Palatomaxillary Defects Research Articles

Postoperative Imaging Appearance of Iliac Crest Free Flaps Used for Palatomaxillary Reconstructions.

The osteomyocutaneous iliac crest free flap is a reconstructive option for segmental mandibular or complex palatomaxillary defects. Familiarity with the radiographic appearance of free flaps such as the iliac crest is necessary for the postoperative evaluation of patients after mandibular, maxillary, or palatal reconstructions because it allows radiologists to properly monitor and interpret the appearance of the flap over time. This study presents a retrospective review of 5 patients who underwent palatomaxillary reconstruction with an iliac crest free flap at our institution. The imaging appearances of the 5 patients were analyzed to determine the key radiographic characteristics of a healthy and successful iliac crest free flap. Radiographic fluency with the imaging appearance of the iliac crest free flap, as well as the new anatomy of the region in the postoperative period, will allow for better interpretation of the flap appearance on imaging and will prevent false identification of tumor recurrence.

Palatomaxillary Reconstruction: Fibula or Scapula.

Palatomaxillary reconstruction presents a unique challenge for the reconstructive surgeon. The maxillofacial skeleton preserves critical aerodigestive functions-it provides a stable hard palate to support mastication and separate the nasal and oral cavities, and buttress support to provide adequate midface contour. Free tissue transfer has become a routine part of the reconstructive ladder in managing palatomaxillary defects. While there is a wide variety of options for bony reconstruction within the head and neck, the fibula and the scapula, and their variations, have become two of the most commonly used options for midface reconstruction. This review will discuss the advantages and disadvantages of both in specific regard to reconstruction of the palatomaxillary area.

Delayed Reconstruction of Palatomaxillary Defect Using Fibula Free Flap.

Introduction. The objective of this study was to evaluate a surgical technique and to present the results of delayed reconstruction of palatomaxillary defects using fibula free flap (FFF). Methods. A review was conducted for nine patients who underwent palatomaxillary reconstruction using FFF. Primary disease, type of reconstruction, defect area, fibula segment length and number of osteotomies, radiotherapy, and implant installation after FFF reconstruction were analyzed. Results. All nine patients underwent delayed reconstruction. The fibula shaft was osteotomized into two segments in seven patients and three segments in one patient with bilateral Brown’s revised classification IV/d defect. One case was planned by using a computer-aided design computer-aided manufacturing (CAD/CAM) system with a navigation system. The mean length of the grafted fibula bone was 68.06 mm. Dental implant treatment was performed in six patients. Six patients received radiation therapy, and there were no specific complications related to the radiation therapy. In one case, the defect was reconstructed with FFF flow-through from a radial forearm free flap. Conclusion. This clinical study demonstrated that the fibula flap is an ideal donor-free flap in a palatomaxillary defect. Delayed reconstruction using an FFF can reduce the complication and failure rates.

Management of orbital complications in palatomaxillary reconstruction: A review of preemptive and corrective measures.

Reconstruction of orbit-sparing palatomaxillary defects requires consideration of globe dystopia, orbital volume, eyelid position and function, and the nasolacrimal system to preserve and optimize vision, globe protection, and appearance. We describe the fundamentals of orbital and eyelid anatomy, common orbital complications related to palatomaxillary reconstruction, and preemptive and corrective surgical techniques to be utilized during and after globe-sparing palatomaxillary reconstruction. We present a review of the literature supplemented by clinical case examples. We advocate for the use of preemptive and corrective techniques to ensure optimal aesthetic and functional outcomes for patients with orbital defects. Recognition and anticipation of problems in patients undergoing midface ablative and reconstructive procedures are vital to the implementation of corrective measures. Incision choice, orbital volume restoration, appropriate orbital floor reconstruction, and permanent or temporary lower eyelid suspension during the primary surgery can all significantly impact the development of long-term orbital complications.

The use of direct metal laser sintering technology in the management of acquired maxillofacial defects due to malignant neoplasm

Rehabilitation of maxillary defects presents a significant challenge in terms of restoration of near normal functions following the healing of large surgical wound. The obturator prostheses as a part of prosthetic management are used for the separation of oral and nasal cavities to allow adequate deglutition and articulation and support for the soft tissue to restore the midfacial contour in palatal defect cases. This clinical report describes a prosthetic approach to the rehabilitation of an acquired palatomaxillary defect with definitive obturator prosthesis as well as guide flange prosthesis for the management of mandibular deviation.

