Maxillectomy Defects Research Articles

The surgical obturator revisited

The rehabilitation of maxillectomy defects can be initiated at the time of resection through interactive treatment planning between the surgeon and maxillofacial prosthodontist. The purpose of this article is to familiarize the recent generations of head and neck surgeons and maxillofacial prosthodontists with the role of the surgical obturator and intraoperative techniques for optimal prosthesis design. The advantages of a surgical obturator and the consequences of not using a surgical obturator for maxillary resections are evaluated. Different types of defects are assessed from the initial presentation to completed design of cast and surgical obturator. The surgical and prosthetic techniques to aid fabrication of surgical obturators for three subjects with very different maxillary defects are shown. Emphasis is placed on the value and versatile functionality of a surgical obturator to initiate and promote successful rehabilitation of the maxillary defect.

Diverse classification systems for maxillectomy defects: Simplifying or complicating the treatment plan?

Diverse classification systems for maxillectomy defects: Simplifying or complicating the treatment plan?

Challenges in the Reconstruction of Bilateral Maxillectomy Defects

Bilateral maxillectomy defects, if not adequately reconstructed, can result in grave esthetic and functional problems. The purpose of this study was to investigate the outcome of reconstruction of such defects. This is a retrospective case series. The defects were analyzed for their components and the flaps used for reconstruction. Outcomes for flap loss and functional indices, including oral diet, speech, and dental rehabilitation, also were evaluated. Ten consecutive patients who underwent bilateral maxillectomy reconstruction received 14 flaps. Six patients had malignancies of the maxilla, and 4 patients had nonmalignant indications. Ten bony free flaps were used. Four soft tissue flaps were used. The fibula free flap was the most common flap used. Three patients had total flap loss. Seven patients were alive and available for functional evaluation. Of these, 4 were taking an oral diet with altered consistency and 2 were on a regular diet. Speech was intelligible in all patients. Only 2 patients opted for dental rehabilitation with removable dentures. Reconstruction after bilateral maxillectomy is essential to prevent esthetic and functional problems. Bony reconstruction is ideal. The fibula bone free flap is commonly used. The complexity of the defect makes reconstruction difficult and the initial success rate of free flaps is low. Secondary reconstructions after the initial flap failures were successful. A satisfactory functional outcome can be achieved.

Issues in Oncologic Surveillance of Patients with Maxillectomy Defects

Objectives: (1) Describe locoregional and distant disease recurrence patterns among patients undergoing maxillectomy from 2001-2011 at Cleveland Clinic and UCSF Medical Center. (2) Analyze the pattern of recurrence in this cohort in order to evaluate whether microvascular reconstruction may delay clinical detection of early cancer recurrence. Methods: Retrospective review of patients undergoing inferior, subtotal, or total maxillectomy, with or without reconstruction, for control of malignant disease from 2001-2011 from 2 tertiary centers (Cleveland Clinic and University of California, San Francisco). Results: A total of 76 patients across the 2 institutions met the inclusion criteria for the study. Squamous cell carcinoma was the most prevelant pathologic diagnosis with overall disease progression of 29%. Recurrence at the skull base and regional lymphatic spread were the most common patterns identified (18 and 32%, respectively). Surveillance imaging, rather than direct observation on physical examination, raised suspicion for disease progression in the majority of cases. A total of 9 patients were found to have disease recurrence that could be surgically salvaged, with only 4 patients requiring modification to their reconstruction as part of the salvage operation. Conclusions: Locoregional recurrence of malignancy after partial or total maxillectomy is uncommon, and the suspicion for disease recurrence is significantly more commonly raised on surveillance imaging, rather than on physical examination. Further, locoregional recurrence is rarely amenable to successful surgical salvage. This suggests that primary microvascular reconstruction of maxillectomy defects does not delay diagnosis or treatment of disease recurrence.

Rehabilitation of maxillectomy defects with obturator prostheses fabricated using computer-aided design and rapid prototyping: a pilot study.

To establish an alternative method to design and fabricate an obturator prosthesis within the maxillectomy defect using a computer-aided design (CAD) and rapid prototyping (RP) technique and to evaluate the functional results of this technique. Eleven patients with acquired maxillary defects resulting from head and neck cancers were treated using a protocol based on three-dimensional (3D) reconstruction, CAD, and RP technologies to fabricate obturator prostheses. To evaluate the quality of the obturator prostheses and the patients' satisfaction, the Obturator Functioning Scale (OFS) of the Memorial Sloan-Kettering Cancer Center was applied. Each patient received an individualized obturator that exactly matched the static shape and fit of the defect. Clinical modifications were required to improve border contours. The patients showed good results in all fields of functional outcomes and social acceptance. The OFS scores were comparable with those reported in other studies using traditional maxillectomy impression methods. This study combined CAD with RP technology to explore an alternative and feasible method for manufacturing individualized obturators for patients after maxillary resection. It has shown significant clinical value, especially for use in developing countries.

