Classification of maxillectomy defects: A systematic review and criteria necessary for a universal description

Avinash S. Bidra, BDS, MS,a Rhonda F. Jacob, DDS, MS,b and Thomas D. Taylor, DDS, MSDc University of Connecticut Health Center, Farmington, Co nn; University of Texas, M.D. Anderson Cancer Center, Houston, Texas
Statement of problem. Maxillectomy defects are complex and involve a number of anatomic structures. Several maxillectomy defect classifications have been proposed with no universal acceptance among surgeons and prosthodontists. Established criteria for describing the maxillectomy defect are lacking. Purpose. This systematic review aimed to evaluate classification systems in the available literature, to provide a critical appraisal, and to identify the criteria necessary for a universal description of maxillectomy and midfacial defects. Material and methods. An electronic search of the English language literature between the periods of 1974 and June 2011 was performed by using PubMed, Scopus, and Cochrane databases with predetermined inclusion criteria. Key terms included in the search were maxillectomy classification, maxillary resection classification, maxillary removal classification, maxillary reconstruction classification, midfacial defect classification, and midfacial reconstruction classification. This was supplemented by a manual search of selected journals. After application of predetermined exclusion criteria, the final list of articles was reviewed in-depth to provide a critical appraisal and identify criteria for a universal description of a maxillectomy defect. Results. The electronic database search yielded 261 titles. Systematic application of inclusion and exclusion criteria resulted in identification of 14 maxillectomy and midfacial defect classification systems. From these articles, 6 different criteria were identified as necessary for a universal description of a maxillectomy defect. Multiple deficiencies were noted in each classification system. Though most articles described the superior-inferior extent of the defect, only a small number of articles described the anterior-posterior and medial-lateral extent of the defect. Few articles listed dental status and soft palate involvement when describing maxillectomy defects. Conclusions. No classification system has accurately described the maxillectomy defect, based on criteria that satisfy both surgical and prosthodontic needs. The 6 criteria identified in this systematic review for a universal description of a maxillectomy defect are: 1) dental status; 2) oroantral/nasal communication status; 3) soft palate and other contiguous structure involvement; 4) superior-inferior extent; 5) anterior-posterior extent; and 6) medial-lateral extent of the defect. A criteria-based description appears more objective and amenable for universal use than a classificationbased description. (J Prosthet Dent 2012;107:261-270)

Clinical Implications

Because of the complex nature and various permutations of the maxillectomy defect, the 6 criteria identified in this systematic review should be used to describe the maxillectomy defect instead of a classification system. Such a systematic method of describing the maxillectomy defect is paramount in diagnosis, treatment planning, communication, and the prospective comparison of treatment outcomes.
Assistant Professor, Department of Reconstructive Sciences, University of Connecticut Health Center. Professor, Department of Head and Neck Surgery, University of Texas, M.D. Anderson Cancer Center. c Professor, Department of Reconstructive Sciences, University of Connecticut Health Center.
a b