Comprehensive approach to functional palatomaxillary reconstruction using regional and free tissue transfer: Report of reconstructive and prosthodontic outcomes of 140 patients.

Palatomaxillary defects were historically restored with a prosthetic obturator; however, advances in local and free tissue transfer has provided a viable alternative for appropriately selected patients with palatomaxillary defects. A retrospective chart review of patients who underwent palatomaxillary reconstruction by the lead author between 1998 and 2016 was conducted. Patients who were restored with a palatal obturator were excluded. One hundred forty patients were reconstructed with a total of 159 local, regional, and free flaps with a 96.7% success rate. Seventy-four patients (52.8%) underwent prosthodontic rehabilitation, with 183 implants placed and an 86% success rate. Palatomaxillary reconstruction applying a systematic approach, using a multitude of techniques, is a safe and effective way to restore patients without compromising the ability to maintain surveillance. Prosthodontic rehabilitation can be achieved in a high percentage of patients using dental implants, leading to optimal aesthetic and functional results.

Continuous Validity of Temporalis Muscle Flap in Reconstruction of Postablative Palatomaxillary Defects.

Postablative palatomaxillary defects (PAPMDs) represent a challenging reconstructive problem. Temporalis muscle flap (TMF) has been widely used for reconstruction of these defects with minimal morbidity and satisfactory outcome. To presents the authors' experience in the reconstruction of PAPMDs with TMF and to evaluate the validity of TMF in the reconstruction of such defects. This prospective study was conducted between July 2011 and July 2016 on selected patients for primary reconstruction of PAPMDs with TMF. Temporalis muscle flaps were assessed during surgery and postoperatively. Patients were followed up to evaluate functional and esthetic outcomes and detect complications. This study included 32 patients with mean age 48.3 years. The pathology was squamous cell carcinoma in 15 patients (46.9%). Twenty-one patients (65.6%) had type II maxillectomy. Mean time of flap harvesting was 43 minutes. Zygomatic arch osteotomy was done in 3 patients while Coronoid osteotomy in 4 patients. Postoperatively, flaps were viable in 31 patients (96.9%) with good healing of recipient site. Flap epithelization completed within 28 to 59 days. Follow-up period was 13 to 55 months. Satisfactory functional and esthetic outcomes were reported in most of patients with no recurrence. Transient temporal nerve palsy occurred in 2 patients, limited mouth opening in 5 patients. One patient had Transient diplopia with enopthalmos and hypophthalmos. Flap failure occurred in another patient. Temporalis muscle flap is still a valid reliable and versatile reconstructive tool in palatomaxillary reconstruction after ablative surgery. It has a good cosmetic and functional outcomes and minimal morbidity.

Palato-maxillary reconstruction by the angular branch-based tip of scapula free flap.

The angular branch (AB)-based tip of scapula free flap is a valuable reconstructive option in palato-maxillary defects needing significant structural support. We herein retrospectively evaluate our surgical series with special focus on functional outcomes and postoperative morbidity. Ninety-seven consecutive palatomaxillary oncologic resections were performed at our institution between August 2008 and November 2015. The analysis focused on those reconstructed by an AB-based tip of scapula free flap (N=18; 19%). A prospective assessment of donor site morbidity was performed by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire in 12 (67%) patients. Among patients reconstructed by an AB-based tip of scapula free flap, 13 (72%) had a Class II and 5 (28%) a Class III defect according to Okay classification. Flap success rate was 94%, with one failure requiring an anterolateral thigh flap. Eight (44%) patients experienced recipient site complications, while donor site problems occurred in two only (11%). Eleven (61%) subjects were able to maintain a normal and 7 (39%) a soft-to-firm diet. The mean DASH score was 10.5. Our results confirm that the AB-based tip of scapula free flap is a reliable choice in palatomaxillary reconstruction, with both satisfactory functional outcomes and negligible donor site morbidity.

Reconstruction of palatomaxillary defects following cancer ablation with temporalis muscle flap in medically compromised patients: a 15-year single institutional experience

Objectives Successful reconstruction of palatomaxillary defects following cancer ablation represents a formidable challenge for surgeons to achieve consistently favorable outcomes. The purpose of this article is to present our experience in oncologic palatomaxillary repair with temporalis muscle flap (TMF) for medically compromised patients who are not ideal candidates for microvascular reconstruction at a Chinese tertiary referral hospital over a 15-year period (1998–2012).

