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Reconstruction of maxilla

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Reconstruction of maxilla

  1. 1. Reconstruction of Maxillary defects Presented by: Akasha amber PGR, PLS BVH, Bahawalpur
  2. 2. INTRODUCTION
  3. 3. ANATOMY
  4. 4. ANATOMY
  5. 5. IMPORTANCE • Facial appearance & contour • Midface height & width • Supports orbit,cheek,lips,nose • Speech,mastication,deglutition
  6. 6. Causes Of Maxillary Defects • Etiology – Tumors • Maxilla • adjacent structures – Traumatic injuries • Sharp/gun shot injuries • Blunt injuries
  7. 7. Goals Of Reconstruction • Reconstruct orbital floor or fill orbital cavity • Reconstruct linings • Separate oral & nasal cavity from skull base & orbit • Restore external skin and 3D facial contour • Obliterate the (maxillectomy) defect
  8. 8. Classification Of Mid-face Defects Cordeiro & Santamaria… (Memorial Sloan-kettering Cancer Center, New York) • Type I (Limited maxillectomy) – One or two walls, preservation of palate • Type II (Subtotal maxillectomy) – Lower 5 walls, preservation of orbital floor • Type III (Total maxillectomy) – Resection of all six walls – Orbital preservation (IIIa) – Exenteration of orbital contents (IIIb) • Type IV (Orbitomaxillectomy) – Upper 5 walls, preservation of palate
  9. 9. Algorithm Of Mid-face Defects
  10. 10. BROWN CLASSIFICATION • Brown class I There are two types of defects in this class: • Alveolar defect without oro-nasal or oro-antral fistulae • A defect in palatal bone without alveolar defect • Brown class II Alveolar and antral wall defect, not including orbital floor and rim. • This class is again subdivided depending on the involvement of the alveolar maxilla and hard palate. • Unilateral,Bilateral (incomplete),Complete
  11. 11. BROWN CLASSIFICATION • Brown class III Alveolar and antral wall defect including the orbital floor. Periorbita and skull base may or may not be involved. • This class is again subdivided depending on the involvement of the alveolar maxilla and hard palate. • Unilateral,Bilateral (incomplete),Complete • Brown class IV Alveolar and antral wall defect including the orbital floor and content. Skull base may or may not be involved. • This class is again subdivided depending on the involvement of the alveolar maxilla and hard palate. • Unilateral,Bilateral (incomplete), Complete
  12. 12. Approach Towards Definitive Problem And Planning • Clinical assessment – Define defect in terms of bony and soft tissue defect – size,extent, involvement of adjacent tissues, surface area to volume ratio, previous radiation, surgery & neck dissection, availability, morbidity, amount, quality of coverage tissues, recepient vessels, dentition, alveloar arch • Plain Radiograph – OPG – PNS View • CT scan • 3-D CT scan • Determine repair options • Plan treatment strategy – Bone 1st priority then coverage with soft tissue and linings,adjacent tissues(later on)
  13. 13. Reconstructive Options For Maxillary Reconstruction • PROSTHETIC OBTURATION • AUTOGENOUS FLAPS – Pedicled flaps • Local • Regional – Vascularized free flaps – Non vascularized autogenous bone grafts – Combination procedure
  14. 14. Prosthetic Obturation Advantages • Shortens operative time & post op hospital stay • Better visualization for surveillance • Helps in speech and swallowing • Restores aesthetics Disadvantages •Hypernasal speech •Regurgitation of food and fluids into nasal cavity •Difficulty maintaining hygiene •Need for repeated adjustments
  15. 15. Autologous Tissues • Small defects – local or regional flaps – with or without bone graft • Large defects: – pedicled flaps – free flaps • Hexahedral box(6 walls) – Anterior wall, floor, roof • Bone replacement • Palate repair • Maxillary sinus • Nasal & oral cavity lining • External cheek skin
  16. 16. BONE REPLACEMENT • Autologous bone grafts – Non vascular bone graft with coverage(orbital rim) – Vascularized bone graft with soft tissue( maxillary arch and vertical buttress) • Alloplastic materials