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Maxillectomy or maxillary resection is defined as surgical removal of a part or all of the maxilla.1 This definition is broad and does not describe the resection 3-dimensionally (3-D) or address the involvement of dental and other contiguous structures as a part of the resection. For better description and for communication purposes, several maxillectomy and midfacial defect classifications have been proposed with no consensus as to use.2-15 Maxillectomy classifications have been characterized either by the nature of the procedure performed4,9 or by resultant tissue loss.2,7,10,15 Classifications in the prosthodontic literature have grouped defects primarily from a prosthodontists perspective that is, after healing has occurred and the patient has outlived the opportunity for immediate surgical reconstruction of the defect.2,5,10 However, classifications reported in the ablative and reconstructive surgical disciplines have classified defects according to the surgical resection.3,4,6-9,11-15 Therefore, future prosthodontic considerations were not incorporated in surgically driven classifications. This reveals an obvious inconsistency between the 2 disciplines with respect to the criteria necessary for a universal description of a maxillectomy defect; furthermore, no single classification system has achieved universal acceptance.16,17 Because of the complex anatomy of each maxillectomy defect, it is necessary to describe the defect accurately for effective communication among clinicians and to derive an appropriate rehabilitative/reconstructive treatment plan. Accurate description of the maxillectomy defect and associated treatment can allow prediction and prospective comparison of treatment outcomes among various patient populations.18 Classification systems are a simple approach for describing and distinguishing defects but require clinicians to enumerate criteria defined in the classification system accurately. Clinicians also need to memorize the description of each class, which is particularly tedious when the system is numeric or alphanumeric (1, 2a, 2b) rather than descriptive (posterior, lateral). Moreover, universal acceptance of a particular system by all clinicians is needed. The presence of several classification systems in the literature demonstrates a lack of consensus and reveals the challenges involved in classifying both maxillectomy defects and the deficiencies of previous classification systems.13,16-18 Most of the classification systems in the literature are based on a retrospective cohort population of maxillectomy patients that presented to that practice or institution.13,16-18 Categories derived with this method may not be applicable to other maxillectomy populations because of referral or surgical bias. Moreover, defects that do not fit a set of criteria listed in a classification system risk being omitted or misclassified. Reporting of such data can confound information related to future treatment outcomes. The lack of a uniform classification system has limited the prospective comparison of treatment outcomes.18 Nevertheless, authors of classification systems in the literature have attempted to provide treatment algorithms based on defect category.6,7,9-11,13-15 However, it is not possible to develop a treatment algorithm for maxillectomy defects with a classification system alone. This is because surgical, prosthodontic, and patient factors vary for each individual and can dictate the choice of prosthetic versus surgical reconstruction.6,7,13,17 Because of disparate sizes and shapes of tumors affecting the maxilla and because of complex surgical anatomy, the broad category of maxillectomy represents a group of diverse defects ranging from a minor oroantral defect of the palate to a major defect bounded superiorly by the anterior skull base and inferiorly by the tongue.13 Given the fact that there is no universal acceptance of a maxillectomy defect classification system, perhaps another approach to standardizing defect descriptions is necessary. This could improve the ability to perform

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systematic reviews, meta-analysis, and randomized clinical trials on different reconstructive approaches.19 Therefore, the purpose of this article was to review current maxillectomy and midfacial defect classification systems, provide a critical appraisal, and identify criteria for a universal description of a maxillectomy or midfacial defect.

MATERIAL AND METHODS

An electronic search of the English language literature was conducted by using PubMed, Scopus, and the Cochrane Library databases. Specific search terms were maxillectomy classification, maxillary resection classification, maxillary removal classification, maxillary reconstruction classification, midfacial defect classification, and midfacial reconstruction classification. The years searched were from 1974 to June 2011. The inclusion criteria were: 1) English language article in a peer-reviewed journal; and 2) any article on humans that included any of the search terms. The exclusion criteria were: 1) articles that did not pertain to maxillectomy or midfacial defect classification; 2) classifications repeated in other included articles; 3) classifications described in a textbook; and 4) articles that did not allow extraction of the required information. The search was conducted in 3 stages. At stage 1, a list of titles was obtained from the electronic databases and pertinent titles were selected based on predetermined inclusion criteria. At stage 2, the abstracts of all selected titles were screened and exclusion criteria applied before they were incorporated into the next stage of full text analysis. When in doubt, an abstract was incorporated into the subsequent stage of analysis. At stage 3, the full text of all included abstracts was analyzed. A manual search complemented this stage by including additional full text articles from citations that were reviewed in stage 3. The manual search was conducted for the following journals: Plastic and Reconstructive Surgery, Laryngoscope,

