Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects

Biomechanics of conventional and miniscrew-assisted rapid palatal expansion

Posterior Crossbite is a common condition resulting because of transverse maxillary deficiency. The growth of the craniofacial complex finishes first in the transverse dimension, followed by sagittal and vertical dimensions. Conventional rapid palatal expansion (RPE) appliances are commonly used to correct transverse maxillary deficiency. Although RPE is efficient in correcting posterior crossbite, it results in dental side effects such as buccal tipping of maxillary molars, root resorption, bone dehiscence, and relapse. Mini-implant-assisted RPE has been introduced to increase the skeletal effects of expansion especially in patients with increased maturation and greater interdigitation of midpalatal suture. This article will review the biomechanics of RPE and mini-implant-assisted RPE. Additionally, the different designs of MARPE and the long-term clinical effects of expansion appliances will also be discussed in detail.

Advances in Microvascular Reconstruction of the Orbit and Beyond: Considerations and a Checklist for Decision-Making

This paper aims to discuss the microvascular reconstruction of the orbit and adjacent regions and to propose a checklist to aid the reconstructive surgeon in this challenging undertaking. The discussion is based on a literature review that includes 32 retrospective case series, 5 case reports published in the last 34 years in PubMed, and 3 textbook chapters. Additionally, it relies on the senior author's expertise, described in a case series, and two case reports published elsewhere. Classifications and treatment algorithms on microvascular orbit reconstruction generally disregard patient-related factors. A more holistic approach can be advantageous: patient-related factors, such as age, comorbidities, prognosis, previous interventions, radiotherapy, and the wish for maximal dental rehabilitation and a prosthetic eye, have the same importance as defect-related considerations and can inform the choice of a reconstructive option. In this manuscript, we examine defect- and patient-related factors and new technologies, provide a checklist, and examine future directions. The checklist is intended as a tool to aid in the decision-making process when reconstructing the orbital region with microvascular flaps.

Surgical and health related quality of life outcomes following treatment with zygomatic implant perforated (ZIP) flaps

BACKGROUND

The zygomatic implant perforated (ZIP) flap is a novel approach to the challenge of reconstructing the maxilla. We report on our experience using the ZIP flap technique for patients undergoing infrastructure maxillectomy at Chris O'Brien Lifehouse, Sydney, Australia.

METHODS

Thirteen patients who underwent a ZIP flap reconstruction between August 2019 and August 2021 were identified. Demographic, surgical, and histopathological information was collected. Health Related Quality of Life (HRQOL) was assessed using the FACE-Q Head and Neck Cancer module, the M.D. Anderson Dysphagia Inventory, and the Speech Handicap Index.

RESULTS

A total of 44 zygomatic implants were placed, of which 42 (95%) survived. The median time from surgery to dental rehabilitation was 35 days. HRQOL data was available for nine patients over 24 months, demonstrating improved speech and swallowing outcomes over the follow up period.

CONCLUSIONS

The ZIP flap is a reproducible surgical technique that facilitates rapid dental rehabilitation post infrastructure maxillectomy.

Maxillary interim obturator prosthesis fabrication for a patient with limited mouth opening with a digital approach: A clinical report

Squamous cell carcinoma is a common malignant condition affecting the oral cavity and may involve the surrounding maxillofacial regions. Treatment commonly involves resection of the tumor, followed by prosthetic rehabilitation of the resection defect. This clinical report presents a 62-year-old Asian male patient who had previously undergone surgical resection, resulting in a post-surgical Aramany Class II maxillary defect. The patient's medical history included severe trismus, characterized by restricted mouth opening, as well as a diagnosis of maxillary sinus verrucous squamous cell carcinoma. This report provides a comprehensive account of the rapid fabrication of an interim obturator using digitally assisted dentistry techniques.

Microvascular Free Flap Outcomes in Maxillectomy Defects from Invasive Fungal Sinusitis

OBJECTIVES

Microvascular free tissue transfer is routinely used for reconstructing midface defects in patients with malignancy, however, studies regarding reconstructive outcomes in invasive fungal sinusitis (IFS) are lacking. We aim to describe outcomes of free flap reconstruction for IFS defects, determine the optimal time to perform reconstruction, and if anti-fungal medications or other risk factors of an immunocompromised patient population affect reconstructive outcomes.

METHODS

Retrospective review of reconstruction for IFS (2010-2022). Age, BMI, hemoglobin A1c, number of surgical debridements, and interval from the last debridement to reconstruction were compared between patients with delayed wound healing versus those without. Predictor variables for delayed wound healing and the effect of time on free flap reconstruction were analyzed.

RESULTS

Twenty-seven patients underwent free flap reconstruction for IFS. Three patients were immunocompromised from leukemia and 21 had diabetes mellitus (DM). Patients underwent an average of four surgical debridements for treatment of IFS. The interval from the last IFS debridement to flap reconstruction was 5.58 months (±5.5). Seven flaps (25.9%) had delayed wound healing. A shorter interval of less than 2 months between the last debridement for IFS and reconstructive free flap procedure was associated with delayed wound healing (Fisher Exact Test p = 0.0062). Other factors including DM, BMI, HgA1c, and bone reconstruction were not associated with delayed wound healing.

CONCLUSION

Patients with maxillectomy defects from IFS can undergo microvascular-free flap reconstruction with good outcomes while on anti-fungal medication. Early reconstruction in the first 2 months after the last IFS debridement is associated with delayed wound healing.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1642-1647, 2024.

Effects of maxillofacial prosthetic treatment on oral health-related quality of life and masticatory ability of patients with head and neck tumors

PURPOSE

Using multivariate analysis, this study investigated the effectiveness of maxillofacial prosthetic treatment in relation to oral health-related quality of life (OHR-QoL), masticatory ability (food intake status score and gum-jelly test score) and related factors in patients who had undergone surgery for head and neck tumors.

METHODS

The study cohort comprised 112 patients who underwent surgical resection and prosthetic treatment among 224 patients with head and neck tumors seen at the Maxillofacial Prosthetics Clinic of Tohoku University Hospital in a 2-year period. Correlations between OHR-QoL, food intake status score, and gum-jelly test score (criterion variables), and age, sex, maxillary defect, tongue/soft tissue defect, reconstructive surgery, and chemoradiotherapy (explanatory variables) were investigated, and the data were examined statistically.

RESULTS

Maxillary defect, tongue and soft palate tissue defect, and chemoradiotherapy were identified as factors that hindered the effectiveness of maxillofacial prosthetic treatment for improvement of the OHR-QoL, food intake status score, and gum-jelly test score. On the other hand, reconstructive surgery was a factor that facilitated the improvement of OHR-QoL and masticatory ability with maxillofacial prosthetic treatment.

CONCLUSION

The factors identified to be related to the success or failure of maxillofacial prosthetic treatment suggest the importance of combining prosthetic intervention with surgical reconstruction.