Versatility of adipofascial anterolateral thigh flap for reconstruction of maxillary defects with infratemporal fossa extension.

Tumors arising from the posterior hard palate or posterolateral maxilla may extend to involve the infratemporal fossa (ITF). Resection of these tumors results in infrastructural maxillectomy with ITF defects. In this study, we describe the use of an adipofascial anterolateral thigh flap (ALT) specifically for such defects. This case series includes four patients who underwent an infrastructure maxillectomy with ITF clearance and the resultant defects were reconstructed using adipofascial anterolateral thigh flaps. The complications as well as the functional outcomes were assessed. This study included patients with lesions involving the hard palate, posterolateral part of maxilla with extension into the ITF. The mean flap dimension was 150 cm(2) (range, 120-180 cm(2)). All flaps were harvested based on a single perforator. The flap was used to obliterate the ITF defect and also to achieve oroantral separation. All flaps mucosalized well within 6 weeks. All patients were on oral diet and had adequate mouth opening. There were no donor-site complications. Adipofascial ALT is an excellent choice for infrastructural maxillectomy defects with ITF extension. The intraoral part got mucosalized well and provided a smooth and taut surface. A large adipofascial tissue flap helps obliterate the ITF, thus minimizing complications.

Zygomatic implants: indications, techniques and outcomes, and the zygomatic success code.

The zygoma implant has been an effective option in the management of the atrophic edentulous maxilla as well as for maxillectomy defects. Brånemark introduced the zygoma implant not only as a solution to obtain posterior maxillary anchorage but also to expedite the rehabilitation process. The zygoma implant is a therapeutic option that deserves consideration in the treatment-planting process. This paper reviews the indications for zygoma implants and the surgical and prosthetic techniques (including new developments) and also reports on the clinical outcome of the zygomatic anatomy-guided approach. An overview of conventional grafting procedures is also included. Finally, a Zygoma Success Code, describing specific criteria to score the success of rehabilitation anchored on zygomatic implants, is proposed.

Articulation of speech of patients treated with radicular attachment assisted obturator following maxillectomy

Background: Obturators are used to separate the oro-nasal opening. These improve speech and other oral functions as well as provide psychological support to the patients. Adding radicular attachments in an obturator makes more effective. Objective: To evaluate and compare the effectiveness of obturator with radicular attachment and conventional obturator in articulation of speech. Materials and Methods: Fifty patients, age ranged from 18 to 72 years, with maxillectomy defect were selected as the sample of the study. Among them 25 patients were treated with obturator with radicular attachment and another 25 patients were treated with conventional obturator. After insertion of obturator, data were collected on the basis of articulation of speech. Results: Patients treated with obturator with radicular attachment showed significantly better (P value <0.001) articulation of speech. Conclusion: Obturator with radicular attachment is more effective than conventional obturator. DOI: http://dx.doi.org/10.3329/bjms.v13i3.19152 Bangladesh Journal of Medical Science Vol.13(3) 2014 p.298-301

English

Benign or malignant tumors of mouth and oropharyngeal region often result in the maxillofacial defects. The acquired maxillectomy defects results in the impairment of speech, mastication, swallowing and facial esthetics. The Prosthodontist plays a significant role in the rehabilitation of the acquired maxillectomy defects with the special emphasis to the reduction of the weight of the prosthesis and thereby enhancing the retention and stability. The weight of the obturator can cause a dislodging force. It must therefore be as light as possible. A suitable technique of fabrication should be selected to achieve this. This case report describes the fabrication of a hollow bulb obturator for a hemi- maxillectomy patient (Aramany's class 1 defect) who had undergone wide excision and alveolar resection squeal of management of adenoid cystic carcinoma of the right palate. This article describes the step by step clinical and laboratory procedure involved in the rehabilitation of a hemimaxillectoy dentate patients using obturator lined with soft liner to restore the functions such as esthetics, mastication, deglutition and speech.