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Lancet Oncology, Archives of Facial Plastic Surgery, Head and Neck, and The Journal of Prosthetic Dentistry. Thereafter, exclusion criteria were applied, and a final list of articles describing maxillectomy and midfacial defect classifications was reviewed indepth to provide a critical appraisal and identify the criteria necessary for universal description of the maxillectomy defect. tion of exclusion criteria. Through a manual search, 6 articles6,8,11,13,20,21 were added, resulting in a total of 23 full text articles. Application of exclusion criteria led to the elimination of 9 articles,16-24 resulting in a total of 14 full text articles. Three classification systems were reported in the prosthodontic literature and 11 classification systems in the surgical literature. After further analysis of the 14 classification systems, the authors tabulated the various descriptive factors of each classification system that resulted in identification of 6 different criteria for description of a maxillectomy defect. Homogeneous descriptive factors from the various classification systems were grouped using standard 3-D descriptions (superior-inferior, anterior-posterior and medial-lateral), which is universally accepted and easy to remember. Three additional criteria were incorporated from heterogeneous descriptive factors, as they were unique and supplemented the description of the maxillectomy defect. The 6 criteria were: 1) dental status; 2) oroantral/nasal communication status; 3) contiguous structure involvement; 4) superior-inferior extent; 5) anterior-posterior extent; and 6) medial-lateral extent of the defect (Table I). Multiple deficiencies were noted in each classification system, and none of them satisfied the 6 criteria that were collectively obtained (Table II). The descriptions of cat-

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RESULTS
The electronic search from the 3 databases yielded a total of 261 titles. Of these, 28 titles were relevant to the study, which resulted in a total of 17 full-text articles after applica-

Table I. Six different criteria (acronymous as DOC-SAM) and their corollaries that are necessary for universal description of maxillectomy defect
Criterion
1. Dental status 2. Oro antral/nasal communication status 3. Contiguous structure involvement 4. Superior-Inferior extent 5. Anterior-Posterior extent 6. Medial-Lateral extent

Outcome
Teeth absent or present*- (right posterior, right anterior, left anterior, left posterior regions) Absent or present Soft palate, lip, cheek, nose, orbital contents, zygoma, pterygoid process or none Anterior base of skull level, orbital level, Nasal/sinus level, palatal level or alveolar level Right anterior, left anterior, right posterior or left posterior regions Isolated, unilateral, bilateral defect

*Anterior teeth include central incisors, lateral incisors, and canines. Posterior teeth include all premolars and molars.

Table II. Summary of criteria satisfaction for 14-maxillectomy defect classifications identified
Classification System (Year)
Aramany2 (1978) Wells et al (1995)
3

Dental Status

Oroantral/ Nasal Communication

Contiguous Structures Involvement

SuperiorAnteriorInferior Extent Posterior Extent

MedialLateral Extent

* ^

Spiro et al4 (1996) Umino et al5 (1998) Davison et al6 (1998) Brown et al7 (2000) Triana et al8 (2000) Cordeiro et al9 (2000) Okay et al10 (2001) Yamamoto et al11 (2004) Carrillo et al12 (2005) Futran et al13 (2006) Rodriguez et al14 (2007) Brown et al (2010)
15

* * * * * * * * *

*Soft palate involvement was not mentioned, but some other contiguous structures were mentioned. ^Except soft palate, no other contiguous structure involvement was mentioned.

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Table III. Summary of descriptions of 14 maxillectomy and midfacial defect classification systems identified in this systematic review
Authors
Aramany2 (1978)

Classification system
I- Defect is along the midline of maxilla with teeth maintained on one side II- Unilateral defect with anterior teeth retained on contra-lateral side III- Palatal defect occurring in central portion of hard palate IV- Defect crosses midline with few posterior teeth on other side in straight line V- Defect is bilateral and lies posterior to abutment teeth VI- Defect is bilateral and lies anterior to abutment teeth

Wells et al (1995)
3

I- Loss of midfacial skin only II- Partial maxillectomy with complete palate and orbital floor III- Partial maxillectomy with resection of portion of palate. Orbital floor and Lockwoods ligament are intact IV- Total maxillectomy with palatectomy with orbital support being intact V- Total maxillectomy with palatectomy with loss of orbital support

