Reconstruction of the maxilla with loss of the orbital floor and orbital preservation: a case for the iliac crest with internal oblique

Abstract

Although many techniques have been described to reconstruct the midface and the maxilla, there remains little agreement on the most effective methods when the orbit itself is preserved but there is loss of the maxilla, orbital floor, and often the medial wall. If the principle of replacing form and function is to be preserved, then a complex three-dimensional bony shape is required, which can support the orbital floor and provide a functioning dentition through an implant-retained prosthesis. At the same time, the oral fistula must be closed and a nasal lining provided. The iliac crest with internal oblique provides a bone structure that can be shaped for the defect and can easily articulate with the malar remnant, the nasal bones, and the upper alveolus. The internal oblique muscle effectively closes the oral fistula and lines the nasal cavity and becomes epithelialized resulting in a natural appearance. This article describes the principles of use of the iliac crest with internal oblique in the reconstruction of this defect and compares this technique with the many other methods reported in the literature. The article is mainly descriptive as there are few comparative studies comparing reconstructive techniques for a similar defect.

Keywords: Maxilla; iliac crest; reconstruction.

Figure 1

Classification of the maxillectomy defect.

Figure 2

Natural healing of the muscle to replace the alveolar and palatal mucoperiosteum. (A) Implant-retained bar appliance for the retention of a partial denture after maxillectomy and reconstruction with iliac crest and internal oblique. (B) Denture in place.

Figure 3

Fashioned iliac crest graft to articulate with the nasal bones, zygomatic buttress, and alveolus.

Figure 4

Class 3b defect reconstructed with iliac crest and internal oblique. (A) Iliac crest graft in place with separate bone from the iliac crest to articulate with the nasal bones and form the orbital floor. (B) Eighteen months postoperative facial view demonstrates good support of the orbit and facial tissues. (C) Orthopantomogram shows the extent of the reconstructed maxilla.

Figure 5

Case report of a patient with recurrent myoepithelioma requiring a class 3b maxillectomy. (A) Facial view prior to reconstructive surgery with an extensive recurrence on the right side. (B) Lateral view to show the extent of the facial collapse. (C) A further view to show the nasal collapse. (D) Computed tomography (CT) scan to show the extent of the recurrent tumor on the right side. (E) Intraoperative view to show the reconstruction of the right side of the maxilla and support of the orbital floor. (F) Further intraoperative view showing the nasal piriforms carved out of the iliac crest. (G) Postoperative facial view showing good support of the orbit. A temporary tarsorrhaphy was required in the early postoperative period. (H) Postoperative lateral profile. (I) Reconstructed CT scan during the planning for implants, which could not be performed due to further recurrent disease. As a result, no longer-term photographs are of value as the recurrence involved the right orbit.