Comparative analysis of surgical and prosthetic rehabilitation in maxillectomy: A systematic review and meta-analysis on quality-of-life scores and objective speech and masticatory measurements

STATEMENT OF PROBLEM

Patients with oro-antral communication, whether from trauma, disease, or congenital anomalies, have options for surgical reconstruction or prosthetic obturation, but guiding interdisciplinary protocols are lacking.

PURPOSE

The purpose of this systematic review and meta-analysis was to compare surgical reconstruction and prosthetic obturation, identifying correlations with baseline characteristics to determine the most effective approach for specific patients.

MATERIAL AND METHODS

A systematic search was conducted in 4 databases. Searching, screening, data extraction, and risk of bias assessment were performed by 2 reviewers. Eligible studies focused on patients with palatomaxillary defects from cancer-related maxilla surgeries. Traumatic or congenital defects were excluded. The study compared prosthetic restoration (either with surgical or definitive obturators) to surgical reconstruction using flaps or grafts. Patients with surgical restoration after tooth extraction were excluded. Both subjective and objective outcomes were used for comparison.

RESULTS

Thirteen articles were included in the qualitative synthesis and 9 in the meta-analysis. Patient scores on quality-of-life questionnaires, objective speech, and masticatory ability evaluations were compared. The number of patients who underwent surgical reconstruction was 206, whereas 260 patients received prosthetic obturators. Results showed no significant differences. In the "activity" domain of the University of Washington QoL questionnaire, however, the 1.92 (0.45, 3.40) score difference was not clinically relevant. However, the heterogeneity of trials, the transient nature of subjective evaluations, the low number of participants, and major confounding biases did not allow a solid conclusion to be drawn.

CONCLUSIONS

The growing number of maxillectomy patients demands firm evidence on which rehabilitation to choose and when it should be done. The result suggests that obturator devices and surgical reconstruction have similar effects on quality of life and health outcomes. A multicentric registry in which patient strata could be analyzed separately by age, adjuvant therapies, defect sizes, and remaining dentition is advocated.

Maxillary resection prosthesis fabricated from urethane dimethacrylate for a patient with polymethyl methacrylate allergy: A clinical report

The surgical resection of malignant tumors often leads to severe bone and soft-tissue deficits that can result in difficulty swallowing, impaired speech, and facial disfigurement. Prosthetic rehabilitation of these patients becomes an integral part of the patient's recovery and allows for improvement in quality of life. This clinical report describes a patient who underwent an anterior maxillectomy secondary to squamous cell carcinoma. After the insertion of a polymethyl methacrylate (PMMA) interim resection prosthesis, the patient developed a severe allergic stomatitis reaction in the oral cavity and oropharynx. By using the patch test approach, true PMMA allergy was diagnosed along with a suitable PMMA replacement for the prosthesis. A subsequent prosthesis was fabricated from urethane dimethacrylate in place of the standard PMMA.

Immediate placement of extra-short implants in refined scapula tip microvascular free flaps: In house virtual planning and surgical technique - Proof of concept

Scapula tip flaps have been introduced in the literature as an ideal surgical treatment option for large defects in the horizontal plane of the maxilla. This article aims to present a unique step by step protocol for a near total maxillectomy with a pterygoid bone resection and consecutive microvascular reconstruction with a harvested scapula tip flap. The protocol includes immediate placement of extra-short implants in donor bone with the aid of Virtual Surgical Planning (VSP), and an in-house 3D printing of medical 3D models and surgical guides. So far, there has been no presented surgical technique combining immediate implant placement in the scapula region with simultaneous microvascular repair. This technique allows: tumour resection; flap harvesting; extra-short implant placements and reconstruction to be performed in one simultaneous procedure. The technique is presented with illustrations, VSP (presented on videos), radiographs, and surgical findings. We discovered that this refinement of the scapula tip surgery has enabled reconstructive procedures to be performed at the same time as implant placements, providing expedited functional and aesthetic outcomes in selected cases. Moreover, modification of the surgical technique could enhance the competence of the oropharyngeal edge. In conclusion, this new surgical protocol utilizing VSP, 3D models and simultaneous extra-short implant placement provides indispensable advantages for such a complicated surgical procedures, while significantly shortening the duration of surgery.

Guided Zygomatic Implantology for Oral Cancer Rehabilitation: A Case Report

Oral rehabilitation after maxillary oncological resection is challenging. This case report presents the rehabilitation of a 65-year-old Caucasian male adenoid cystic carcinoma patient using a myo-cutaneous thigh flap, zygomatic implant placement, and an immediate fixed provisional prosthesis made with computer-aided technologies. The patient presented complaints of asymptomatic enlarged swelling of 5-mm on the right hard hemi-palate. There was an oro-antral communication deriving from a previous local excision. Preoperative radiographs showed the involvement of the right maxilla, maxillary sinus, and nose with a suspect involvement of the maxillary division of the trigeminal nerve. Treatment was planned through a fully digital workflow. A partial maxillectomy was performed endoscopically, and maxilla was reconstructed using an anterolateral thigh free flap. Two zygomatic implants were inserted simultaneously. A provisional fix full-arch prosthesis was manufactured preoperatively through a fully digital workflow and was placed in the operating room. Following post-operative radiotherapy, the patient received a final hybrid prosthesis. During the follow-up period of two years, the patient reported good function, aesthetics, and significant enhancement in quality of life. According to the results of this case, the protocol represented can be a promising alternative for oral cancer patients with large defects, and can lead to an improved quality of life.

Palatal mucoperiosteal flap for oro-nasal fistula following maxillectomy for maxillary sinus cancer

OBJECTIVES

This study aimed to describe the technique and clinical outcomes of using a palatal mucoperiosteal flap for oro-nasal fistula closure following resection of maxillary sinus cancer.

METHODS

The study was conducted with the permission of the internal review board of the Japanese Red Cross Wakayama Medical Center. Five consecutive cases from 2016 to 2020 of surgically treated maxillary sinus cancer in which the oro-nasal fistulas were closed using a palatal mucoperiosteal flap were retrospectively reviewed.

RESULTS

Following tumor resection, the oro-nasal fistula was closed using a palatal mucoperiosteal flap. Complete separation of the oral and nasal cavities was achieved in four patients. Oral intake was resumed within two weeks in four patients. All the patients were able to eat foods similar to those in the preoperative period. Their postoperative speech function was excellent, with no difficulty in communicating with others.

CONCLUSION

In the selected cases of maxillary sinus cancer, preservation of the palatal mucosa and closure of an oro-nasal fistula using a palatal mucoperiosteal flap was possible with reasonable outcomes for swallowing and speech functions. The use of this local flap is recommended as a minimally invasive procedure that can be performed especially in patients with limited physiological reserves which preclude free flap reconstruction.

Classification of maxillectomy in edentulous arch defects, algorithm, concept, and proposal classifications: A review

OBJECTIVES

Aramany's classification of postsurgical maxillectomy defects was introduced for partially edentulous situations, and has been widely used for education and effective communication among practitioners. Numerous classifications of maxillofacial defects, based on surgical procedure, resultant defects, or prosthodontist's perspective after rehabilitation, exist in the literature. However, no single classification has incorporated all these factors. The purpose of this review was to highlight the classification systems and describe a pragmatic classification series for edentulous maxillary arch defects (maxillectomy) by applying the Aramany classification criteria, to enhance treatment outcomes and communication among practitioners.