Spiro et al (1996)
4

I- Limited maxillectomy- removal of one wall of antrum II- Subtotal maxillectomy- removal of at least 2 walls including palate III- Total maxillectomy- complete resection of maxilla

Umino et al (1998)
5

I- Confined to hard palate a. no communication between oral and nasal cavities b. communication between oral and unilateral nasal cavity c. communication between oral and bilateral nasal cavities II- Confined to anterior of soft palate in addition to hard palate a. communication between oral and unilateral nasal cavity b. communication between oral and bilateral nasal cavities

Davison et al6 (1998) Brown et al (2000)

7

I- Complete maxillectomy II- Partial maxillectomy (supra-structure or infra-structure) VERTICAL I- No oroantral fistula II- Low maxillectomy (at level of sinuses and nasal cavity but not involving orbital floor and contents III- High maxillectomy (involving orbital contents with globe preservation) IV- Radical maxillectomy (includes orbital exenteration with or without resection of anterior skull base) HORIZONTAL I- Unilateral alveolar and palatal resection less than or equal to half II- Bilateral alveolar and palatal resection III- Total alveolar and palatal resection

Triana et al (2000)
8

I- Inferior or partial maxillectomy, including defects of the hemipalate and anterior arch II- Inferior or partial maxillectomy with subtotal or total palate defects III- Total maxillectomy with and without orbital exenteration

Cordeiro et al (2000)
9

I- Limited (1 or 2 walls of the maxilla, excluding the palate) II- Sub-total (resection of the maxillary arch, palate, anterior and lateral walls with preservation of orbital floor) IIIa- Total (resection of all 6 walls of the maxilla with preservation of orbital contents IIIb- Total (resection of all 6 walls of the maxilla with orbital exenteration) IV- Orbito-maxillectomy (resection of the orbital contents and upper 5 walls of the maxilla, with preservation of the palate)

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Table III. continued Summary of descriptions of 14 maxillectomy and midfacial defect classification systems identified in this systematic review
Authors
Okay et al10 (2001)

Classification system
Ia- Defects of any portion of hard palate excluding tooth bearing maxillary alveolus Ib- Defects of premaxilla or any portion of alveolus or dentition posterior to canines II- Defects include any portion of hard palate, alveolus and only one canine tooth. Also includes transverse palatectomy involving less than 50% of hard palate III- Defects include resection of any portion of hard palate, alveolus and both canine teeth. Also includes transverse palatectomy involving greater than 50% of the hard palate IV- Subclasses f and z denote involvement of orbital floor and any portion of zygoma respectively.

Yamamoto et al (2004)
11

I- Limited and sub-total maxillectomy (pterygo-maxillary butress and partial naso-maxillary buttress are ablated) II- Orbito-maxillectomy and orbitozygomatic maxillectomy (zygomatic-maxillary buttress and partial naso-maxillary buttress are ablated) III- Total maxillectomy and extended to total maxillectomy defects (all 3 buttresses are ablated)

Carrillo et al (2005)
12

I- Total maxillectomy (resection of 5 walls of the maxillary antrum trying to preserve as much as possible of floor of orbit) IIa- Subtotal superior maxillectomy (resection of 4 walls of antrum with preservation of palate) IIb- Subtotal inferior maxillectomy (resection of 4 walls of antrum preserving floor of orbit) III- Medial maxillectomy (resection of medial wall of antrum with varying extensions of floor of orbit as well as ethmoid cells; may be combined with resection of palate)

Futran et al (2006)
13

I- Palatal defects (Small defects involving alveolar ridge, teeth, and surrounding mucosa with adequate dentition and no oroantral fistula) a. Inferior maxillectomy b. Total maxillectomy without orbital exenteration c. Total maxillectomy with orbital exenteration

