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ab
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ab c
A. A. Slijepcevic et al.
Fig. 28.10 A hemi-maxillectomy defect involving the anterior hard
palate that was reconstructed with a bula free ap. Figure (a) shows
the bula ap with reconstruction plating used to conform the ap to
the shape of the hard palate defect. Figure (b) shows the ap reconstruc-
Fig. 28.11 A palate defect
that was reconstructed using a
prosthesis. Figure (a) shows a
full-thickness defect of the
hard and soft palate, with
exposure of the left intranasal
cavity. Figure (b) shows the
defect following rehabilitation
with a palatal prosthesis that
reconstructed the palate defect
and missing dentition
poor vascularity of the lower extremity, who are unable to
withstand the donor site morbidity of a bula free ap, may
undergo palate reconstruction with a scapula free ap. Both
the lateral border and tip of the scapula may be used in palate
and maxillary defect reconstruction. The aps receive their
blood supply from the circumex scapular artery and angular
branch of the thoracodorsal artery, respectively [138, 139].
The palate reconstruction may be completed with surrounding musculature of the composite ap, including the teres
major muscle, to close oronasal defects. The scapula bone is
used to reconstruct maxillary process defects, while
surrounding composite tissue reconstructs the palate [139].
tion with the defect site. Fibula aps contain adequate bone stock for
dental implants as shown. Figure (c) shows full restoration of the palate
defect with dentures that adhere to the underlying implants
should be considered and evaluated by the prosthodontist.
Patients with small midline hard palate defects or even maxillectomy defects should be evaluated for rehabilitation with
a prosthesis [141]. The ability to xate the prosthesis is critical to patient acceptance and satisfaction. If adequate teeth
and abutments are available for support, then a complex orodental prosthesis will work extremely well [142].
Figure 28.11 shows a palatal prosthesis that was used to
reconstruct a through-and-through palate defect. When lack
of dentition or more signicant resection of the alveolar
ridge and hard palate is undertaken, xation of the prosthesis
becomes problematic. Prosthesis with extensions that protrude into the defect will work well in some circumstances
[140].
28.8.3 Reconstruction ofPalatal Defects
withProsthetics
Edentulous patients or those with larger resections where
the framework is cantilevered on remaining teeth without a
stable platform will have difculty with retention and sup-
A comprehensive rehabilitative team of which the maxillofacial prosthodontist plays a key role should assess patients
who are going to have surgery of the hard or soft palate. As
with any oral cavity carcinoma, assessment by the team to
receive input to guide future rehabilitative potential is a key
to obtaining the best outcomes [140]. Lesions that require
through and through resection of either the hard or soft palate require further complex reconstructive algorithms.
During the resection of the oral cavity tumour, preserva-
tion of anatomy that is conducive to prosthetic rehabilitation
port. Unless osseointegrated implants are used, patient satisfaction is poor [143, 144].
Soft palate resections are a difcult area to rehabilitate
with prosthesis. Lifts that mobilize the remaining soft palate
or provide for a blockage in the posterior pharyngeal wall
can be fashioned [145]. The same issues concerning stabilization to the anterior aspect of the hard palate or dental alveolar processes is encountered. Finding the right t to allow
for posterior oropharyngeal closure of the nasopharynx on
swallowing and articulating can be difcult [146, 147].
28 Excision ofPalatal Neoplasms
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267
In summary, in the hands of a skilled oral maxillofacial
prosthodontist when there exists soft tissue abutments that
will support the prosthetic, prosthodontics is an excellent
rehabilitative modality. Unfortunately, in the patient with a
history of radiation or poor oral dental support, patient satisfaction with prosthetics is poor [148, 149].
With any intraoral prosthetic device, there may be issues
with keeping the maxillectomy cavity clean and residual
buildup on the obturator that requires vigilant and fastidious
cleaning. In patients who are elderly, they may lack the manual dexterity and visual acuity required to maintain this area.
When the device is removed, the ability to eat or communicate effectively is markedly impacted. Finally as time goes
on and the soft tissues continue the healing process, the palatal defect will change in size and shape requiring repeated
adjustments of the obturator [149, 150]. Unless the patient
has access to a prosthodontist and can afford constant care,
the initial prosthesis may be useless.