MATERIAL AND METHODS

An electronic search of the literature published in English was conducted using the PubMed/MEDLINE and Google Scholar database. Keywords used were "maxillectomy classification" AND "surgical resection," "maxillectomy classification" AND "complete edentulous." In addition, a manual search was also performed followed the same criteria in the following journals: Journal of Prosthetic Dentistry and Journal of Prosthodontics.

RESULTS

Several classification systems for partial dentition were found in terms of size, location, dentition, and extension of the defect (isolated or communication defects). The findings revealed a variety of maxillectomy defect classifications for partially dentate, considering surgical factors and rehabilitation. However, no study or classification system exist for the edentulous arch defects.

CONCLUSIONS

Different classification systems for maxillectomy defects exist in the literature, only for partially dentate patients. To the authors best knowledge, no classification system for completely edentulous maxillary arch defects have been proposed till date. A simple classification system with clear characteristics for edentulous maxillectomy dental arch defects has been proposed. This classification was modeled after Aramany classification for easier memorization and application.

Pronator Quadratus Musculo-osseous Free Flap for Wide Hard Palatal Defect Reconstruction: An Anatomical Study

Wide hard palate defects include congenital and acquired defects that are six square centimeters or larger in size. Obturator prostheses and autologous soft tissue transfers have been used to reconstruct palatal defects. This study aims to repair wide, hard palatal defects by using a pronator quadratus musculo-osseous free flap to achieve subtotal reconstruction. Seventeen formalin-fixed cadavers were dissected. Free musculo-osseous pronator quadratus flaps were prepared after a 12 cm curvilinear volar skin incision. Standard 30 × 23 mm (690 ± 52.12 mm²) hard palate defects were made by chisels and saws. A subcutaneous tunnel was created between the mandibular edge cross point of the facial vessels and the retromolar trigone through the subcutaneous to the superficial musculoaponeurotic system by dissection. Area measurements of the pedicle and palate defects were performed by the ImageJ program (National Institutes of Health, Bethesda, MD, USA) on drawings over an acetate layer of materials. Mandibular distances of gonion-facial vessel cross point (a), gonion-gnathion (m), and facial vessels' cross point-retromolar entrance point (h) were measured. Ratios of h/m and a/m were calculated. The mean pronator quadratus area was 2349.39 ± 444.05 mm², and the arterial pedicle pronator quadratus diameter was 2.32 ± 0.34 mm. The mean pedicle length of the pronator quadratus was 117.13 ± 8.10 mm. Study results showed that musculo-osseous pronator quadratus flaps' bone and muscle parts perfectly fit on the defects in all cadavers. Pronator quadratus musculo-osseous flap is a feasible surgical option for wide, hard palatal defect reconstruction strategies.

Management of Palatal Defects after Free-Flap Reconstruction and Radiotherapy

Palatal fistulas have significant effects on quality of life. Traditional prosthetic rehabilitation and surgical reconstruction of palate defects in radiation-naïve tissues are well described. However, palatal fistulas developing after initial tumor extirpation, free-flap reconstruction, and adjuvant radiation or chemoradiation are associated with challenging secondary tissue effects. In this review, we will discuss the management of palatal fistulas after surgical reconstruction and radiotherapy.

Reverse Facial-Submental Artery Osteomyocutaneous Flap, a Novel Choice for Previously Operated Huge Alveolar Clefts

Adult previously operated alveolar cleft palate presents a pronounced challenge for optimal surgical reconstruction. This optimal reconstruction dictates the restoration of soft tissues in addition to hard tissues to achieve prime functional results. Regional flaps usually used for the reconstruction of such defects were considered as either bulky or none bone bearing flaps. Furthermore, using free flaps for reconstruction can rise the concerns of increased intraoperative complications and greater suspected donor site morbidities. Here we present three unfavorably previously operated patients with current huge alveolar cleft palates, planned for the reconstruction with reverse facial-submental artery osteomyocutaneous flap. Besides, detailed flap harvesting technique, results, prosthetic restoration post to flap surgery, and follow up are presented in this article. We found the reverse facial- submental osteomyocutaneous flap as a novel and reliable choice for functional reconstruction of challenging huge alveolar cleft palates. The reverse facial-submental flap has not been yet mentioned in the medical literature for the reconstruction of alveolar clefts.

Virtual Surgical Planning in Free Tissue Transfer for Orbito-Maxillary Reconstruction

Since its introduction, virtual surgical planning (VSP) has been rapidly adopted as a part of reconstructive surgeon's armamentarium. VSP allows reconstructive surgeons to simulate resection, plan osteotomies, and design custom plates. These unique advantages have been especially beneficial for head and neck reconstructive surgeons as there is small room for error and high technical demand in head and neck reconstruction. Despite its popularity, most surgeons have limited experience in using VSP for orbito-maxillary reconstruction as tumors that involve the midface are relatively rare compared with other head and neck oncologic defects. In our institution, we routinely use VSP for orbito-maxillary reconstruction using free fibula flap to provide support for orbit, to restore normal dental occlusion, and to restore midface projection. In this chapter, we will discuss the role of virtual surgical planning and our algorithmic approach of performing orbito-maxillary reconstruction using free tissue transfer.

Current Concepts in Maxillary Reconstruction

SUMMARY

Defects involving the midface and maxilla pose unique challenges to reconstructive surgeons. The maxilla serves as the central keystone of the face and interfaces with various other facial subunits to affect form and function. Reconstructive methods range from prosthetics to free tissue transfer, and the indications for different options are reviewed here. Finally, special considerations including management of the orbit, dental rehabilitation, and future directions are discussed.

Versatility of the subscapular system of flaps in head and neck oncologic reconstruction

PURPOSE OF REVIEW

This review analyzes the different ways of applying the subscapular system of flaps (SSSF) as a convenient and versatile solution for a large variety of head and neck oncologic defects.

RECENT FINDINGS

The ventral approach permits safe and efficient harvest of various chimeric SSSF in a supine position, thus allowing simultaneous flap preparation and tumor ablation. Conformational studies have revealed how similar the tip of the scapula is to the hard palate in terms of dimensions, shape, and conformation. This has led to favor horizontal placement of the scapular tip for palate reconstruction in most instances, addressing the vertical extension of the postmaxillectomy defect using denuded bony grafts surrounded by well vascularized chimeric muscular components.

SUMMARY

The SSSF possesses an unparalleled versatility to efficiently address small-medium sized soft tissue defects up to vast and complex composite resections. The chimeric components of these flaps benefit from a considerable independency provided by the length of the named arteries arising from the thoracodorsal pedicle, offering a high degree of freedom to accomplish the required in-setting. This reconstructive option should be implemented in every head and neck surgical team and offered to suitable patients.