Rodriguez et al (2007)
14

I- Unilateral dentoalveolar defect II- Missing inferior orbital rim in addition to ipsilateral maxilla III- Bilateral maxillary dentoalveolar loss IV- Bilateral maxillary dentoalveolar loss and at least one orbital rim

Brown et al (2010)
15

VERTICAL I- Maxillectomy not causing an oronasal fistula II- Maxillectomy not involving orbit III- Maxillectomy involving orbital adnexae with orbital retention IV- Maxillectomy with orbital enucleation or exenteration V- Orbitomaxillary defect VI- Nasomaxillary defect HORIZONTAL I- Palatal defect only, not involving dental alveolus II- Less than or equal to 1/2 unilateral III- Less than or equal to 1/2 bilateral or transverse anterior IV- Greater than 1/2 maxillectomy

egories in many classification systems were vague, lacked clarity between the categories, and did not elucidate a specific clinical depiction of the defect. Though most articles described

the extent of the defect in a superiorinferior dimension, few described the defect in anterior-posterior and medial-lateral dimensions. Only 3 articles listed dental status and only 2 articles

listed soft palate involvement as criteria for classifying defects. The qualitative data of the 14 classification systems are shown in Table III.

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DISCUSSION
Dental Status Dental status around a defect is an important criterion when describing a maxillectomy defect. This is because dentition is important for mastication, speech, esthetics, and the retention of future prostheses. Any surgical reconstructive option that prevents the dentition from being restored should generally be avoided.17 Only 3 out of 14 classification systems have described dental status as a criterion for describing the maxillectomy defect.2,10,14 Dental caries, periodontal condition, and number and positions of remaining teeth (right anterior, right posterior, left anterior, left posterior) be considered by surgeons and prosthodontists when contemplating surgical versus prosthodontic management of the defect. From a surgical perspective, the goal is not just reconstruction and rehabilitation of the palatomaxillary defect but rehabilitation of the entire dentomaxillary complex of the patient.18 The position and quality of the patients residual dentition and denture-bearing alveolar arch have also been reported to determine the type of osseous flap needed for surgical reconstruction.8 The success of dental implants in osseous flaps is well established and can provide retention and support for future dental prostheses.25-27 However, factors such as the patients age, motivation, mental status, systemic comorbidities, motivation, and manual dexterity can dictate surgical closure of the defect with an osseous microvascular free flap versus a soft tissue microvascular flap versus prosthodontic rehabilitation.6,8,13,17 From a prosthodontic perspective, the number, quality, and location of the remaining teeth can alter the biomechanics of an obturator prosthesis and, eventually, the success of prosthodontic rehabilitation.2,10 It is prosthodontic axiom that it is more difficult to retain a removable prosthesis when teeth are absent or when there are few remaining teeth, and an obturator prosthesis usually has the added anatomic loss of bony support.28 Inclusion of dental status as a criterion for the description of a maxillectomy defect can also aid in treatment planning for dental implants in the remnant maxilla. Therefore, for a fair comparison of prospective treatment outcomes among different patient populations, dental status should be included in the description of a maxillectomy defect. Oroantral/Nasal Communication The presence or absence of oroantral/nasal communication is an important criterion for planning reconstruction and or prosthodontic rehabilitation because it directly affects the basic functions of speech and deglutition.5,18 Treatment procedures are generally simpler and outcomes more favorable when there is absence of oroantral communication.18 All 14 classification systems identified in this systematic review discussed oroantral communication with respect to the maxillectomy defect. However, few articles in this review discussed the maxillectomy defect that does not involve an oroantral/nasal communication.5,9,15 There are 2 types of maxillectomy defects that do not involve oroantral/nasal communication. The first type results from a dentoalveolar resection or a partial palatectomy without including the nasal cavity or the maxillary sinus. The second type include superior resections, that create nasomaxillary and orbitomaxillary defects without including the palate and dentoalveolar structures.9,15 From a surgical perspective, dentoalveolar maxillectomies that do not include oroantral communication may be treated with onlay-type bony reconstructive procedures to provide a bony foundation for dental implants. Other defects may be treated with small local flaps or split thickness skin grafts.17 The primary goal of reconstructive surgery for defects that have oroantral communication is to