Evaluation of Zygomatic implant retained obturator in rehabilitation of partial palato-maxillectomy patients

ObjectivesTo evaluate clinically, radio-graphically and electro-myographically the added value after converting conventional obturator to implant retained one using Zygomatic implant for patients with acquired partial palatomaxillary defect, as regards residual tissue preservation, masticatory muscle activity and quality of the life. MethodsEight patients were selected form Prosthodontic Clinic of the Faculty of Dentistry, Tanta University with palatomaxillary defects. The conventional hollow type obturator was fabricated for each patient. After 6 months of obturator insertion, each patient received tapered threaded implant at the Zygomatic bone of the resected side. During Osseointegration period, all patients continued using the conventional hollow obturators. After another 6 months the obturator was connected to the implant by ball and socket attachment. Clinical and radiographic evaluation of the abutment teeth in addition to Electromyographic evaluation of masseter and temporalis muscles and assessment of the oral health related quality of life were done. ResultsFor the abutment teeth, there was no statistically significant difference in gingival index, tooth mobility, and bone level in comparison between conventional obturator and implant retained obturator. Implant retained obturator showed significant improvement over conventional obturator in patient quality of life. In addition, increase of muscle activity of the masseter and temporalis muscles in patients with implant retained obturator was recorded. ConclusionThe implant retained obturator highly improved the masticatory function and Oral Health Related Quality of Life (OHRQOL) in comparison to conventional obturator.

Reconstruction of palatomaxillary defects following cancer ablation with temporalis muscle flap in medically compromised patients: a 15-year single institutional experience

Successful reconstruction of palatomaxillary defects following cancer ablation represents a formidable challenge for surgeons to achieve consistently favorable outcomes. The purpose of this article is to present our experience in oncologic palatomaxillary repair with temporalis muscle flap (TMF) for medically compromised patients who are not ideal candidates for microvascular reconstruction at a Chinese tertiary referral hospital over a 15-year period (1998-2012). A retrospective chart review was performed to identify patients with compromised medical conditions who underwent oncologic palatomaxillary reconstruction using TMF. Patients' demographics, clinicopathological variables, and surgical techniques were presented. Postoperative functional and aesthetic outcomes were assessed by measurements and patients self-evaluations. Sixty-nine TMFs were successfully harvested and used for immediate oncologic palatomaxillary reconstruction in 67 patients (31 males and 36 females, mean age 60.4 years) with diverse primary malignancies. These patients' co-morbidities included systemic diseases, preoperative chemotherapy/radiotherapy, and elder over 65 years which precluded the ideal utility of free flaps. Fifty-one patients remained alive without disease, while nine had recurrences/metastases and seven died during the follow-up (0.5-10.4 years, mean 3.7 years). All flaps survived with only partial necroses in four cases. Complications and donor-site morbidities were minimal with five transient facial paralysis and four mild diplopia and enophthalmos. Unrestricted diet and mouth opening, intelligible speech, and satisfactory temporal aesthetics were obtained in most patients. The TMF is a reliable, versatile, and alternative option for oncologic palatomaxillary reconstruction with satisfactory functional and aesthetic outcomes and minimal complications, especially when appropriately selected for those medically compromised patients.

Vascularized bone graft is a better option for the reconstruction of maxillary defects

We read the article of Kinnunen et al., which evaluated the result of maxillary defects, and feel some objections. We present our considerations of their operative indication and thoughts based on our surgical experiences. Defects after palatectomy, which have left no dentition for the retention of an obturator, require vascularized bone-containing free flaps. Local flaps are available in only small defects of Class 1 and 2a. Most palatomaxillary defects following malignant tumor abrasion are classified as 2b, 2c, 3, or 4, which require microsurgical free flap transfer combined with bony reconstruction. Regarding bony reconstruction, non-vascularized bone grafts tend to be absorbed. Thus, we believe that bony reconstruction should be performed with vascularized bone. We agree with the authors' comment that PTMF may be useful in repairing defects due to complications in microvascular procedures in the palatal area. However, even when bone segment is required for salvage surgery, using a vascularized bone flap is more preferable. A parietal bone-fascial-periosteal flap based on the superficial temporal vessels is a suitable and reliable bone flap for the reconstruction of a maxillary defect following free skin flap transfer to the palate.

