Physical

In addition to reconstruction of the skull base and orbit, which have been covered in Chapter 19, there are several other aspects that should be considered when the upper jaw is involved. These may be divided into temporary and permanent, and the choice is dependent on the extent of the defect and factors related to the patient and facilities available.

A classification system has been proposed for maxillary and midface defects (Fig. 21.1)1,2 that assists in these decisions, but whatever the choice, the involvement of a team that includes both prosthodontists and maxillofacial technicians is necessary as well as dietetic and psychological support.

In Class I where only a portion of the alveolus has been resected, a local flap and/or modification of an existing denture may suffice. Similarly, small midline palatal defects may be closed with mucosal flaps or a small obturator can be used (Fig. 21.2).

Class II, which represents a partial maxillectomy without loss of the orbital floor, also does well with obturation. At the time of surgery, a temporary obturator can be fashioned with material such as gutta percha on a modified preexisting or new denture plate, taking account of the surgical cavity and any hemostatic packing (Fig. 21.3 a, b). This allows the patient to eat, drink, and speak immediately following the surgery. It can be removed and modified over the immediate postoperative period as packing is removed and a new lightweight obturator can be made in due course to more accurately conform to the cavity as it alters with healing (Figs. 21.4, 21.5, 21.6).

To improve retention and stability, an implant-retained prosthesis may be used, particularly when the defect is larger (Fig 21.7 a–d). In contrast, a variety of free vascularized flaps may also be used, including fibula, iliac crest, and scapula flaps. The scapula flap may be based on the angular branch of the thoracodorsal artery or circumflex scapula artery, of which the former offers a longer pedicle.

Class III defects include the orbital floor and may extend into the nasal bridge. In the past if the orbital periosteum was intact, obturators alone were still the rehabilitation of choice, but in recent years pedicled or free vascularized flaps are most often used, often in combination with an implant-retained prosthesis (Fig. 21.5). Adequate support of the eye is essential if ectropion, conjunctival exposure, epiphora, and diplopia are to be avoided (Chapter 19). Many options of varying complexity have been described in the literature,3 some representing the triumph of technique over common sense. The rectus abdominis, latissimus dorsi, scapula, rib, or fibula are commonly used, but it should be remembered that transplanted bone in the more complex osseomusculocutaneous flaps may not withstand postoperative radiotherapy.

Class IV involves a more extensive orbital defect that may be treated with soft tissue alone in the form of a rectus abdominis flap, but inclusion of bone as in the iliac crest with the internal oblique can provide better implant options.

In Class V, where the orbit has been cleared and an orbital prosthesis is required, a less bulky repair is preferred such as temporalis muscle or a temporoparietal flap. Other options to consider are a radial forearm or anterolateral thigh flaps.

Class VI encompasses a large midfacial defect including skin, soft tissues, and nasal structure as in a rhinectomy. If there is sufficient bony support, an entire osseointegrated nasal prosthesis may be considered, although patients are often resistant to the concept of a “plastic nose.” Reconstruction using a radial forearm flap with associated skin and fascia is an option. This may be augmented by glabellar or even forehead flaps in the older patient, though both require some form of internal support. Patients should understand that such complex reconstructive surgery may require several subsequent procedures to refine the result, especially if postoperative radiotherapy is given.