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establish permanent separation between oral and nasal cavities.8,13 Techniques for closing these communications vary from local flaps for small defects to microvascular free flaps for large defects.18 When an osseous microvascular flap is used, facial form and a foundation for dental implants are also achieved. From a prosthodontic perspective, defects with the absence of oroantral communication result in fewer issues of air and fluid leakage and simpler prosthodontic procedures, than defects with oroantral communication. Therefore, for an accurate representation of the maxillectomy defect, oroantral/nasal communication status should be included in the description of a maxillectomy defect. Contiguous Structure Involvement Experienced clinicians accept that no 2 maxillectomies are the same and variations in normal anatomy and tumor extension beyond the confines of the maxilla may necessitate resection of adjacent structures.4 Additionally, diversity in the site of origin and the histology and behavior of tumors treated by maxillectomy result in variations in the procedure.4 Depending upon the extent of the resection, contiguous structures that may be involved in the maxillectomy procedure are: soft palate, lips, nose, cheek and outer skin, orbital contents, zygoma, and pterygoid plates. No single classification system in the literature has addressed the involvement of all these contiguous structures. Only a few classification systems have described the involvement of the soft palate in describing maxillectomy defects.2,4,5,7 Involvement of the soft palate as a part of a maxillectomy can significantly affect treatment outcomes related to speech and deglutition.5,18 From a surgical point of view, the dynamic nature of the soft palate makes it a difficult structure to reconstruct. No reconstructive technique has been able to duplicate the function of the soft palate satisfactorily.18