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Inferior Maxillectomy andResection
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ofTumour oftheUpper Alveolus
AdamP.Fagin, DanielPetrisor, andPeterA.Brennan
29
29.1 Introduction
Maxillary tumours have historically proved difcult to adequately treat surgically without signicant morbidity. Among
the reasons is the close anatomic proximity of the maxilla to
many vital structures, including the skull base, orbits, infratemporal fossa, pterygopalatine fossa, and nasal cavity. Also, until
the advent of CT and MRI, accurate preoperative classication
and visualization of maxillary pathology was difcult, requiring exploratory surgery, and unexpectedly aggressive surgical
resection, classically with a Weber- Fergusson approach, might
be needed. The advent of three- dimensional imaging modalities has allowed surgeons to accurately plan a more conservative surgical resection when indicated [1]. This chapter
discusses inferior maxillectomy for the operative management
of pathology of the upper alveolus and palate.
29.2 Background andIndications
Surgeons have long appreciated the signicance of the relative location of pathology and surgery in the maxillary region
and its subsequent impact on patient morbidity. This concept
was rst described in 1933 by Öhngren. “Öhngren’s line”
divides the maxilla into antero-inferior and postero-superior
by drawing an imaginary plane from the medial canthus to
the angle of the mandible [2]. As might be expected, pathology in the postero-superior region, above Öhngren’s line, is
associated with greater morbidity and a poorer prognosis,
A. P. Fagin (*) · D. Petrisor
Department of Oral and Maxillofacial Surgery, Oregon Health and
Science University, Portland, OR, USA
e-mail: petrisord@ohsu.edu
P. A. Brennan
Department of Oral and Maxillofacial Surgery, Portsmouth
Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
e-mail: peter.brennan@porthosp.nhs.uk
because of the proximity of vital structures including the
skull base, orbits, pterygopalatine fossa, and temporal fossa.
Neoplasms, which can be benign or malignant, can arise
from any of the surrounding tissues, including bone, salivary
glands, blood vessels, or overlying skin, or they may have odontogenic origin. The required resection margin is typically one
unviolated anatomic layer for benign disease and up to 15mm
or more for malignant disease, depending on the specic diagnosis and the aggressiveness of the tumour. These resection
margins may be difcult to achieve (or even unattainable), given
the proximity to vital anatomic structures, but a resection might
still be planned for palliation. Despite advances in chemotherapy and radiation therapy, surgery remains the mainstay of treatment for most maxillary pathology, with the exception of
lymphoreticular malignancies, including lymphomas.
To guide an appropriate surgical procedure, diagnostic
and staging investigations should be performed prior to
denitive planning of the intervention. Preoperative investigations should include a thorough history and physical
examination, including exible nasopharyngoscopy, to evaluate the nasal cavity, nasopharynx, and oropharynx.
Appropriate imaging should include CT and possibly an
MRI as well, if better soft-tissue characterization is required.
In the setting of malignancy, an appropriate metastatic staging investigation, including a chest CT scan and, possibly, a
PET-CT scan, should be considered.
Once all investigations have been completed, an appropriate
surgical plan can be formulated. Several maxillary defect classication systems have been proposed [3–5]. The authors nd
the updated classication system by Brown and Shaw the most
useful to conceptualize the planned surgical resection [3]. If
planned resection margins translate to a class I or II a–d defect,
then an inferior maxillectomy technique (as described here)
may be appropriate to achieve the desired resection (Fig.29.1).
Though reconstructive considerations should never compromise an adequate resection, it is necessary to consider
reconstructive principles prior to nalizing a surgical plan.
The maxilla has two major anatomic functions: it serves as
the support for the maxillary dentition, and it acts as a divider
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_29
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II
IIII
IIIIII
IVVVI
ba
c d
Fig. 29.1 Brown and Shaw classication of vertical and horizontal maxillectomy and midface defects. Vertical classication: I—maxillectomy
not causing an oronasal stula; II—not involving the orbit; III—involving the orbital adnexae with orbital retention; IV—with orbital enucleation
or exenteration; V—orbitomaxillary defect; VI—nasomaxillary defect. Horizontal classication: (a)—palatal defect only, not involving the dental
alveolus; (b)—less than or equal to 1/2 unilateral; (c)—less than or equal to 1/2 bilateral or transverse anterior; (d)—greater than 1/2 maxillectomy.
Letters refer to the increasing complexity of the dentoalveolar and palatal defect, and qualify the vertical dimension
ab
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between the various cavities of the midface, including the
orbits, nasal cavity, maxillary sinus, and oral cavity.
29.3 Preoperative Considerations
andAnaesthesia
Historically, reconstructive surgeons had only local tissue
aps and obturators at their disposal to restore anatomy and
function, so preservation of a distal tooth as a support for an
obturator could potentially make a big difference in functional restoration [6]. However, microvascular free tissue
transfer and dental implants have revolutionized the ability to
provide patients with functional outcomes after large resections. When free tissue transfer is planned, the volume of tissue available for reconstruction is often not a factor in the
midface, so resection size is not a major issue. Additionally, it
can be easier to resect and recreate an entire subunit rather
than to attempt to reconstruct only half, a factor particularly
relevant for dental implants. The authors believe that reconstructive considerations should not compromise a planned
resection, but it is always important to work with reconstructive colleagues during the planning stage to lay the groundwork for an optimal nal outcome. To this end, all patients
should be discussed at a multi- disciplinary team (MDT)
meeting to ensure the best treatment is offered.
