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

doi:10.1067/mpr.2001.119524

The Journal of Prosthetic Dentistry

Volume 86, Issue 4, October 2001, Pages 352-363

https://doi.org/10.1067/mpr.2001.119524 Get rights and content

Abstract

Surgical reconstruction of maxillectomy defects has been described as an alternative to prosthetic rehabilitation to close the oral cavity. Advancements in microvascular surgical techniques require comprehensive treatment planning guidelines for functional rehabilitation. This retrospective study evaluated acquired maxillectomy defects after surgical reconstruction and/or prosthodontic rehabilitation in an attempt to establish surgical and prosthodontic guidelines that could be organized into a classification system. Forty-seven consecutive patient treatments of palatomaxillary reconstruction at a single facility, The Mount Sinai Medical Center (New York, N.Y.), were reviewed. All patients were rehabilitated with a tissue-borne obturator, a local advancement flap, a fasciocutaneous free flap, or a vascularized bone-containing free flap. Palatomaxillary defects were divided into 3 major classes and 2 subclasses. The aim of this defect-oriented classification system was to organize and define the complex nature of the restorative decision-making process for the maxillectomy patient. (J Prosthet Dent 2001;86:352-63.)

Section snippets

Functional anatomy for surgical reconstruction

The maxilla comprises the paired structures of the right and left maxillae.¹⁷ The body of each maxilla is hollow and shaped like a pyramid, with the base situated medially and adjacent to the nasal cavity. When the anatomy relevant to palatomaxillary reconstruction is considered, the maxilla can be conveniently divided into supportive buttresses and processes. The former constitute the foundation essential for resisting the forces of mastication, and the latter are responsible for the form of

Prosthetic prognosis and surgical reconstruction

Every effort should be made to re-establish a favorable distribution of force to achieve stabilization of an obturator prosthesis during mastication and function.18, 19, 20 The distribution of force derived from the metal framework and obturator bulb emulates the stable base that the native maxilla can provide for function. The engagement of structures within the defect diminishes the counterproductive lever forces placed on the obturator; contributes to the support, stability, and retention of

Proposed classification system

Defect classification systems enable surgeons and prosthodontists to use the characteristics of a particular defect to establish a functional prognosis. Since the publication of Ohngren's classification system for maxillectomy defects in 1933,³³ a number of oncologically oriented classification schemes have served to describe the anatomic boundaries of the maxillectomy defect.34, 35, 36 Few classification systems, however, address the issues specifically related to reconstruction of the

Discussion

The palatomaxillary classification system presented here was based on clinical experience at Mount Sinai Medical Center, which was used to establish an algorithm for functional reconstruction, midface restoration, and orodental rehabilitation (Fig. 14).

. Algorithm for palatomaxillary reconstruction.

This system may provide a methodology to enroll larger patient numbers from multiple institutions to study various methods of rehabilitation.

The defect-oriented approach of the proposed system is

Summary

The classification system presented in this article may facilitate further study of the surgical reconstruction and prosthodontic rehabilitation of maxillectomy defects. Although the system does not address all factors related to the restorative decision-making process, it is intended as a guide and algorithm for reconstruction of the palatomaxillary defect.

Supplementary Files

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Cited by (288)

Clinical value of reconstruction with a soft tissue graft versus reconstruction with an obturator alone after partial maxillectomy: A systematic review
2024, Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology
The aim of this systematic review (SR) was to verify whether soft tissue graft reconstruction or prosthetic obturator reconstruction alone is more useful for defects after partial maxillectomy.
We searched the MEDLINE, Cochrane CENTRAL, and Ichushi-Web databases to identify CPGs, SRs, randomized controlled trials (RCTs), and prospective and retrospective nonrandomized clinical (observational) studies according to preestablished criteria. We performed a statistical analysis using the Review Manager 5.4 software program and assessed the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach.
One RCT, which included 60 subjects, was eligible. The analysis showed that the oral function and quality of life assessments favored graft reconstruction in seven outcomes (chewing, swallowing, speech, pain, taste, mood, and anxiety) and in favor of obturators in one (appearance). The assessment of treatment complications was not reported in the articles and could not be estimated. The risk of bias is serious because the assessment of the oral function and quality of life was judged by a subjective assessment, and the certainty of evidence was "low" for both the oral function and quality of life due to the small total sample size.
We could not determine the superiority of reconstruction with soft tissue grafts versus obturators after partial maxillectomy because of the small number of studies and high risk of bias. Future multicenter data collection using measures that are as objective and universal as possible is desirable to better clarify the indications for graft reconstruction.
Soft Tissue Reconstruction of the Maxilla
2024, Atlas of the Oral and Maxillofacial Surgery Clinics of North America
History of Maxillary Reconstruction
2024, Atlas of the Oral and Maxillofacial Surgery Clinics of North America
Classification of the Midface Defect: A Defect-Oriented Approach to Reconstruction
2024, Atlas of the Oral and Maxillofacial Surgery Clinics of North America
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
2024, Journal of Prosthetic Dentistry
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.
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.
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.
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.
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.
Reconstructive Surgery
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^☆: ^aAssistant Professor, Departments of Dentistry and Otolaryngology-Head and Neck Surgery.

^☆☆: ^bAssociate Professor, Department of Otolaryngology—Head and Neck Surgery.

^★: ^cProfessor and Chair, Department of Oral and Maxillofacial Surgery.

^★★: ^dProfessor and Chair, Department of Otolaryngology—Head and Neck Surgery.

^♢: Reprint requests to: Dr Devin Okay, Department of Otolaryngology—Head and Neck Surgery, The Mount Sinai Medical Center, Oral and Maxillofacial Associates, Box 1191, 5 East 98th St, 8th floor, New York, NY 10029, Fax: (212)427-4088, E-mail: [email protected]

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Prosthodontic guidelines for surgical reconstruction of the maxilla: A classification system of defects☆,☆☆,★,★★,♢

Abstract

Section snippets

Functional anatomy for surgical reconstruction

Prosthetic prognosis and surgical reconstruction

Proposed classification system

Discussion

Summary

Supplementary Files

J Prosthet Dent

J Prosthet Dent

J Prosthet Dent

J Prosthet Dent

J Prosthet Dent

J Prosthet Dent

J Prosthet Dent

J Prosthet Dent

J Prosthet Dent

J Prosthet Dent

J Prosthet Dent

J Prosthet Dent

J Prosthet Dent

Otolaryngol Clin North Am

Int J Oral Surg

Br J Plast Surg

Maxillofacial rehabilitation: prosthodontic and surgical considerations

Free-tissue transfer reconstruction of midfacial and cranio-orbito-facial defects

Arch Otolaryngol Head Neck Surg