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Failure of reconstruction is usually associated with velopharyngeal incompetence and its associated functional deficits relating to deglutition and speech.18 From a prosthodontic perspective, the obturator prosthesis may be bulkier and may have issues of retention and leakage, as it extends posteriorly to make functional contact with the posterior pharyngeal wall. Sometimes, the remaining band of soft palatal tissue may need to be surgically removed if it has inadequate velopharyngeal function due to fibrosis, tethering, and lack of motor function and if it physically impedes successful contact of the obturator prosthesis with the posterior pharyngeal wall.29,30 Depending upon the nature of the disease, the resection of lips, nose, cheek, and outer skin may be performed along with the maxillectomy. Few classification systems have addressed the involvement of these structures, which can affect the treatment outcomes of maxillectomies.4,7,9,13-15 From a surgical perspective, considerations include immediate reconstruction of lips, nose, cheek, and outer skin with local flaps, advancement flaps, or microvascular free flaps.4,7,9,13-15Additional considerations for nonreconstructed structures such as the nose may include placement of craniofacial implants for future prosthetic rehabilitation.31-33 From a prosthodontic perspective, the inclusion of this information can facilitate the identification of patients requiring intraoral and extraoral prostheses for structures not amenable to surgical reconstruction. Surgical procedures such as cheek advancement flaps are reported to cause microstomia, which can challenge prosthodontic procedures.34,35 In situations where intraoral and extraoral defects are continuous, the treatment teams must make a decision as to how the extraoral defect will be reconstructed and what its impact on the intraoral prosthetic rehabilitation will be. Combined extraoral and intraoral prostheses are often affected by food and liquid leakage from the oral cavity around the extraoral prosthesis margins, causing failure of the adhesive retention of the facial prosthesis. All of these factors can affect reconstructive and prosthetic decision-making and treatment outcomes; therefore, it is necessary to note the involvement of any of these contiguous structures along with a maxillectomy defect description. Most classification systems have addressed involvement of the orbit and its contents as a part of the maxillectomy procedure. It is necessary to clarify whether a maxillectomy involves an orbital exenteration or preservation of orbital contents.7,9,13,15 Some orbitomaxillary defects may involve resection of the orbital structures and a portion of the maxilla but spare the dentoalveolar and palatal components.9,15 From a surgical perspective, reconstruction after a maxillectomy with preservation of the orbital contents is technically more challenging than after a maxillectomy with orbital exenteration.24 Orbital exenteration can dictate that the surgeon establish a permanent separation between oral, nasal, and orbital cavities through free flap reconstruction.8,13,24 An extraoral flap and concurrent intraoral flap closure of the palate may be technically difficult and require more than 1 free flap. Therefore the prosthodontist should be involved in the presurgical planning to determine whether the residual palate will be adequate for prosthetic rehabilitation either by using existing dentition or dental implants in the remnant maxillary or facial bones. Often, the orbital flap requires recontouring to create a concave surface and placement of craniofacial implants to allow for optimal orbital prostheses. From a prosthodontic perspective, orbital defects that are continuous with the oral cavity are much more challenging as they require connection of the extraoral prosthesis with the intraoral prosthesis for retention purposes.36 Use of dental implants may ameliorate the situation, but prosthetic procedures are simplified if the oral cavity is permanently separated from the nasal and orbital cavities through surgical means. Therefore, for an accurate description and a fair comparison of treatment outcomes, this criterion should be included in a maxillectomy defect description. Involvement of the zygoma has been described as a criterion in few classification systems.4,8,10,11 Fortunately, loss of the zygoma concurrent with a maxillectomy is not a common maxillectomy defect. From a surgical standpoint, reconstruction of the zygoma dictates the use of osseous flaps to establish appropriate midfacial projection and restore facial esthetics. From a prosthodontic perspective, the loss of the zygoma in a large maxillectomy defect can prevent the use of zygomatic implants that can provide retention and support for prosthodontic restorations.37-39 However, due to the quantity and quality of the zygoma, any remnant bone can serve to retain zygomatic implants. Resection of the pterygoid plates is often required as a part of a posterior maxillectomy that includes the palate. Few articles have described this structure in their classification systems.4,11,12 Pterygoid plates rarely require surgical reconstruction, but from a prosthodontic perspective, the loss of pterygoid plates can prevent the clinician from using pterygoid implants to aid in prosthodontic rehabilitation.40 Superior-Inferior Extension Maxillectomy and midfacial defects can range from a minor oroantral fistula to a major defect bordered by the skull base superiorly and tongue inferiorly.13 Therefore, the superior and inferior extension of the defect with respect to the alveolar level, the palatal level, the nasal/sinus level, the orbital level, or the level of the anterior base of the skull should be described. All of the 11 classification systems from the surgical literature described superiorinferior extension of the maxillectomy defect. From a surgical perspective, the superior extent of the defect in-