Health-related quality of life in maxillectomy patients undergoing dentoalveolar rehabilitation

OBJECTIVES

Surgical resection of the maxilla impairs aesthetics, speech, swallowing, and mastication. Maxillary reconstruction is increasingly performed with virtual surgical planning (VSP) to enhance functional dental rehabilitation with a conventional denture or osseointegrated implants. The aim of this study was to determine whether dental status and VSP is associated with health-related quality of life (HRQOL) and function in patients who have undergone maxillectomy.

MATERIALS AND METHODS

A cross-sectional study was conducted among patients who underwent free flap reconstruction or obturation of the maxilla between July 2009 and December 2020. The FACE-Q Head and Neck Cancer (FACE-Q) module, M.D. Anderson Dysphagia Inventory (MDADI), and Speech Handicap Index (SHI) were used to evaluate HRQOL.

RESULTS

Forty-three patients (response rate 59%) completed questionnaires and 48% underwent dental rehabilitation. In Okay Class II and III defects, adjusting for the effect of radiotherapy and time from surgery, there was a positive association between denture status and FACE-Q smiling (p = 0.020), eating (p = 0.012), smiling (p = 0.015), and MDADI global (p = 0.015), emotional (p = 0.027), functional (p = 0.028), and composite (p = 0.029) scores. VSP was associated with FACE-Q swallowing (p = 0.005), drooling (p = 0.030), eating (p = 0.008), smiling (p = 0.021), MDADI global (p = 0.017), emotional (p = 0.041), functional (p = 0.040), composite (p = 0.038), and SHI total scores (p = 0.042).

CONCLUSIONS

Dentoalveolar rehabilitation and VSP were associated with higher HRQOL scores relating to eating and drinking, smiling, and speaking.

Changing trends in the microvascular reconstruction and oral rehabilitation following maxillary cancer

Purpose

The maxillectomy defect is complex and the best means to achieve optimal reconstruction, and dental rehabilitation is a source of debate. The refinements in zygomatic implant techniques have altered the means and speed by which rehabilitation can be achieved and has also influenced the choice regarding ideal flap reconstruction. The aim of this study is to report on how the method of reconstruction and oral rehabilitation of the maxilla has changed since 1994 in our Institution, and to reflect on case mix and survival.

Methods

Consecutive head and neck oncology cases involving maxillary resections over a 27-year period between January 1994 and November 2020 were identified from hospital records and previous studies. Case note review focussed on clinical characteristics, reconstruction, prosthetic rehabilitation, and survival.

Results

There were 186 patients and the tumour sites were: alveolus for 56% (104), hard palate for 19% (35), maxillary sinus for 18% (34) and nasal for 7% (13). 52% (97) were Brown class 2 defects. Forty-five patients were managed by obturation and 78% (142/183) had free tissue transfer. The main flaps used were radial (52), anterolateral thigh (27), DCIA (22), scapula (13) and fibula (11). There were significant changes over time regarding reconstruction type, use of primary implants, type of dental restoration, and length of hospital stay. Overall survival after 24 months was 64% (SE 4%) and after 60 months was 42% (SE 4%).

Conclusion

These data reflect a shift in the reconstruction of the maxillary defect afforded by the utilisation of zygomatic implants.

Medication-related osteonecrosis of the jaw: Prosthodontic considerations

Medication-related osteonecrosis of the jaw (MRONJ) can be triggered by several antiresorptive and antiangiogenic medications, including bisphosphonates (BRONJ), denosumab (DRONJ), and other agents used to treat osteoporosis and metastatic bone cancer. Prosthodontists and surgeons continue to face new challenges because of this condition. Despite the current evidence showing that extensive surgical intervention and laser surgery have the highest healing rates, surgical reconstruction is not always possible for large jaw defects requiring prosthetic reconstruction. Moreover, surgical treatment may not be an option in some patients because of other medical conditions. In these patients, MRONJ may develop into a chronic disease with limited resolution and they may seek prosthetic rehabilitation for aesthetic and functional reasons. Therefore, prosthetic intervention may be necessary for some patients with MRONJ even in the absence of a surgical defect. Denture trauma has been reported to be a risk factor for MRONJ, and few reports have discussed the prosthodontic considerations needed for patients with this condition. The aim of this review is to highlight the prosthodontic considerations that would decrease the risk of triggering MRONJ in susceptible patients.

Influence of socioeconomic status on psychological distress and treatment satisfaction levels among patients undergoing prosthetic rehabilitation following maxillectomy: An observational study

Aim:

The aim of this study was conducted to evaluate the effect of socioeconomic status (SES) on psychological distress and treatment satisfaction levels of patients who underwent maxillectomy and rehabilitation with obturator prosthesis.

Settings and Design:

Prospective, observational, analytic study.

Materials and Methods:

Forty-three patients undergoing maxillectomy were enrolled and divided into upper, middle, and lower SES groups, according to the updated Kuppuswamy SES scale. Psychological distress levels were assessed using Hospital Anxiety and Depression Scale (HADS) before maxillectomy (T0) and at 3 weeks after delivery of definitive obturator (T1). Treatment satisfaction levels with obturator prosthesis were assessed using Obturator Functioning Scale (OFS) at T1. HADS and OFS scores were then correlated with the SES of the participants.

Results:

Out of 43 participants, 7 were lost to follow up. The total number of participants in upper, middle, and lower SES groups was 14, 11, and 11, respectively. Before surgery, there was no significant difference in anxiety levels (P > 0.05) among different SES groups. However, the depression levels were the highest in the lower SES and decreased significantly with increasing SES. Prosthetic rehabilitation led to statistically significant (P < 0.05) fall in the levels of both anxiety and depression assessed at 3 weeks after delivery of prosthesis. The upper SES group was found to be less anxious and depressed compared to middle and lower SES groups after prosthodontic rehabilitation. Treatment satisfaction level was found to be significantly low (P = 0.005) in lower SES group as compared to upper SES group while no difference was found in between the middle SES when compared to higher or lower SES groups.

Conclusions:

SES has a profound impact on the patient's psychosocial well-being and treatment satisfaction. Patients of lower SES reported with higher psychological distress and lesser treatment satisfaction compared to those belonging to upper SES.