터널화 안면동맥 협부 근점막 도피판을 이용한 구개상악 결손의 재건: 증례보고

There are many challenges for reconstruction after intraoral tumor resection. Especially, palatomaxillary reconstruction has two primary goals: closure of the oronasal communication and re-creation of proper myomucosal function. Prosthodontic treatment using obturator and several surgical procedures are selected depending on the size and site of the defect, the difficulty of operative procedure, operation time and donor site problem. Above all, it is considered that radial forearm free flap is the first choice for palatal reconstruction. Our department introduces a novel method using tunnelized-facial artery myomucosal island flap for palatomaxillary defect reconstruction, which can successfully reduce donor-site morbidity, and duration of surgery and hospitalization.

Multidisciplinary Reconstruction of a Palatomaxillary Defect With Nonvascularized Fibula Bone Graft and Distraction Osteogenesis

Reconstruction of extensive palatomaxillary defects with oronasal/antral communication represents a challenge to surgeons. Bone-containing microvascular flaps have been suggested as a promising option for rehabilitation of function and esthetics. These types of flaps, however, might be associated with high morbidity. A combination of less complicated treatments might also provide acceptable results while diminishing potential donor site complications. This clinical report presents a bilateral maxillary defect with oronasal communication due to resection of malignant melanoma of the palate. The lost alveolar bone was initially reconstructed with a nonvascularized fibula bone graft. After 6 months, the alveolar segment was subjected to vertical distraction osteogenesis to increase bone height. After a 3-month consolidation period, the patient received 10 dental implants and an implant-supported fixed prosthesis. To preclude graft harvesting morbidity for reconstructing the oronasal fistula, the frame of the prosthesis was designed to include 3 ball attachments on which a palatal obturator, merely covering the palate, could be stabilized. The removable implant-retained obturator restored function perfectly. During the 5-year follow-up, no complication regarding bone graft, the dental implants, and the obturator has been observed.

Immediate reconstruction of palatomaxillary defects by mandibular osteomuscular flap pedicled with temporalis and radial forearm free flap

Objective To evaluate the clinical effect of mandibular osteomuscular flap pedicled with temporalis and radial forearm free flap to repair palatomaxillary defects. Methods From March 2008 to March 2011,nine patients with palatomaxillary defects following malignant tumor ablation,were repaired with mandibular osteomuscular flap pedicled with temporalis and radial forearm free flap. According to Brown's classification for the maxillectomy defect,eight cases were type Ⅱ B and 1 case was type Ⅱ C. There were 6 males and 3 females with an average age of 57 years(range,34-68 years). Results All the 9 osteomuscular flaps and forearm flaps survived.The patients were followed up for 12 to 24 months with an average of 14 months. The patients acquired satisfactory appearance and complete functional restoration except 1 case of chondrosarcoma of recurrence was encountered 6 months after operation. Conclusions Palatomaxillary defects were reconstructed by mandibular osteomuscular flap pedicled with temporalis and radial forearm free flap immediately.It is easy to elevate,safe,and there were no donor site problems.This is an ideal method of repairing the palato maxillary defects. Key words: Radial forearm free flap; Mandibular osteomuscular flap pedicled with temporalis; Palatomaxillary defects; Reconstruction

Computer-Assisted Virtual Planning in Maxillofacial Reconstruction Using Microvascular Free Fibula Flaps

Statement of the Problem: Reconstruction of segmental mandibular and palato-maxillary defects using fibular free flaps is challenged by the surgeon's ability to accurately insert the neomandibular or neomaxillary construct into an optimal position relative to the opposing jaw, so that the patient may receive osseointegrated implants and prosthetic restoration of occlusion. Recently, a computer-aided design/computer aided manufacturing (CAD/CAM) technique was introduced that utilizes CT guided 3D virtual technology to fabricate precise intraoperative cutting guides in an attempt to achieve orthogonal jaw relationships.

