Authors of section

Authors

Brian Burkey, Neal Futran

Executive Editors

Gregorio Sánchez Aniceto, Marcelo Figari

General Editor

Daniel Buchbinder

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Obturator

1. Introduction

For patients who do not desire tissue reconstruction of this defect and have adequate remaining dentition, the palate can be sealed and the cheek can be supported by an obturator.

This reconstruction is made in collaboration with a maxillofacial prosthodontist and has the advantage of a shorter and less extensive surgery.

The patient has to be capable of inserting and removing the prosthesis and maintaining adequate hygiene of the maxillary cavity.

The inner aspect of the cheek is resurfaced with a skin graft to minimize soft tissue retraction and create a scar band that will help in the retention of the obturator.

Prior to surgery the patient needs maxillofacial prosthodontic consultation. Dental impressions of the maxilla and mandible are required. A surgical obturator is fabricated for use during the surgery. This can be made with teeth as a conventional denture or simply as a cover for the palatal defect.

Reconstruction of midface Brown III defect: Obturator

2. Approach

For this procedure the Weber Ferguson approach to the midface is utilized.

Reconstruction of midface Brown II defect

3. Resection

Incision of the palate

An incision is made along the midline of the palate, extending posteriorly and lateral to the maxillary tuberosity. This can be done with a surgical blade or a needle tip cautery.

Reconstruction of midface Brown III defect: Obturator

Osteotomies

A sagittal saw is used to make an osteotomy through hard palate and one to two teeth beyond the tumor margin, to the nasal floor. The nasal mucosa can either be preserved or excised depending on the involvement of the tumor. The nasal septum is typically able to be preserved.

Reconstruction of midface Brown III defect: Obturator

One tooth may be removed for easier access, but is usually not necessary.

Reconstruction of midface Brown III defect: Obturator

A malleable retractor is placed along the orbit to protect the globe.

The next osteotomy is made lateral to the nasal bone into the orbital floor.

Reconstruction of midface Brown III defect: Obturator

A malleable retractor is maintained along the orbit to protect the globe.

The osteotomy is then extended along the floor to the medial aspect of the zygoma.

Reconstruction of midface Brown III defect: Obturator

A sagittal saw is then used to osteotomize the zygomatico maxillary junction.

Reconstruction of midface Brown III defect: Obturator

Posteriorly a fine curved osteotome is used with the curvature pointing downwards to complete the cut, and to separate the posterior maxilla from the pterygoid plates.

Reconstruction of midface Brown III defect: Obturator

Pitfall: An upward oriented osteotome will not reliably separate the posterior maxilla and palate from the pterygoid. It is also associated with increased danger of bleeding from the pterygoid plexus and internal maxillary artery.

Reconstruction of midface Brown III defect: Obturator

Tumor delivery

The remaining soft tissues are incised with electrocautery and the tumor is delivered.

The specimen is submitted en bloc for permanent pathological examination.

Surgical margins are now checked with frozen sections to ensure the adequacy of the tumor resection.

Reconstruction of midface Brown III defect: Obturator

Preservation of lacrimal drainage

Because the lacrimal system is interrupted, the punctae are intubated with a silicon lacrimal tube and left in the nasal cavity for at least six weeks (Dacrocystorhynostomy).

Reconstruction of midface Brown III defect: Obturator

4. Reconstruction

Reconstruction of the orbital floor

The orbital floor can be reconstructed in the same fashion as in a trauma case.

When a mesh is used, it can be extended over the missing zygoma and face of the maxilla to improve facial contour.

Reconstruction of midface Brown III defect: Obturator

Skin grafting of inner cheek surface

The proposed graft donor site is chosen eg. thigh, and prepared and draped in a normal sterile fashion. The area of skin to be harvested is infiltrated with local anaesthetic containing epinephrine.

A dermatome is used to harvest the split thickness skin graft.

Hemostasis of the donor site is obtained and the wound is dressed with a temporary/removable nonadherent dressing.

Reconstruction of midface Brown II defect: Obturator

The skin graft is now placed onto the inner cheek surface, trimmed, and secured into place with a running locking absorbable suture eg. 4-0 chromic gut.

Reconstruction of midface Brown III defect: Obturator

Reconstruction of maxillary defect

The maxillary defect is filled with medicated gauze and the palatal obturator is placed. If there is sufficient remaining dentition the clasps of the obturator will hold the obturator in place.

Alternatively interproximal holes are drilled into the obturator and Circumdental wires can be used to secure the obturator to the remaining teeth.

Reconstruction of midface Brown III defect: Obturator

If not, 1.5 mm holes are drilled through the plate into the remaining palate and the obturator is temporarily fixated with two 2.0 mm screws.

