reconstruct the lip defects. Herein we present our experience of using free double-paddle peroneal flaps for extensive lip defect reconstruction. From 1996 to 2014, 16 patients with extensive lip defects after tumor ablation were included. Free double-paddle peroneal flaps were used for reconstructions. In terms of flap design, one skin paddle superiorly placed on the lateral lower leg was used to reconstruct intraoral defects, whereas the other was inferiorly located and was used to reconstruct extraoral defects. A part of the inner skin paddle was everted, and the suture line with the outer skin paddle became the new vermilion border. A portion of the outer skin paddle could be de-epithelized and tucked into the fold of the inner skin paddle, leading to greater fullness of the new lip. Skin paddle sizes were 10-15 cm × 3-13 cm and 4-10.5 cm × 2.5-10.5 cm. Venous thrombosis occurred in one patient but was salvaged, and one flap had superficial necrosis over the outer paddle that was conservatively treated. In the 0.5-33 month follow-up period, all patients were able to close their mouths without obvious drooling. Free double-paddle peroneal flap transfer could augment lip definition, deepen the labial vestibule, and provide an acute-angle oral commissure, leading to satisfactory oral competency and improved cosmetic results. Therefore, this technique may be considered a viable option for extensive lip defect reconstruction.

Prosthetic management of patients with oro-maxillo-facial defects: a long-term follow-up retrospective study.

The aim of this study is to determine the outcome of maxillofacial prosthetic rehabilitation after oncological resections, including both intra- and extra-oral prosthetic devices. In this study were included 72 patients, who have undergone an intra or extra-oral maxillofacial prosthetic rehabilitation after an oncologic resection. Tumors on the head and neck were analyzed and the defects of these resections have been divided in two different groups: intra and extra-oral defects. 72 participants were treated with maxillofacial prosthesis, 3 of which with post-traumatic wounds and 69 with resections of tumors on the head and neck. Of the 69 treated for neoplastic disease, 43 received an intraoral prosthesis (palatal obturator) and 29 with an extraoral epithesis (18 with nasal prostheses, 8 with orbital implants and 3 with ear implants). The group included patients with different types of tumors. All the patients were evaluated in terms of aesthetic appearance after the construction of the prostheses and the results were satisfactory. Within the limitations of this study, after the use of maxillofacial protheses patients feel more confident and self-assured. Maxillofacial protheses are a good solution in order to improve the life's quality in patients with tumors resections: prostheses are easy to handle and provide a satisfying social interaction for the patients.