  17. 17. Surgical Reconstruction Titanium Mesh • bone grafts not available or disallowed • in combination with bone grafts or hydroxyapatite cement • Biocompatible • Readily available • No donor site morbidity • Contraindicated in radiotherapy
  18. 18. Maxillary Defects Types And Their Management
  19. 19. TYPE I/Limited Maxillary Defects • One or two walls,excluding palate • Anterior,medial wall • Orbital rim occasionally • High surface area to low volume ratio • Radial forearm flap • For orbital rim: split calvarial or rib bone graft • Others: – scapular,parascapular,anterolateral thigh fasciocutaneous flap
  20. 20. TYPE II/Subtotal Maxillary Defects • All five walls excluding orbital floor – with <50% transverse palatal resection:Type II A – With >50% transverse palatal resection:Type II B • Classic hemimaxillectomy/infrastructure maxillectomy • large surface area-to-moderate-volume-ratio • 2 skin islands
  21. 21. TYPE II/Subtotal Maxillary Defects • For type IIA: • Skin graft with obturator • Free flap; radial forearm fasciocutaneous flap – Keep soft palate taut,avoid prolapse into oral cavity – Denture or osseointegrated dental implants • Small defects:temporalis muscle flap
  22. 22. TYPE II/Subtotal Maxillary Defects • For type IIB: • Osteocutaneous radial forearm flap folded into sandwitch • Advantages: – Anterior projection – Sufficient vascularized bone for dental implants osseointegration – Support for upper lip – Palatal and nasal lining – Moderate volume,large surface area – Easily inset – Long pedicle
  23. 23. TYPE II/Subtotal Maxillary Defects • Others: • Scapula flap • Positioning ,interrupts osteotomies,tenuous blood supply • Fibula flap • Good blood supply,allows osteotomies,positioning easy,difficult inset needing secondary procedures,pedicle not longer than radial forearm flap,
  24. 24. TYPE III/Total Maxillectomy • Subdivided into: • TYPE IIIA: preservation of orbital contents • TYPE IIIB: orbital exenteration
  25. 25. TYPE III/Total Maxillectomy • Type III A: • Medium large-volume & large surfac area requirements • Reconstruction of orbital floor: non vascularized bone graft with a vascular flap coverage – Rectus abdominis flap(bulk,multiple skin islands to line) – Temporalis muscle flap(need obturator for palate,older and unfit patients) – Fibula flap(denture requirements)
  26. 26. TYPE III/Total Maxillectomy • Type IIIB: • Large volume and large surface area • Rectus abdominis flap • Linings • Bulk • Revisions for contour refinement • Lateral nasal lining: – flap skin island collapses – obliteration with posteriorly based nasal septal mucosal flap
  27. 27. TYPE III/Total Maxillectomy • Type IIIB defects combined with hemimandibulectomy • Fibula flap with rectus abdominis flap • Other options for both type IIIA & IIIB: – Vastus lateralis – Latissimus dorsi – gracilis
  28. 28. TYPE IV/Orbitomaxillectomy • Resection of all 5 upper walls and orbit,excluding palate • Rectus abdominis flap
  29. 29. Adjacent Important Facial Structures • Lip,oral commisures – Prior to maxillary recon., lip switch flaps,oral sphincter competence – >80% upper and lower lip loss: free flap • Nose – Only aesthetically important – Delayed nasal reconstruction – Prosthetic recon. But autologous recon. preferred • Eyelids – Type I & IIIA defects needed – Ectropion post-op problem: tarsal strip procedure,STSG,canthopexy – Patch,dark glasses,prosthesis
  30. 30. Algorithm For Maxillary Reconstruction
  31. 31. THANKS
  • WaleedAbdullah4

    Aug. 21, 2021
  • shreyajraut

    Aug. 9, 2021
  • NainaKumar6

    Aug. 7, 2021
  • SreelakshmiBalakrishnan

    Jun. 28, 2021
  • nirmalasubramani2

    Jun. 20, 2021
  • akku99

    Jun. 10, 2021
  • MaanasaVasantham

    May. 27, 2021
  • KaramSujitha

    Apr. 13, 2021
  • AnukrityChandra

    Apr. 6, 2021
  • sagarbhusal1

    Apr. 1, 2021
  • jalapatt

    Mar. 16, 2021
  • SaifulArefin2

    Feb. 14, 2021
  • HemailS

    Dec. 29, 2020
  • GouthamiChowdary1

    Dec. 17, 2020
  • k_ahilan75

    Oct. 5, 2020
  • PrimeLily

    Sep. 27, 2020
  • ammarkhider1

    Sep. 8, 2020
  • sapna_ladhani

    Sep. 4, 2020
  • SatyaaShandilya

    Aug. 28, 2020
  • BharathiRamGuduri

    Aug. 12, 2020

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