Maxillectomy - Classification

Considerations

• • Anatomy

    • Two horizontal butresses

    • Three vertical butresses 

    • Hexahedron with six walls 

    • Roof = orbital support  

    • Floor - anterior hard palate 

    • Serves as the insertion of most muscles of facial expression and mastication 

  • History 

    • 1820s - The first total maxillectomy by have been performed by Dupuytren and Gensoul

    • 1841 - First recorded maxillectomy by Liston

    • 1933 - Extensive review authored by Ohngren 

  • Indications - Tumors or benign conditions involving or destroying the maxilla, specifically the 

    • Orbit

    • Nasal cavity 

    • Paranasal sinuses 

    • Palate

    • Oral mucosa

  • Implications - Major functional impact on  

    • Speech

    • Deglutition 

    • Orbital function

    • Cosmesis 

  • Reconstruction 

    • Know your defect

      • Volume

      • Surface area

      • Bone - orbital floor, anterior arch of the maxilla 

      • Soft tissue 

    • Assess critical structures

      • Eyelids, nasal airway, palate, oral commissure 

    • Time tested options 

      • Skin graft 

      • Cervicofacial flap

      • Pectoralis myocutaneous flap 

    • Local and regional flaps

      • Palatal mucoperichondrial island flap 

        • Up to 15 cm2 surface area 

        • Strong enough for through-and-through defects 

        • Can rotate 180 deg on its pedicle 

      • Buccal fat pad 

        • Rich vascular supply 

        • Best for defects up to 4 cm in diameter 

        • Can be used in combination with free bone grafts 

      • Submental island 

        • 7-15 cm in size 

        • Well hidden donor site scar 

      • Temporalis 

        • Good for orbital support

    • Free flaps

      • Needed for larger defects 

      • Provide like-for-like tissue matching 

        • Inner lining, bone, soft tissue bulk, skin 

      • Require 10-15 cm long vascular pedicle 

      • May be combined with free bone grafts 

      • Advantages 

        • Allows for dental restoration (osseointegrated implants) 

        • Freedom to orient, shape and inset flap as needed 

      • Disadvantages 

        • Longer surgical and recovery times 

        • Increased potential for complications 

        • Delay in diagnosis of local recurrence

      • Options

        • Radial forearm - large surface area with minimal bulk, may include bone, excellent for lining 

        • Fibula - excellent bone stalk 

        • Rectus abdominus - large surface area and volume, may be divided into 2-3 flaps, ideal of type III and IV defects 

        • Iliac crest - excellent bone stalk but short pedicle 

        • Scapula - soft tissue rotatability around bone 

        • Anterolateral thigh - large volume but short pedicle

    • Prosthesis - Obturation

      • Advantages 

        • Shorter operative time 

        • Shorter postop hospital stay 

        • Better visualization of maxillectomy cavity for surveillance 

      • Disadvantages 

        • Hypernasal speech 

        • Regurgitation of foods and liquids into nasal cavity 

        • Constant patient care and difficulty maintaining hygiene 

        • Need for repeated adjustments

Brown (2000) 

• • 2000: A modified classification for the maxillectomy defect aka "Liverpool classification" 

  • Class 1 - maxillectomy without an oro-antral fistula

  • Class 2 - low maxillectomy (not including orbital floor or contents)

  • Class 3 - high maxillectomy (involving orbital contents)

  • Class 4 - radical maxillectomy (includes orbital exenteration)

  • Classes 2 to 4 are qualified by adding the letter a, b, or c

    • The horizontal or palatal component is classified as follows

      • a - unilateral alveolar maxillectomy

      • b - bilateral alveolar maxillectomy

      • c - total alveolar maxillary resection

Santamaria and Codeiro (2000)

• 2000: A classification system and algorithm for reconstruction of maxillectomy and midfacial defects

  • Type I (Limited maxillectomy) 

    • One or two walls, preservation of palate 

  • Type II (Subtotal maxillectomy) 

    • Lower 5 walls, preservation of orbital floor 

  • Type III (Total maxillectomy) 

    • Resection of all six walls 

    • Orbital preservation (IIIa) vs exoneration (IIIb) 

  • Type IV (Orbito-maxillectomy)

    • Upper 5 walls, preservation of palate

Okay and Urken (2001)

• 2001: Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects

  • 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

High-Yield

Links

• 2011: Current Strategies in Reconstruction of Maxillectomy Defects

• 2013: A Study of Classification Systems for Maxillectomy Defects

• YouTube (8:32) - Total maxillectomy

• eMedicine - Maxillectomy