Prosthetic Rehabilitation of Maxillectomy Defect with Cast Metal Framework and an Acrylic Hollow Bulb -A Case Report

Prosthetic Rehabilitation of Maxillectomy Defect with Cast Metal Framework and an Acrylic Hollow Bulb -A Case Report

A Comprehensive Prosthodontic Management of Subtotal Maxillectomy

ABSTRACT Patient A 21-year-old female patient was diagnosed with intraosseous mucoepidermoid carcinoma on the left side of maxilla, which was planned for subtotal maxillectomy involving the left maxillary sinus. Discussion Prosthodontic rehabilitation of patients with maxillectomy is a challenge as it involves restoring speech, deglutition, mastication and respiration. This clinical report describes a comprehensive prosthodontic management of a young girl treated for a subtotal maxillectomy due to intraosseous mucoepidermoid carcinoma. The prosthodontic manage- ment that was carried out right from the surgical obturator to a definitive prosthesis with a two-piece closed hollow bulb, magnet-retained obturator shows the ease and simplicity in the management of a case with subtotal maxillectomy. Conclusion Subtotal maxillectomy defects represent a complex challenge for the maxillofacial prosthodontist. The comprehensive technique described in this clinical report can be employed in any similar case. How to cite this article Sundar MK, Kumar GPS, Lakhanpal S. A Comprehensive Prosthodontic Management of Subtotal Maxillectomy. Int J Prosthodont Restor Dent 2014;4(4):120-126.

Rehabilitation of maxillectomy defect with obturator prosthesis

The acquired defects of the palate are created commonly surgical intervention of benign or malignant neoplasms. The size and location of the defect influence the level of difficulty in prosthetic rehabilitation. Surgical intervention creates anatomic defect which forms communication among the oral cavity, nasal cavity and maxillary sinus. The goal of prosthodontist is to rehabilitate missing oral and extra oral structures with restoration of normal anatomic and physiologic function. Prosthetic rehabilitation with obturator restores the oral structures and also acts as barriers between communications among the cavities. Acquired maxillary defects of the palate are seen in patients suffering from benign and malignant neoplasms, trauma, pathologic changes, radiation therapy and surgical intervention. Ablative surgical therapy is frequently adopted for the control of malignancies and other abnormal growths. This results in anatomic defect that allows the oral cavity maxillary sinus and nasal cavity to become one compartment, abrupt alteration of physiologic functions such as speech, mastication, deglutition and salivary control. Prosthodontics rehabilitation for an acquired maxillary defect begins immediately at the time of surgical resection. Prosthetic rehabilitation begins with a surgical obturator, which is inserted at the time of surgery to help retain the packing, prevent oral contamination of the surgical wound and skin graft, and to allow the patient to speak and swallow during the initial post operative period. The surgical obturator is commonly converted into an interim obturator with the addition of resilient lining material to adapt to the defect. Definitive obturator is initiated approximately 3 to 4 months after surgery when healing is complete. The impression for definitive obturator prosthesis should include the skin graft mucosal junction, lateral aspect of the orbital floor, and the dynamic physiology of the velopharyngeal mechanism during speech and swallowing. The obturator bulb must also be contoured to prevent obstruction of nasal breathing and to maintain nasal resonance during speech. The degree of extension into the defect varies depending upon the configuration of the defect, character of its lining tissue, and functional requirement for retention, stability and support of the prosthesis. This article describes a case report of a patient who had undergone partial maxillectomy secondary to squamous cell carcinoma and rehabilitated with definitive obturator.

Prosthetic rehabilitation of acquired maxillectomy defect:A case report with 10 years follow-up

Acquired maxillary defects are created by surgical removal of benign or malignant tumors, congenital malformation and by trauma. Surgery is the fi rst choice for some benign tumors, early cancers and for cancers that do not respond to radiation and chemotherapy. Surgery or trauma can result in cosmetic, functional and psychological impairment greatly aff ecting the patient’s quality of life. Surgical reconstruction of the maxillary defects can be carried out either by using temporal fl ap or a wide range of microvascularized fl aps. Rehabilitation via palatal obturators to obturate a palatal defect in a dentulous or edentulous patient is one of the choices in restoring masticatory function and improving speech, deglutition and cosmetics. Rehabilitation of such patients is quiet challenging and requires a multidisciplinary team for comprehensive care and optimal post-treatment functional outcomes. Hence, it is crucial to work in close collaboration with the team members who makes the prosthesis and who evaluates the case for planning the surgical procedures and obtaining the necessary anatomical and functional information.

Use of a Three-Dimensional Model to Optimize a MEDPOR Implant for Delayed Reconstruction of a Suprastructure Maxillectomy Defect

The use of a three-dimensional (3-D) model has been well described for craniomaxillofacial reconstruction, especially with the preoperative planning of free fibula flaps. This article reports the application of an innovative 3-D model approach for the calculation of the exact contours, angles, length, and general morphology of a prefabricated MEDPOR 2/3 orbital implant for reconstruction of a suprastructure maxillectomy defect. The 3-D model allowed intraoperative modification of the MEDPOR implant which decreased the risk of iatrogenic harm, contamination while also improving aesthetic results and function. With the aid of preoperative 3-D models, porous polypropylene facial implants can be contoured efficiently intraoperatively to precisely reconstruct complex craniomaxillofacial defects.