Case Report: Reconstruction of a Large Maxillary Defect With an Engineered, Vascularized, Prefabricated Bone Graft

The reconstruction of complex midface defects is a challenging clinical scenario considering the high anatomical, functional, and aesthetic requirements. In this study, we proposed a surgical treatment to achieve improved oral rehabilitation and anatomical and functional reconstruction of a complex defect of the maxilla with a vascularized, engineered composite graft. The patient was a 39-year-old female, postoperative after left hemimaxillectomy for ameloblastic carcinoma in 2010 and tumor-free at the 5-year oncological follow-up. The left hemimaxillary defect was restored in a two-step approach. First, a composite graft was ectopically engineered using autologous stromal vascular fraction (SVF) cells seeded on an allogenic devitalized bone matrix. The resulting construct was further loaded with bone morphogenic protein-2 (BMP-2), wrapped within the latissimus dorsi muscle, and pedicled with an arteriovenous (AV) bundle. Subsequently, the prefabricated graft was orthotopically transferred into the defect site and revascularized through microvascular surgical techniques. The prefabricated graft contained vascularized bone tissue embedded within muscular tissue. Despite unexpected resorption, its orthotopic transfer enabled restoration of the orbital floor, separation of the oral and nasal cavities, and midface symmetry and allowed the patient to return to normal diet as well as to restore normal speech and swallowing function. These results remained stable for the entire follow-up period of 2 years. This clinical case demonstrates the safety and the feasibility of composite graft engineering for the treatment of complex maxillary defects. As compared to the current gold standard of autologous tissue transfer, this patient’s benefits included decreased donor site morbidity and improved oral rehabilitation. Bone resorption of the construct at the ectopic prefabrication site still needs to be further addressed to preserve the designed graft size and shape.

PEEK versus Metallic Attachment-Retained Obturators for Patient Satisfaction: A Randomized Controlled Trial

Objective  The aim of the study was patients’ satisfaction evaluation and radiographic evaluation of the terminal abutments of attachment-retained maxillary obturators with metal framework versus milled polyetheretherketone (PEEK) framework in the management of maxillectomy cases.

Materials and Methods  Eighteen participants were randomly divided into three parallel groups ( n = 6). Participants of the PEEK group received attachment-retained obturators with milled PEEK framework, the metal group received an attachment-retained obturator with a metallic framework, and the conventional group received conventional clasp-retained obturators with a metallic framework (Control group). The evaluation included was radiographic evaluation and patients’ satisfaction in this study included two scales—”The Obturator Functioning Scale” and “The European Organization for Research and Treatment of Cancer Head and Neck 35” using one-way ANOVA test.

Results  Both PEEK and metal groups showed a statistically significant lower mean bone loss ( p <0.050) compared with the conventional group during all follow-up periods. There is no statistically significant difference between the PEEK and metal groups during all follow-up periods. Regarding patient satisfaction, both the PEEK and metal groups showed a statistically significant decrease score ( p <0.050) compared with the conventional group in various aspects of patients’ satisfaction scales as satisfaction with the look and difficulty of talking to the public, and noticeable clasps. In comparison, the PEEK group showed a statistically significant decrease score ( p <0.050) than the metal group with respect to satisfaction with the look along all follow-up periods.

Conclusions  PEEK attachment-retained maxillary definitive obturators could be considered a promising treatment modality for patients with acquired maxillary defects with regard to esthetics and satisfaction.

Rehabilitation of Maxillary Defect Using Zygomatic Implant Retained Obturator

Tumors involving the hard palate, maxillary sinus, or nasal cavity require maxillectomy based on the extent of the lesion. Lack of these boundaries affects the speech, esthetics, and masticatory function. Prosthetic rehabilitation of these defects can be done utilizing zygomatic implants. This present case describes the use of a zygomatic implant to retain a maxillary obturator in a 22-year-old male patient following partial maxillectomy (Brown's Class 2b) due to odontogenic myxoma. A surgical obturator was secured in position subsequent to the implant placement. Following the healing period, an interim obturator using heat cure acrylic was fabricated. Mechanical retention for the definitive obturator was obtained through the ball attachment suspended from the multiunit abutment of the zygomatic implant. The case was followed up closely for a year to evaluate the function of the prosthesis. The prosthetic rehabilitation not only promoted esthetics and function but also improved the patient's quality of life.

Association of Virtual Surgical Planning With External Incisions in Complex Maxillectomy Reconstruction

Importance

Maxillectomy can commonly be performed through a transoral approach, but maxillectomy defect reconstruction can be difficult to precisely design, contour, and inset through this approach.

Objective

To evaluate whether the use of virtual surgical planning (VSP) and 3-dimensional (3-D) modeling is associated with a decrease in the requirement of lateral rhinotomy (LR) for patients undergoing total and partial maxillectomy reconstruction.

Design, Setting, and Participants

This retrospective cohort study was conducted among patients undergoing subtotal or total maxillectomy with microvascular free flap reconstruction with or without VSP and 3-D modeling at a single tertiary care academic medical center between January 1, 2008, and October 3, 2019.

Interventions

Maxillectomy and free flap reconstruction with or without VSP.

Main Outcomes and Measures

Necessity of LR or other external incision for contouring, placement, and fixation of reconstruction as well as surgical complications.

Results

Fifteen patients (12 men [80%]; mean age, 64 years) underwent maxillectomy with free flap reconstruction without VSP. Eight patients (53%) in this group underwent total maxillectomy, and 4 patients in this group (27%) underwent partial maxillectomy. Twenty-three patients (18 men [78%]; mean age, 58 years) underwent maxillectomy with free flap reconstruction and VSP and 3-D modeling. Twelve of these patients (52%) underwent total maxillectomy, and 11 (48%) underwent partial maxillectomy. Lateral rhinotomy was necessary for 1 patient (4%) in the VSP group vs 12 patients (80%; 95% CI, 54%-98%) in the pre-VSP group. There were no LR complications in the VSP group vs 6 in the pre-VSP group. Among both groups, 14 patients underwent fibula free flap, 22 patients underwent subscapular system free flap, and 2 patients underwent cutaneous or osteocutaneous radial forearm free flap. There were no flap failures in the LR group and 1 flap failure in the group without LR.

Conclusions and Relevance

This cohort study suggests that the use of VSP and 3-D modeling for maxillectomy reconstruction is associated the a decrease in the need for external incisions without compromising reconstructive flap utility.

Biomechanical Stress in Obturator Prostheses: A Systematic Review of Finite Element Studies

AIM

This systematic review is aimed at investigating the biomechanical stress that develops in the maxillofacial prostheses (MFP) and supporting structures and methods to optimize it. Design and Methods. A literature survey was conducted for full-text English articles which used FEA to examine the stress developed in conventional and implant-assisted MFPs from January 2010 to December 2020.

RESULTS

87 articles were screened to get an update on the desired information. 74 were excluded based on a complete screening, and finally, 13 articles were recruited for complete reviewing. Discussion. The MFP is subjected to stress, which is reflected in the form of compressive and tensile strengths. The stress is mainly concentrated the resection line and around the apices of roots of teeth next to the defect. Diversity of designs and techniques were introduced to optimize the stress distribution, such as modification of the clasp design, using materials with different mechanical properties for dentures base and retainer, use of dental (DI) and/or zygomatic implants (ZI), and free flap reconstruction before prosthetic rehabilitation.

CONCLUSION

Using ZI in the defective side of the dentulous maxillary defect and defective and nondefective side of the edentulous maxillary defect was found more advantageous, in terms of compression and tensile stress and retention, when compared with DI and free flap reconstruction.

Evaluation and comparison of oral function after resection of cancer of the upper gingiva in patients who underwent reconstruction surgery versus those treated with a prosthesis

BACKGROUND

We retrospectively analyzed the articulation, mastication, and swallowing function of patients who underwent reconstruction or used a prosthesis after resection of the upper gingiva.

