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Fig. 29.5 (continued)
A. P. Fagin et al.
Fig. 29.6 Osteotomies complete; maxilla downfractured with digital pressure
that an inferior maxillectomy with preservation of the infraorbital rim and orbital oor would provide adequate oncologic margins. (If superior extension of the tumour requires a
total maxillectomy, refer to Chap. 42.)
The osteotomy is then performed. The anaesthesia team is
informed that this part of the procedure carries the highest
risk for intraoperative blood loss, which can be limited with
hypotensive anaesthesia if it is medically safe to do so. A
reciprocating saw is used to complete each side sequentially,
with a horizontal cut extending from the pterygomaxillary
junction anteriorly across the zygomaticomaxillary buttress
to end medially through the lateral nasal wall. The lateral
nasal wall osteotomy can be conrmed using single-sided
guarded nasal osteotomes. The nasal septum is transected
with maxillectomy scissors if septal resection is desired, or it
is separated from the maxilla with a curved, double-ball
nasal septal osteotome if the septum can be preserved.
gomaxillary junction; care is taken to angle the osteotome
downwards (inferiorly), with a nger placed intraorally
behind the maxillary tuberosity. The osteotomy is then carried out until the osteotome is felt on the intraoral nger.
Digital pressure is then placed on the anterior maxilla in an
inferior direction to complete the downfracture in a controlled fashion (Fig.29.6). The greater palatine arteries can
then be located at the posterior lateral aspect of the superior
side of the downfractured maxilla and can be safely ligated
with surgical clips. Once haemorrhage is controlled, attention is turned to the posterior aspect of the resection specimen. Cautery is used to carry the dissection posteriorly in the
planned resection marking along the posterior aspect of the
maxilla. This dissection is carried across the posterior aspect
of the hard palate and connected with the contralateral side
to free the remaining attachments.
Next, a curved osteotome is rmly placed into the ptery-
29 Inferior Maxillectomy andResection ofTumour oftheUpper Alveolus
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The inferior maxillectomy specimen is then delivered
(Fig.29.7). The resection bed is inspected for haemostasis,
which is obtained with cautery, surgical clips, and suture
ligation where appropriate. In the authors’ experience, a
tracheostomy is rarely necessary unless the reconstructive
technique is particularly bulky.
a
To aid in airway patency, prior to any reconstruction,
nasal trumpets to create an nasopharyngeal airway can easily
be placed and secured to the nasal septum without risking
damage to reconstructive aps (Fig.29.8). At the same time,
it is convenient to place a nasogastric feeding tube.
b
Fig. 29.7 (a) Resection bed after removal of inferior maxillectomy specimen. (b) Superior view of inferior maxillectomy specimen. (c) Inferior
view of inferior maxillectomy specimen
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Fig. 29.7 (continued)
A. P. Fagin et al.
Fig. 29.8 Bilateral nasal
trumpets placed prior to any
reconstruction, to assist in
airway patency
postoperatively and help
avoid tracheostomy
29.4.1 Reconstructive Options
Though the focus of this chapter is not on maxillary reconstruction, this section briey reviews some reconstructive
options. The goal of reconstruction is re-creation of anatomic
boundaries between the oral cavity, maxillary sinus, and
nasal cavity, and restoration of masticatory function. For
small resections of the maxillary alveolus, primary closure
with local advancement of tissue is possible, although care
should be taken not to obliterate the maxillary vestibule if the
patient has a maxillary denture. Transposition of the buccal
fat pad can often assist in creating a layered closure for small
29 Inferior Maxillectomy andResection ofTumour oftheUpper Alveolus
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communications between the maxillary sinus and oral cavity.
For larger defects, local aps (such as the facial artery myomucosal ap) can help provide a layered closure. For even
larger defects (such as the one created in this case), obturators historically were the only option to restore anatomic
separation, but the advent of microvascular free tissue transfer has created many more options. For soft tissue, a radial
forearm ap works well, owing to its relative lack of bulk
(Fig.29.9).
When more extensive dental rehabilitation is planned, a
bone ap is required to support eventual dental implant prostheses. The bula is the workhorse for bony reconstruction
Fig. 29.9 Radial forearm
ap inset to restore separation
between the maxillary sinus,
nasal cavity, and oral cavity
of the jaws, although bony transfer with a radial forearm,
scapula, or deep circumex iliac artery bone ap is possible.
The amount of bone available with a radial forearm bone ap
is relatively small, however, and there is also the real risk of
fracture of the radius, which sometimes can occur several
weeks after the procedure, even if a bone plate has been
placed on the radius.
Figures 29.10 and 29.11 show a case of mucoepidermoid
carcinoma treated by bilateral inferior maxillectomy and
reconstructed with an osteocutaneous bula graft followed
by restoration with an implant-supported prosthesis to completely restore both masticatory and cosmetic function.
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A. P. Fagin et al.
Fig. 29.10 (a) Preoperative
image of mucoepidermoid
carcinoma of a minor salivary
gland. (b) Inferior
maxillectomy specimen. (c)
Osteocutaneous bular graft
with plates xated, ready for
implantation into the resection
bed. (d) Postoperative
orthopantomogram
a
b
c
d
29 Inferior Maxillectomy andResection ofTumour oftheUpper Alveolus
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abc
d
281
Fig. 29.11 (a and b) Frontal and prole clinical photos with immediate
prosthesis in place, demonstrating the restoration of lip support and
cosmetic smile. (c) Orthopantomogram with six implants in bula in
29.5 Postoperative Care
Postoperative care is based on the extent of resection, reconstruction, and any medical comorbidities. Small resections
can often be performed under day-case anaesthesia. Sinus
precautions are of course important for all patients in whom
the reconstruction includes the maxillary sinus, to limit pressure changes across it that could impede healing. The authors
do not routinely recommend postoperative antibiotics unless
a microvascular free tissue transfer is used for reconstruction. In the case of smaller resections, the patient can often
resume an oral soft diet, but for larger resections and especially for those with free ap reconstruction, nasogastric
feeding for 5–7days is recommended. Finally, the authors do
not routinely use postoperative steroids.