Pure soft tissue flaps for maxillectomy defects reconstruction with favourable functional and satisfaction outcomes, case series of the Boston Medical Center

Purpose: The aim of this abstract to share our experience utilizing pure soft tissue flaps in maxillectomy defects reconstruction.

Maxillectomy Reconstruction with Various Flaps: Preliminary Results and Suggested Algorithm

Objectives: Although maxillary reconstruction after maxillectomy for the malignant tumor is still controversial, various reconstruction techniques have been introduced. Since reconstruction methods could be varied by the defects and surgeon’s preference, we would like to share our reconstruction algorithm and show preliminary results. Methods: Thirteen cases of maxillectomy reconstruction during the past 18 months were reviewed. The types of defects, reconstruction methods, and outcomes were reviewed. The types of defects after maxillectomy were as various as Brown class IIa, IIb, IIIb, IIId, IVb, IVd, and V. Reconstructions were performed using free flaps from the iliac crest, radial forearm, rectus abdominis, and latissimus dorsi. When the maxillectomy included orbital exentration, soft tissue free flaps for defects were preferred. On the other hand, defects for bony lesions including alveolar ridge and orbital rim were reconstructed with iliac crest osteomuscular (or osteomusculocutaneous) free flap. Results: All of them were well reconstructed without any complication. The content, especially the orbital content and bony structure, and size of the maxillectomy defect, tumor characteristics, and patients’ prognosis should be considered in the selection of maxillectomy reconstruction. Conclusions: The iliac crest free flap might be one of the best options to reconstruct the bony defect after maxillectomy.

Vastus lateralis muscle-only free flap: an option in the reconstruction of the post maxillectomy defect

Vastus lateralis muscle-only free flap: an option in the reconstruction of the post maxillectomy defect

Microsurgical reconstruction of maxillectomy defects: experience of 24 cases

Introduction The defect complexity and reconstructive options make the maxillary reconstruction a controversial theme and in a constant debate. The maxilla is a fundamental aesthetic and functional structure of the face. Microsurgical vascularized flaps replaced the usage of prosthetic material and pedicled flaps as a “gold standard” for the reconstruction of complex defects following maxillectomy.

Usefulness of the anterolateral thigh flap with vascularized fascia lata for reconstruction of orbital floor and nasal surface after total maxillectomy

The aim of this study was to describe a technique using the fascia lata (FL) component of the anterolateral thigh (ALT) flap to re-create the orbital floor and lateral nasal wall after total maxillectomy. Retrospective analysis of medical records. A total of 22 patients underwent maxillary reconstruction using a composite ALT-FL flap following cancer resection. All patients underwent total maxillectomies via the Weber-Ferguson approach. The ALT flap was harvested with the deep fascia of the thigh with the aim of using it for lining of the orbital floor and lateral nasal cavity. The FL was sutured to the palatine bone inferiorly, nasal bone and zygomatic bone superiorly, and nasopharyngeal mucosa posteriorly to provide an orbital floor and make a neonasal cavity. There was 100% free flap survival. Speech was normal in eight (36%) patients, near normal in 10 (46%), and intelligible in four (18%). Seventeen (77%) patients gained a good facial appearance, and five (23%) a fair appearance. Sixteen (73%) patients complained of mild nasal crust formation, and the rest (27%) developed moderate crust. Microvascular reconstruction using a composite ALT-FL flap provided a reliable fascial component for orbital floor and nasal surface reconstruction of total maxillectomy defects.

Brown Class III Maxillectomy Defects Reconstruction With Prefabricated Titanium Mesh and Soft Tissue Free Flap

Midface reconstruction is one of the most challenging tasks for the reconstructive surgeon. We present a technique for the reconstruction of the midface after total maxillectomy with preservation of orbital contents. Skeletal reconstruction is achieved with a preoperatively bent titanium sheet mesh on a universal skeletal model. The alveolar ridge, the anterior wall of the maxillary sinus, the zygomatic prominence, the lower orbital rim, and the orbital floor are reconstructed with a titanium mesh. A soft tissue free flap, preferably anterolateral thigh free flap, is harvested as well. A part of the flap is deepithelized and put in front of the mesh to prevent exposure, and the other part is used for palatal reconstruction. Four male and 1 female patients were reconstructed with titanium mesh. Four free flaps were raised: 3 anterolateral thigh and 1 latissimus dorsi. All free flaps survived. All patients received postoperative irradiation with 64 Gy. Median follow-up was 12 months; no major complications occurred. Mesh was exposed in only 1 case, which was managed successfully with resuspension of the heavy latissimus dorsi myocutaneous flap. Midface projection and height, globe position, ocular movements, and vision where satisfactory in all cases. Midface reconstruction with titanium mesh and soft tissue free flap is a reliable and safe method for functional and aesthetic reconstruction after maxillectomy.