METHODS

This study included patients who underwent resection of cancer of the upper gingiva from January 2014 to December 2018. Articulatory function was evaluated with Hirose's conversational function evaluation criteria. Mastication function was evaluated with the Yamamoto's occlusion table. Swallowing function was assessed with the MTF (Method of intake, Time, Food) score.

RESULTS

The mean articulatory function score was 8 points in the Reconstruction Surgery Group (RSG) and 8.8 points in the Prosthesis Group (PG). The mean mastication function score was 2.8 points in the RSG and 3.3 points in the PG. The mean swallowing function score was M3T4F4 in the RSG and M4T4F4.3 in the PG.

CONCLUSIONS

The prosthesis depends on the remaining occlusal support area. Our study suggest that prosthesis is better indication when there is more than one occlusal support area.

Changes in Quality of Life After Secondary Closure of Palatal Defects: Prosthetic Obturation Versus Surgical Reconstruction

BACKGROUND

The closure of palatal defects after tumor resection or irradiation is performed with either a prosthesis or autogenous tissue; however, there are no clear criteria regarding selection of the method. Thus, this study aimed to investigate the real-world situation and problems of palatal closure using prostheses, and examined patient opinion on how palatal closure using autogenous tissue improved their postoperative quality of life (QOL).

METHODS

In 5 patients whose palatal defects resulted from treatment for head and neck cancer and were closed with a prosthesis, the palate was closed secondarily with autogenous tissue; a questionnaire on daily life was administered pre- and post-operatively.

RESULTS

Functional improvements in terms of speech and eating were achieved in all and in 4 of 5 cases, respectively. In all cases, the QOL was better for palatal closure with autogenous tissue than with the prosthesis.

CONCLUSIONS

As postoperative QOL was considered to be better when reconstructing the palate with autogenous tissue than with the prosthesis, we recommend to actively select autogenous tissue for palate reconstruction.

Dentoalveolar outcomes in maxillary reconstruction: A retrospective review of 85 maxillectomy reconstructions

BACKGROUND

Although microvascular free flaps are often used to reconstruct maxillary defects, dentoalveolar rehabilitation is arguably less common despite its importance to midface function and aesthetics. The aim of this study is to review the contemporary management of maxillary defects in a single quaternary referral institution to identify factors that assist or impede dentoalveolar rehabilitation.

METHODS

A retrospective review of maxillary reconstructions performed between February 2017 and December 2020 was performed. Patient characteristics, defect classification, operative techniques, complications and dentoalveolar outcomes were recorded.

RESULTS

A total of 85 maxillary reconstructions were performed in 73 patients. Of the 64 patients where dental rehabilitation was required, 31 received a functional denture (48%) with 24 (38%) being implant-retained. Significant predictors of successful rehabilitation included the use of virtual surgical planning (VSP; 86% vs. 25%, p < 0.001), preoperative prosthodontic assessment (82% vs. 21%, p < 0.001), prefabrication (100% vs. 40%, p = 0.002) and use of the zygomatic implant perforator flap technique (100% vs. 39%, p = 0.001). Preoperative prosthodontic consultation was associated with 21-fold increase in the odds of rehabilitation (odds ratio 20.9, 95% confidence interval 6.54-66.66, p < 0.005).

CONCLUSION

Preoperative prosthodontic evaluation, VSP and reconstructive techniques developed to facilitate implant placement are associated with increased dental rehabilitation rates. Despite using an institutional algorithm, functional dentures are frequently prevented by factors including soft tissue constraints, disease recurrence and patient motivation.

Two-piece oral facial prothesis retained with magnets for a complex maxillary facial defect: A clinical report

Total flap failure is a devastating complication in head and neck reconstruction. This clinical report describes the rehabilitation of an extensive maxillectomy defect communicating with the midface by using a 2-piece magnet-retained orofacial prosthesis fabricated in heat-processed acrylic resin. The innovative design and choice of material allowed early rehabilitation of a patient receiving palliative care at a resource-constrained tertiary care oncology center. Prosthetic treatment served to reduce the period of hospitalization and helped the patient to resocialize.

Maxillofacial Bony Considerations in Facial Transplantation

Alloplastic facial transplantation has become a new rung on the proverbial reconstructive ladder for severe facial wounds in the past couple of decades. Since the first transfer including bony components in 2006, numerous facial allotransplantations across many countries have been successfully performed, many incorporating multiple bony elements of the face. There are many unique considerations to facial transplantation of bone, however, beyond the considerations of simple soft tissue transfer. Herein, we review the current literature and considerations specific to bony facial transplantation focusing on the pertinent surgical anatomy, preoperative planning needs, intraoperative harvest and inset considerations, and postoperative protocols.

A retrospective cross-sectional analysis of swallowing and tongue functions in maxillectomy patients

PURPOSE

To investigate the profiles of swallowing and tongue functions, and to identify factors influencing swallowing in maxillectomy patients.

METHODS

Maxillectomy patients whose swallowing function defined by Eating Assessment Tool (EAT-10) score and tongue functions (oral diadochokinesis: ODK, maximum tongue pressure: MTP) with or without obturator prostheses had been evaluated were enrolled in this study. The effects of the history of radiotherapy and soft palate defect on swallowing function were evaluated. The effect of radiotherapy on oral dryness was also evaluated. To examine correlations of swallowing function with continuous variables, Spearman correlation coefficients were calculated.

RESULTS

A total of 47 maxillectomy patients (23 males and 24 females, median age: 71 [IQR: 63-76]) were registered. The median value of EAT-10 scores was 3 [IQR: 0-14]. Patients with the history of radiotherapy, but not with soft palate defect, showed significantly declined swallowing function. ODK and MTP of patients wearing obturator prostheses were significantly improved. No significant effect of radiotherapy on oral dryness was found. A significant correlation was found between EAT-10 score and MTP (P = 0.04).

CONCLUSIONS

Swallowing function in maxillectomy patients was relatively impaired and the patients with the history of radiotherapy showed lower swallowing function. Obturator prostheses could contribute to the improvement of MTP and ODK (/ta/). MTP may play a crucial role in swallowing in maxillectomy patients.

Mucosal Melanoma of the Hard Palate: Surgical Treatment and Reconstruction

Mucosal melanomas of the head and neck region are uncommon pathologies that can affect the oral cavity, and are characterized by a high rate of mortality. Considering the lack of knowledge regarding risk and prognostic factors, current best clinical practice is represented by a large surgical excision with disease-free margins, eventually associated with a reconstructive flap. Indeed, given the frequent necessity of postoperative radiotherapy and fast healing process, a reconstruction of the surgical gap is advisable. Even if several flaps have been most commonly used, the submental island flap represents a valid alternative thanks to local advantages and similar oncologic outcomes compared to free flaps.