Reconstruction of the Mandible and the Maxilla

The upper and lower jaws play an essential role in mastication, articulation, and cosmetic form. The mandible provides support for tongue position and elevation of the larynx during swallowing, while the maxilla provides support for the nasal structures as well as an opposing structure to the mandible during mastication. The evolution of mandibular and maxillary reconstruction dates back to the early 19th century. Before the introduction of free tissue transfer, a variety of local flaps, regional flaps, and prosthetics were introduced, yet each was met with eventual failure. Since the introduction of free tissue transfer, mandibular and maxillary reconstruction has become as much of an art as it has a science. Whether the mandibular or the palatomaxillary defects are a result of trauma, congenital deformity, or tumor extirpation, the resultant effect often disrupts both form and function. With these considerations taken together, jaw reconstruction is a unique undertaking in which the artistic reconstruction of the facial skeleton is met with the science of reestablishing the mechanics of mastication. The site, size, and associated soft-tissue defects represent the 3 most important factors in determining the impact of a given defect on function and aesthetics. There is also an inherent difference between defects that are sustained in a controlled fashion, such as during cancer ablation, and those that result from trauma. The consideration of these complexities in jaw reconstruction is reflected in the wide variety of approaches and techniques that have evolved over the past century.

Reconstruction of the Mandible and the Maxilla

The upper and lower jaws play an essential role in mastication, articulation, and cosmetic form. The mandible provides support for tongue position and elevation of the larynx during swallowing, while the maxilla provides support for the nasal structures as well as an opposing structure to the mandible during mastication. The evolution of mandibular and maxillary reconstruction dates back to the early 19th century. Before the introduction of free tissue transfer, a variety of local flaps, regional flaps, and prosthetics were introduced, yet each was met with eventual failure. Since the introduction of free tissue transfer, mandibular and maxillary reconstruction has become as much of an art as it has a science. Whether the mandibular or the palatomaxillary defects are a result of trauma, congenital deformity, or tumor extirpation, the resultant effect often disrupts both form and function. With these considerations taken together, jaw reconstruction is a unique undertaking in which the artistic reconstruction of the facial skeleton is met with the science of reestablishing the mechanics of mastication. The site, size, and associated soft-tissue defects represent the 3 most important factors in determining the impact of a given defect on function and aesthetics. There is also an inherent difference between defects that are sustained in a controlled fashion, such as during cancer ablation, and those that result from trauma. The consideration of these complexities in jaw reconstruction is reflected in the wide variety of approaches and techniques that have evolved over the past century.

Reconstruction of Extensive Head and Neck Defects with Multiple Simultaneous Free Flaps

Extensive head and neck defects may not be amenable to reconstruction with a single flap. The authors' evaluated the feasibility and functional outcomes of reconstructive surgery involving multiple simultaneous free flaps. Cases involving multiple simultaneous free flaps for head and neck reconstruction between 2001 and 2007 at the University of Texas M. D. Anderson Cancer Center were reviewed. Seventy-nine free flaps were performed in 39 patients. Thirty-four patients (87 percent) underwent mandibular reconstruction for 14 bone and full-thickness cheek defects (36 percent), nine bone and hemiglossectomy defects (23 percent), and 11 bone and near total or total glossectomy defects (28 percent). Five patients (13 percent) had extensive palatomaxillary defects. The mean operation time, including the time for extirpative surgery, was 13.8 hours. The mean intensive care unit stay was 4.3 days, and the mean hospital stay was 11.5 days. Two patients had laryngectomies and the remainder received tracheostomies. Of the tracheostomy group, 33 patients (89 percent) were decannulated. In this same group, 30 patients (81 percent) demonstrated speech with greater than 80 percent of words intelligible. Twenty-three of 29 patients (79 percent) who were feeding tube-independent preoperatively received all of their nutrition orally postoperatively. Patients who were partially or totally feeding tube-dependent postoperatively underwent either a hemiglossectomy or near total or total glossectomy, with mandibulectomy. Multiple simultaneous free flaps can be performed safely in patients, with acceptable recovery times and functional outcomes. In select cases, the authors advocate multiple free flap reconstruction to maximize quality of life even in patients with advanced cancers.

Reconstruction of Velopharyngeal Competence for Composite Palatomaxillary Defect With a Fibula Osteocutaneous Free Flap

Velopharyngeal competence reconstruction is indispensable for acquiring the fine speech and ingesting function. However, the maxillary prosthesis becomes unstable in some patients who have undergone extensive palatomaxillary. We present a case of total palatomaxillary defect resulting from squamous cell carcinoma ablation of the palate, which was reconstructed using a fibula-free osteocutaneous flap. Velopharyngeal competence was reconstructed owing to the flap so that the patient could ingest a soft diet and speak without hypernasality 2 weeks after surgery.