Reconstruction of midface Brown II defect: Obturator

The obturator stays in place for 7-10 days and then the gauze packing is removed. The maxillofacial prosthodontist modifies the obturator to fill the maxillary defect.

A permanent obturator will eventually be fabricated as soon as the tissues are completely healed and any adjuvant treatment is completed.

Reconstruction of midface Brown II defect: Obturator

5. Rehabilitation following midface resection and reconstruction

Medication

The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative medications.

  • Analgesia as necessary
  • Antibiotics (many surgeons use perioperative antibiotics). There is no clear advantage of any one antibiotic but evidence supports their use for 24h. The spectrum should be according to the existing bacterial flora, especially in the combined intra and extra cranial procedures.
  • Steroids may help with postoperative edema.
  • Regular perioral and oral wound care has to include disinfectant mouth rinse, lip care, etc.
  • Antibiotic ointment is used on the wounds for 72 hours
  • If a free flap is utilized for the reconstruction, 100 mg of aspirin/day is recommended.

Wound care

Remove sutures from skin after approximately 7 days if nonresorbable sutures have been used. If the patient has had previous radiation, the sutures should be left in for 10 – 14 days.
Moisturizing lotion should be used on the skin wounds to minimize excessive scarring after sutures are removed.

Avoid sun exposure and tanning to skin incisions for several months.

Diet

Diet depends on the reconstructive method. For patients who have obturators placed, initial liquid diet followed by a soft diet as tolerated is initiated after surgery.

For patients with free flap reconstruction of the maxilla, a feeding tube is placed during sugery allowing the patient to be kept nil per os for 5-7 days. If issues develop with velopharyngeal insufficiency or dysphagia, assessment by a speech and swallowing rehabilitation specialist may be indicated. When the lateral nasal wall is reconstructed, especially when a bulky soft tissue flap is used, the nasal airway should be stented with gauze packing or a merocel sponge for five days.

Clinical follow-up

Typically the patients are seen in clinical follow-up one week after discharge, and then on a weekly basis until such time the clinician determines that less frequent follow ups are needed.

Oral hygiene

Patients with intraoral incisions and/or wounds must be instructed in appropriate oral hygiene procedures. A soft toothbrush (dipped in warm water to make it softer) should be used to clean the surfaces of the teeth. Chlorhexidine oral rinses should be prescribed and used at least 3 times a day to help sanitize the mouth. For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris.

Reconstruction with obturator

For individuals reconstructed with a maxillary prosthesis, the surgical packing is left for seven to ten days postoperatively. The patient will need to remain on appropriate gram positive antibiotic coverage over that time.

Upon returning to clinic, the patient is seen by the maxillofacial prosthodontist and the obturator and the packing are removed, the cavity is cleaned and inspected and the patient is then started on frequent nasal saline irrigations and home humidification. The obturator is modified as needed and replaced.

Over time, the maxillary prosthesis can be altered to best fit the evolving defect.

Reconstruction with free flap

When a free flap is utilized, it should be regularly monitored to ensure vascular integrity. Physical examination, assessing the flap color, turgidity, and capillary refill should be routine for at least the first 48 hours postoperatively. Hand-held Doppler probes can be used to assess blood flow. In case of doubt of the vitality of the flap, pin-prick assessment with a 25 gauge needle to look for bright red bleeding.. In cases of buried flaps, an implantable Doppler placed just distal to the venous anastomosis can be utilized

Radial forearm free flap
The radial forearm free flap donor site should be closed with a skin graft and a bolster placed over the area. The arm is then cast or placed in a volar splint for 7 days prior to removal to ensure graft take. If bone is taken and the radius plated, appropriate follow-up with an orthopedic or hand specialist should be arranged.

Fibula free flap
After a fibula free flap, the donor lower leg should be cast with the ankle slightly dorsiflexed for 5 days. The patient can touch-down their body weight as tolerated. After the cast is removed they can ambulate and work with physical therapy to optimize leg function. A splint should be placed to keep the foot flexed when in bed.

Scapula free flap
Flaps from the subscapular system require no particular rehabilitation care but closed suction drains should remain until a minimal output is still draining to avoid seroma formation.

Rectus abdominous and iliac crest
Rectus abdominous and iliac crest donor sites require that the patient not strain or lift heavy objects for at least 4 weeks to avoid hernia formation.

Anterolateral thigh
Patients should avoid climbing stairs for 2-4 weeks after surgery. They should also be observed for seroma formation at the wound bed.

Furthermore, patients often need physical therapy to rehabilitate the donor site.