Fig. 29.2 Preoperative
clinical and radiographic
imaging. (a) Clinical photo of
the maxillary alveolar
squamous cell carcinoma. (b)
Representative axial CT
demonstrating potential
tumour spread into the
maxillary sinus. (c)
Representative sagittal CT
demonstrating the possible
superior extent of tumour into
maxillary sinus. (d)
Representative coronal CT
demonstrating possible
superior extent of tumour into
the maxillary sinus
c
The operative surgical technique will be discussed with a
representative case of malignant pathology of the maxillary
alveolus. This case demonstrates that even with the advent of
CT, the ability to dene a denite resection plan for the maxillary alveolus preoperatively can be challenging because of
the difculty in visualizing possible extension into the maxillary sinus (Fig.29.2). In cases such as this, the preoperative
discussion at the MDT and with the patient should include
the possible need to resect and reconstruct the infraorbital
rim and orbital oor, but an attempt should always be made
to preserve these structures if oncologically safe to do so,
thereby only completing an inferior maxillectomy.
A preoperative discussion should be held with members
of the anesthesia team. In the authors’ experience, oral intubation works best for these cases, because nasal intubation
risks laceration or interference of the endotracheal tube during the nasal osteotomies. Nasal intubation does not provide
any signicant benet, because intraoperative maxilla-
d
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mandibular xation is not required. The anaesthesia team
also should be made aware that this procedure can be associated with considerable intraoperative blood loss, and hypotensive anaesthesia can help to minimize this loss during the
maxillary downfracture.
A preoperative dose of antibiotics with appropriate anaerobic coverage should be selected, typically ampicillinsulbactam in the United States, or co-amoxiclav or
amoxicillin with metronidazole in Europe. Clindamycin is
an alternative for the penicillin-allergic patient.
29.4 Surgical Technique
The planned resection margins can be marked out with cautery
or a disposable marker pen. In the case of malignant pathology, as shown in the case presented, this typically involves
obtaining 10- to 15-mm margins beyond the clinical extent of
the tumour, to include the oral mucosa. The planned incision
follows a circumvestibular pattern anteriorly, around the maxillary tuberosity posterolaterally, and connected across the soft
palate posteriorly, as shown in Fig.29.3. For benign disease,
resection of one anatomical boundary is often sufcient, and
oral mucosa should be preserved to help reconstruction if
appropriate. In the case presented, an anterior circumvestibular incision was used, extending from rst molar to rst molar.
Next, the marked incision is deepened down to bone
across the anterior maxillary sinus wall, taking care to preserve an adequate resection margin around the tumour. In
areas closer to the tumour, this may require continuing
through soft tissue in a stepped-like manner prior to changing direction towards the bone. A periosteal elevator is then
used to raise a full-thickness mucoperiosteal ap to expose
the pyriform rim, infraorbital nerve, and zygomaticomaxil-
lary buttress, and continuing posteriorly to the pterygomaxillary junction (Fig.29.4).
Once exposed, the appropriate superior extent of the
resection must be determined. If the superior extent of the
tumour is unclear (as in this example), endoscopic visualization of the maxillary sinus, with biopsy as needed, can be
useful to assess for frank tumour invasion. Small osteotomes
are used to make a 5-mm× 5-mm window in the anterior
wall of the maxillary sinus as required, and a 30° endoscope
can be readily inserted. In this case, the maxillary sinus was
inspected and frozen sections were sent, which conrmed a
benign mucocele (Fig.29.5). It was clear to the surgical team
Fig. 29.3 Planned resection margins marked circumferentially with
cautery, extending in a circumvestibular pattern anteriorly and around
the maxillary tuberosity and soft palate posteriorly
Fig. 29.4 Circumvestibular incision carried down to bone, with care to preserve adequate margins on the left closer to the tumour, and a fullthickness mucoperiosteal ap raised to expose the pyriform rim, infraorbital nerve, and zygomaticomaxillary buttress
29 Inferior Maxillectomy andResection ofTumour oftheUpper Alveolus
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a
b
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Fig. 29.5 Endoscopic evaluation of the left maxillary sinus. (a and b) Intra-operative photo of antrostomy. (c) Endoscopic view of left maxillary
sinus anterolateral wall, demonstrating mucocele without tumour extension
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