Surgical reconstruction of maxilla and midface: Clinical outcome and factors relating to postoperative complications

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Summary

Aim

The aim of this study was to evaluate the success rate of different techniques of repairing maxillary and midfacial defects according to their extent.

Patients and methods

In this retrospective study, 47 maxillary reconstructions in 41 patients were reviewed. Evaluation took place an average of 4.5 years postoperatively. The cases were divided into three groups according to the classification of Brown et al. (Br J Oral Maxillofac Surg 40: 183–190, 2002): Group 1: maxillary defects limited to one side (Class 2a); Group 2: bimaxillary defects (Classes 2b and 2c); Group 3: maxillary/midfacial defects (Classes 3 and 4). Most reconstructions were performed with non-vascularized bone grafts in the first patient group, whilst microvascular soft tissue flaps combined with free bone grafts were used in the second group, and re-vascularized osteocutaneous flaps in the third group.

Results

Overall flap survival was 79%. Dental reconstruction was successfully completed in 31 cases (66%). Postoperative infection leading to transplant loss was the main reason for failure. This complication was specifically associated with temporal osteomuscular flaps (50%) and free iliac crest grafts (61%) and was related to the extent of the defect. In the reconstructive methods evaluated here, associated radiotherapy had a minor influence on the occurrence of complications.

Conclusion

Non-vascularized iliac bone grafts should be used sparingly in Class 2b, even in combination with microvascular flaps. There is a very limited indication for these grafts in Classes 3 and 4. Temporal osteomuscular flaps do not seem to be suitable for maxillary reconstruction.

Introduction

Midfacial and maxillary defects caused by ablative tumour surgery or trauma involve the stomatognathic complex, including the palate, teeth, nasal cavity and maxillary sinus. Functional and aesthetic restoration is still a challenge. The surgery is complex, and includes sealing of the oral cavity from the nasal cavity, re-establishment of the paranasal sinus(es), and restoration of the facial contour (Muzaffar et al., 1999). For better aesthetic and functional results, the final goal should ideally be successful oral rehabilitation and restoration of dental occlusion using prosthetic means (Okay et al., 2001).

For reconstruction, various pedicled and free tissue transfer techniques with and without bone grafts have been reported (Choung et al., 1991; Turk et al., 1994; Clauser et al., 1995; Cordeiro et al., 1998; Urken et al., 2001; Brown et al., 2002). Although the selection of methods depends on the extent of the bony and soft tissue defect, there seems to be no clear and generally accepted recommendation for this. Analysis and comparison of the clinical outcomes associated with different reconstruction techniques is rare (Davison et al., 1998). Maxillary reconstruction is frequently associated with complications, leading to insufficient outcome (Pogrel et al., 1997). Additionally, some tissue transfer techniques permit only limited dental rehabilitation; if there is restoration without reconstruction of the bony buttress(es), the only option is a removable denture. As a result, selection of the method for reconstruction and oral rehabilitation remains controversial.

The aim of this study was to evaluate different techniques of repairing maxillary defects including partial and complete alveolar ridge loss. The reconstructive techniques used were locally pedicled soft tissue flaps, locally pedicled osteomuscular flaps, non-vascularized free bone grafts covered with locally pedicled flaps or covered with re-vascularized soft tissue flaps as well as re-vascularized osteocutaneous flaps. Data were analysed to point out specific problems associated with different reconstruction techniques in relation to the extent of the defect. Special attention was paid to the success or failure of dental rehabilitation.

Section snippets

Patients and Methods

This retrospective study included 41 patients who underwent sequential reconstructions of the midface between 1991 and 2001. There were 27 males and 14 females. They ranged in age from 17 to 84 years, with a mean of 54.4 years.

A total of 47 reconstructive operations in the midfacial region were evaluated. Thirty-six operations were performed in 31 patients who had defects after ablative tumour surgery. Reconstruction was primary in 25 tumour patients and secondary in 11. Twenty patients had

Results

The types of reconstruction used in each class are shown in Table 2 according to the extent of the defect. In the first patient group, 19 defects were repaired, in the second group 8 defects (7 cases in Class 2b, 1 case in Class 2c), and in the third group 20 were repaired (11 cases in Class 3a, 3 cases in Class 3b, 1 case in Class 3c, 5 cases in Class 4a). Most of the Class 2a defects were repaired with locally pedicled flaps and non-vascularized free bone grafts. Large defects in Classes 2b,

Discussion

There are many possible techniques for repairing maxillary and midfacial defects. The selection of the surgical method depends on the extent of the bony and soft tissue defect. In small defects of Classes 1 and 2a, local flaps with or without bone grafts are often sufficient (Cheung et al., 1994). However, the relatively small amount of soft tissue available for cover limits the use of such local flaps to minor and partial defects (Muzaffar et al., 1999). Most bimaxillary and combined

Conclusion

Focusing on dental rehabilitation, some factors related to surgical technique were found in this study. One of the decisive factors making dental rehabilitation difficult was transplant loss associated with temporalis osteomuscular flaps and non-vascularized iliac bone grafts. Associated radiation therapy had no marked influence on the occurrence of complications. The extent of the defect may affect options for dental rehabilitation. The results of this study suggest careful use of

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