Considerations in Free Flap Reconstruction of the Midface

Midface reconstruction has been a consistent challenge for reconstructive surgeons even with the significant advances in technology and technique achieved over the recent years. A meticulous preoperative assessment of the patient is required to properly assess the defect or anticipated defect, determine proper reconstructive surgical plan, and discuss expected functional and aesthetic outcomes with the patient. For years we have employed local flaps, regional flaps, obturators, alloplastic implants, free flaps, or a combination of the previously mentioned techniques to address complex midface reconstruction. Free flap reconstruction in the midface requires special considerations for the pedicle, flap selection, and flap design to ensure an optimal outcome. The introduction of virtual surgical planning for reconstruction has enhanced patient outcomes to include advances in immediate dental rehabilitation at the time of free flap surgery. Postoperative considerations including quality of life, functional and aesthetic outcomes, and management of complications will also be discussed.

Functional and aesthetic outcomes of pedicled temporalis muscle flap for mesostructure reconstruction

The purpose of this work is to analyse the soundness of the Temporalis Muscle Flap as a safe and reliable flap to restore the aesthetic and functions of the facial mesostructure after its partial resection. Subjects were selected retrospectively and were invited to come to our outpatient clinic. Here, subjects completed a clinical evaluation in which the medical examiners evaluated the aesthetic outcome, the phonation, the ocular motility and the swallowing. Twenty-two subjects were enrolled in this study and completed the clinical evaluation. The mean value of the score obtained for the aesthetic outcome was 2.91 ± 0.92, slightly less than good. The VHI-30 questionnaire for voice evaluation obtained a mean score of 22.5 ± 11.5, pointing out minor voice problems. The mean value of the P-score evaluated during Fiberoptic Endoscopic Evaluation of Swallowing was 4.64 ± 0.95, highlighting the near absence of endoscopic signs of dysphagia. On the evaluation of ocular function, only one subject showed an inferior displacement of his right eyeball without vertical diplopia. The Temporalis Muscle Flap is a safe and reliable flap that can be used to reconstruct numerous surgical defects of the maxilla, giving an excellent recovery of physical aspect, phonation, and swallowing.

Microsurgical reconstruction of the hard palate after resections for malignant tumors

Background. The main aims of hard palate reconstruction include separation of the nasal and oral cavities, restoration of chewing, swallowing, speech, ensuring good aesthetic results, and preparation for dental rehabilitation. The choice of reconstruction method is determined by such factors as the nature and location of the defect, surgeon’s experience in certain reconstruction methods, cancer prognosis, and patient’s preference. The study objective is to analyze the results of microsurgical reconstruction of hard palate defects using different types of flaps.

Materials and methods. Forty-one (41) patients underwent microsurgical reconstruction of defects of the hard palate, soft palate, and alveolar process between 2014 and 2020. Defects of the anterior portion of the hard palate (grade I, IIc, IId according to the classification of J.S. Brown; grade IB, II, III according to the classification of D.J. Okay) were formed in 13 cases; all of them involved the alveolar margin of the maxilla to some extent. To repair these defects, we used flaps containing revascularized bone (n = 10; scapular tip flaps in 8 patients and fibular flaps in 2 patients) and fasciocutaneous or musculocutaneous flaps (n = 3; radial fasciocutaneous flaps in 2 patients and musculocutaneous flap from the anterior surface of the thigh in 1 patient). Defects of the posterior portion of the hard palate (grade Ib according to the classification of J.S. Brown; grade Ib according to the classification of D.J. Okay) were formed in 18 patients. To repair these defects, we used radial fasciocutaneous flaps (n = 17) and fibular autologous graft containing skin, muscles, and bone (n = 1). Soft palate resection was performed in 10 patients; all surgeries were combination, since the lateral oropharyngeal wall was included in the block of removed tissues. None of the patients had the opposite side affected. These defects were repaired using radial fasciocutaneous flaps.

Results. Six patients (15 %) developed total flap necrosis due to venous thrombosis on days 2, 3, and 6 postoperatively; two patients developed flap necrosis due to arterial thrombosis 2 days postoperatively. Good speech quality was achieved in 33 patients (80 %), while 6 patients (15 %) had satisfactory speech; rhinolalia was observed in 2 patients (5 %). All patients with defects of the posterior hard palate and of the soft palate had excellent aesthetic results. Among participants with defects of the anterior hard palate and alveolar process, 10 patients had excellent aesthetic results, while 5 individuals had good results. Three patients had unsatisfactory results due to scarring in the middle portion of the face.

Conclusion. Patients with subtotal defects of the hard palate and defects of its anterior portion (grade I, IIb, IIc according to the classification of J.S. Brown; grade II, III according to the classification of D.J. Okay) require repair of the alveolar margin of the maxilla; flaps containing revascularized bone are preferable in this case. The method of choice is defect repair using musculoskeletal scapular tip flap. In patients with short defects, defects located posteriorly, minimal or no defect of the alveolar margin of the maxilla (grade Ia, IB according to the classification of J.S. Brown; grade Ia, Ib according to the classification of D.J. Okay; grade V according to the classification of M.A. Aramany), soft palate defects, radial fasciocutaneous flaps should be used.

Serializing prosthetic rehabilitations to minimize time for patients with a maxillectomy without dentoalveolar support

An oral prosthesis can help maintain a sense of normalcy by preserving psychosocial and physiologic function in the aftermath of a maxillary resection. Rehabilitating the resulting defect in a timely manner requires strategic choices in treatment sequencing and prosthetic design. This clinical report describes the process of fabricating a series of removable and implant-retained prostheses to minimize a patient's time without the restoration of critical craniofacial structures.

Maxillofacial reconstruction with prefabricated prelaminated osseous free flaps

BACKGROUND

The prefabricated fibula flap is an advanced method of occlusal-based reconstruction that combines placement of osseointegrated dental implants with prelamination, using a split skin graft on the fibula, weeks prior to the definitive reconstruction. This approach is resource intensive but has several advantages including eliminating the delay from reconstruction to dental rehabilitation.

METHODS

A retrospective cohort study of all prefabricated fibula flaps used for mandible and maxillary reconstruction from 2012 to 2020 was performed. Outcome measures were implant survival, implant utilization and functional dental rehabilitation.

RESULTS

A total of 17 prefabricated fibula flaps were performed including two analogue and 15 digital plans. There were nine maxillary and eight mandibular reconstructions, of which 11 were primary and seven were secondary. There were no free flap failures. A total of 65 implants were placed (average 3.8, median 3 implants). There was one implant failure at 6 years giving a 1.5% failure rate. There was 91% implant utilization and 94% functional dental rehabilitation.

CONCLUSION

The prefabricated fibula flap provides outstanding dental rehabilitation in well-selected patients.

Management of a late presentation of bear mauling with a complex maxillofacial defect in a tertiary care hospital - A case report

Rationale:

Patient Concerns:

Diagnosis and Treatment:

Outcome:

Take-away Lessons:

[Use of radial forearm free flap for the reconstruction of hard and soft palate]

OBJECTIVE

Improvement functional and aesthetic results of treatment patients with defects of the hard and soft palate after resections for malignant tumors.