29.6 Results andConclusions
When oncologically appropriate margins can be achieved
without resecting the infraorbital rim or zygoma, a transoral approach to an inferior maxillectomy is a well-toler-
preparation for implant- supported prosthesis. (d) Intraoral photo of
immediate implant-supported prosthesis
ated procedure that spares the need for facial incisions in
the classic Weber-Fergusson approach. Tumours of the
maxilla have historically been difcult to clinically observe
in the preoperative setting, but the advent of CT and, where
appropriate, MRI has provided improved visualization for
preoperative planning, often allowing for a more conservative maxillectomy. Even with modern imaging, however, it
is not always possible to denitively determine an appropriate surgical plan preoperatively. Intraoperative endoscopic evaluation of the sinus and intraoperative
pathological evaluation can help the surgeon perform the
minimum resection required to maintain oncologically
acceptable margins. Reconstructive options aim to restore
the anatomical separation between the oral cavity, nasal
cavity, and maxillary sinus, as well as preserving masticatory function and phonation. The advent of microvascular
free tissue transfer (with or without bony transfer) has revolutionized a reconstructive surgeon’s ability to restore form
and function to patients undergoing this procedure. Finally,
consideration should be given to the neck, particularly for
patients with maxillary alveolus carcinomas, which have a
high risk of micrometastasis. In the authors’ series of max-
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illary alveolus carcinomas, 15% of patients developed neck
metastasis within 18months of the original primary tumour
surgery [7].
References
1. Pogrel MA. Inferior hemi-maxillectomy for treatment of palatal
tumors. J Oral Maxillofac Surg. 1988;46:85–7.
2. Öhngren LG.Malignant tumors of the maxilla-ethmoid region. Acta
Otolaryngol Suppl. 1933;13:1.
3. Brown JS, Shaw RJ. Reconstruction of the maxilla and midface:
introducing a new classication. Lancet Oncol. 2010;11:1001–8.
4. Okay DJ, Genden E, Buchbinder D, Urken M.Prosthodontic guidelines for surgical reconstruction of the maxilla: a classication system of defects. J Prosthet Dent. 2001;86:352–63.
5. Brown JS, Rogers SN, McNally DN, Boyle M.A modied classication for the maxillectomy defect. Head Neck. 2000;22:17–26.
6. Davison SP, Sherris DA, Meland NB.An algorithm for maxillectomy defect reconstruction. Laryngoscope. 1998;108:215–9.
7. Mourouzis C, Pratt C, Brennan PA.Squamous cell carcinoma of the
maxillary gingiva, alveolus, and hard palate: is there a need for elective neck dissection? Br J Oral Maxillofac Surg. 2010;48:345–8.
Part XI
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Surgery of the Mandible
Perioral Marginal Mandibulectomy
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JoshuaE.Lubek
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30.1 Introduction
Oral cavity cancers involving the mandibular gingiva can
become a signicant dilemma for the ablative surgeon with
respect to the correct amount of mandibular bone required
for surgical resection and achievement of appropriate surgical margin. Marginal mandibulectomy is dened as the partial resection of the mandible. It is generally reserved for
cases in which a gingival cancer has involved only the alveolar bone adjacent the teeth or the cortical bone has not been
violated by tumour inltration. Marginal mandibulectomy
can be performed both in the sagittal plane or the horizontal
plane (rim resection). Although both techniques have been
described the sagittal resection is fraught with more complications, removes the ability to wear a removable dental prosthesis, the inability to place dental implants without
signicant bone grafting and signicantly weakens the mandibular bone increasing the risk of mandibular fracture.
Furthermore, if the cortical bone is violated, then a sagittal
resection will likely result in a positive oncologic margin
(Fig.30.1a–c).
The purpose of the marginal mandibulectomy is to avoid
the morbidity of a segmental resection while maintaining
proper oncologic principles and disease control. To this
extent the American Joint Committee on Cancer (AJCC 8th
edition) has modied its denition of bone invasion involving the alveolar dental segment. The cortical bone surrounding the teeth is thin with little marrow, and thus, involvement
of this bone occurs early and does not upstage the tumour to
true marrow invasion. True pathologic bone invasion (pT4)
requires involvement of the marrow bone below the apices of
the teeth (Fig.30.2).
This chapter will focus on the technique of performing
the marginal rim mandibulectomy, indications, and postoperative care.
J. E. Lubek (*)
Department of Oral and Maxillofacial Surgery, Head & Neck
Surgical Oncology/Microvascular Reconstructive Surgery,
University of Maryland, Baltimore, MD, USA
e-mail: jlubek@umaryland.edu
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
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J. E. Lubek
Free gingival
margin
Attached
gingiva
Anterior oral
vestibule
c
Sublingual
Condylar process
Coronoid process
Submandibular
fossa
fossa
Free gingival
margin
Attached
gingiva
Anterior oral
vestibule
Mandibular foramen
Alveolar
process
Mental
foramen
Mental
protuberance
(chin)
Body
Ramus
Fig. 30.1 (a) Sagittal rim mandibulectomy. (b) Horizontal marginal rim mandibulectomy. (c) Horizontal rim marginal mandibulectomy
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