MATERIALS AND METHODS

During the period from 2014 to 2020, 30 patients underwent microsurgical reconstruction of hard and soft palate defects using a radial forearm free flap. For the primary tumor process, surgery was performed in 21 patients (70%), for relapse after chemotherapy, combined or complex treatment - in 9 patients (30%). The majority of patients at the time of surgery had a locally advanced process of the T2 category (12 patients - 40%), T3 (2 patients - 7%) and T4 - 2 patients (7%). Localized stage T1 process was diagnosed in 5 patients (17%).

RESULTS

Total flap necrosis was noted in 3 cases (10%) due to venous thrombosis on the 2nd and 3rd days after surgery and arterial thrombosis on the 2nd day. In one observation, on the 2nd day after surgery, a tense hematoma was diagnosed in the zone of formation of microanastomoses without signs of impaired flap perfusion, which required an emergency surgical intervention. All patients returned to their normal meals. No rhinolalia was observed in any of the cases. In one case, a patient with a defect in the anterior part of the hard palate obtained an unsatisfactory aesthetic result deformity of the midface; in all other cases, an excellent aesthetic result was obtained.

CONCLUSION

For defects of the hard palate of posterior localization and minimal or no defect of the alveolar edge of the maxilla (class I, a, b according to Braun, class Ia, Ib according to Okay, class V according to Armany), as well as for the defects of the soft palate, the method of choice is radial forearm free flap. The size of the skin area of the flap can reach 6X8 cm, which makes it possible to replace the combined defects of the hard and soft palate, the lateral wall of the oropharynx, and the retromolar region. The plasticity of the flap makes it possible to reconstruct the total defects of the soft palate by forming it in the form of a duplication.

Midface Reconstruction: Planning and Outcome

Reconstruction of the complex anatomy and aesthetics of the midface is often a challenge. A careful understanding of this three-dimensional (3D) structure is necessary. Anticipating the extent of excision and its planning following oncological resections is critical.

In the past over two decades, with the advances in microsurgical procedures, contributions toward the reconstruction of this area have generated interest. Planning using digital imaging, 3D printed models, osseointegrated implants, and low-profile plates, has favorably impacted the outcome. However, there are still controversies in the management: to use single composite tissues versus multiple tissues; implants versus autografts; vascularized versus nonvascularized bone; prosthesis versus reconstruction.

This article explores the present available options in maxillary reconstruction and outlines the approach in the management garnered from past publications and experiences.

Effect of submental flap reconstruction versus obturator rehabilitation after maxillectomy on quality of life: a randomized clinical trial

The surgical removal of a maxillary tumour will result in an oronasal communication, which can negatively affect the patient's life and daily functions. Following maxillectomy, the defect can be treated with a prosthetic obturator or microvascular flap. However, the gold standard technique remains controversial. The aim of this study was to evaluate and compare quality of life (QoL) outcomes of submental island flap versus maxillary obturator reconstruction after partial maxillectomy. Sixty patients indicated for maxillectomy were allocated randomly to two equal-sized groups. Control group patients underwent reconstruction with a surgical obturator, while intervention group patients underwent submental island flap reconstruction. Patient QoL was evaluated at the 6-month follow-up using the University of Washington Quality of Life Questionnaire. Statistically significant differences in QoL were found between the two groups. Chewing (P = 0.034), swallowing (P < 0.001), speech (P = 0.009), taste (P = 0.04), mood (P = 0.01), and anxiety (P = 0.003) domains showed a statistically significant improvement in the submental group compared to the obturator group. However, the obturator group showed a greater improvement in appearance (P < 0.001). The masticatory function scores in the obturator group were significantly higher after obturator rehabilitation (P < 0.001). In conclusion, this study found that submental flap reconstruction provided better function and QoL than the obturator. This reconstruction was associated with less pain and better pronouncing of words, chewing, swallowing food, and psychosocial adjustment.

Validation of masticatory function and related factors in maxillectomy patients based on the concept of "oral hypofunction": A retrospective cross-sectional study

PURPOSE

Although oral functions have been evaluated by various methods in maxillectomy patients, there exists substantial difficulty in the assessment procedures. The purpose of this study was to evaluate masticatory function, maximum occlusal force (MOF), and maximum tongue pressure (MTP) in maxillectomy patients objectively as per the "oral hypofunction" criteria, and examine the factors that correlate with masticatory function.

METHODS

This retrospective cross-sectional study included 50 maxillectomy patients with maxillofacial prostheses (23 males and 27 females, median age, 72 years; interquartile range (IQR), 63.75-77). The records of masticatory function, MOF, and MTP as per the "oral hypofunction" criteria and their profiles (age, number of occlusal supports, and maxillary defect configuration) were reviewed. The number of patients who exceeded a threshold value of "oral hypofunction" and the effects of occlusal support and defect configuration on masticatory function and MOF were calculated. Multiple regression analysis was performed to assess the associations between masticatory function and other variables.

RESULTS

The median value of masticatory function (114 mg/dL, IQR: 73-167.5) exceeded a threshold value, but not MOF (229.2 N, IQR: 110.2-419.6) and MTP (25.9 kPa, IQR: 21.4-29.0). The number of patients who exceeded each threshold value was 27 (masticatory function), 8 (MOF), and 12 (MTP), respectively. The influence of the number of occlusal supports, but not the defect configuration, was statistically significant. Multiple regression analysis revealed that MOF was independently related to masticatory function (P=0.042).

CONCLUSIONS

Within the limitations of this study, the median value of masticatory function in maxillectomy patients could exceed a threshold and MOF might be an independent predictor of masticatory function.

The use of 3D virtual surgical planning and computer aided design in reconstruction of maxillary surgical defects

PURPOSE OF REVIEW

The present review describes the latest development of 3D virtual surgical planning (VSP) and computer aided design (CAD) for reconstruction of maxillary defects with an aim of fully prosthetic rehabilitation. The purpose is to give an overview of different methods that use CAD in maxillary reconstruction in patients with head and neck cancer.

RECENT FINDINGS

3D VSP enables preoperative planning of resection margins and osteotomies. The current 3D VSP workflow is expanded with multimodal imaging, merging decision supportive information. Development of more personalized implants is possible using CAD, individualized virtual muscle modelling and topology optimization. Meanwhile the translation of the 3D VSP towards surgery is improved by techniques like intraoperative imaging and augmented reality. Recent improvements of preoperative 3D VSP enables surgical reconstruction and/or prosthetic rehabilitation of the surgical defect in one combined procedure.

SUMMARY

With the use of 3D VSP and CAD, ablation surgery, reconstructive surgery, and prosthetic rehabilitation can be planned preoperatively. Many reconstruction possibilities exist and a choice depends on patient characteristics, tumour location and experience of the surgeon. The overall objective in patients with maxillary defects is to follow a prosthetic-driven reconstruction with the aim to restore facial form, oral function, and do so in accordance with the individual needs of the patient.