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dicates the volume of the defect and thus dictates the choice of reconstructive surgical procedures and free flaps for closure of the defect.9,13,15,24 These can range from a small volume bone graft for alveolar defects to a small local flap or large osseomyocutaneous free flap.13,16,17 There is debate about the number and choice of osseous flaps needed to reconstruct large defects that preserve the orbit.9,15,19 Defects that extend to the anterior base of the skull may require additional surgical procedures to separate the maxillectomy defect from the brain.9,12,13,24 Furthermore, surgical reconstruction of orbitomaxillary defects that exclude the palate and dentoalveolar structures are relatively simple to treat and do not involve oral rehabilitation.15 From a prosthodontic perspective, adequate superior extension of the prosthesis is needed for stability and to minimize air and fluid leakage into the nasal cavity.28 However, over extension of a prosthesis into the infratemporal fossa may impinge on mandibular movement and dislodge the seal of a prosthesis.5 Furthermore, the height of the prosthesis should be limited to only what is necessary to create a peripheral seal as additional height adds to the weight of the prosthesis and challenges its retentive forces. When possible, large volume defects with little remaining palate and teeth should be surgically reconstructed for a better prosthodontic prognosis to assure the restoration of rudimentary speech and swallowing.10 However, osseous flaps are the ideal choice, as they facilitate the placement of dental implants and the fabrication of an implant-retained prosthesis for dentoalveolar rehabilitation. When bone is not used to reconstruct the palate and alveolar area, implants from the remaining maxilla or remote sites such as the zygoma and pterygoid plates may be used for better retention and support of the prosthesis. Extraoral prostheses are usually fabricated independently of the intraoral prosthesis by using defect undercuts and/or craniofacial implants. Anterior-Posterior Extension The anterior-posterior extent of a maxillectomy defect can be described in the horizontal and saggital planes as involvement of the right posterior, right anterior, left anterior, or left posterior regions of the maxilla. Only 6 classification systems in the literature have addressed this criterion.2,5,8-10,15 This criterion is important because treatment consequences can differ significantly between the anterior and posterior regions.2,10,28 The considerations for defects involving anterior regions are: poor lip support, scarring of the lip, mid-facial collapse, lip incompetency, drooping commissures, and collapse of the nose when the nasal septum or anterior nasal spine is resected. These anterior defects are difficult to reconstruct surgically and numerous flap designs have been used. From a functional and esthetic perspective, these defects, whether surgically reconstructed or not, often require special consideration when making an obturator prosthesis. Posterior defects do not generally result in esthetic issues, but planning for functional reconstruction or prosthetic rehabilitation may be altered if the soft palate has been resected, because functional surgical reconstruction of the soft palate is unpredictable.18 Description of the soft palate resection concurrent with the maxillectomy can assist in the discussion of the reconstruction/rehabilitation method. Therefore, subsequent prosthodontic treatment may be necessary for the rehabilitation of the velopharyngeal (VP) inadequacy. Care should be taken that a flap not be inset along a margin of the soft palate, as this will likely not alleviate VP inadequacy and can restrict the prosthetic access to the pharynx necessary to provide VP rehabilitation. From a prosthodontic perspective, if 3 out of 4 regions of the maxilla remain around the defect, the treatment outcomes are more favorable because of improved support and favorable biomechanics due to tripodiza-

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tion.2,10,28 Defects involving both right and left anterior regions are challenging to the prosthodontist because of issues of collapse and fibrosis of the middle-third facial envelope. Anterior teeth can offer lip support; however, the teeth cannot be positioned too far anterior to the margin of the defect because of potential ulceration, loss of stability, and dislodgement of the prosthesis.28 Severe facial collapse may require reverse articulation (cross bite) of the maxillary and mandibular teeth. Defects involving the posterior region may have prosthetic contours terminating in the pterygoid area or extend further to the posterior pharyngeal wall when the soft palate has been resected or has limited functional movement. This not only increases the weight of the prosthesis but also results in loss of retention and stability, which can cause leakage of air and fluids into the paranasal cavities. The presence of implants and the number of natural teeth in the remaining regions of the maxilla will significantly improve prosthesis retention and allow maximal prosthetic support of heavy facial tissues. It is important to note that the absence of teeth in various regions of the maxilla can be independent of the defect location because teeth may have been lost before the maxillectomy. Therefore, it is important to describe the criteria for remaining maxillary teeth independent of the volume of the maxilla resected when describing a maxillectomy defect. Medial-Lateral Extension The medial-lateral extent of a maxillectomy defect can be described in the horizontal and frontal planes as unilateral, bilateral, or isolated defects. All 3 classification systems in the prosthodontic literature2,5,10 and only a few articles in the surgical literature have addressed this criterion.7,14,15 Though the maxilla is 1 out of the 2 paired bones of the skull, maxillary resections may involve a part or whole of the contralateral

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bone because of variations in normal anatomy, biological characteristics of the tumor, and margin status of the defect.4 Therefore, unilateral defects are those involving only 1 maxilla and bilateral defects are those involving both maxillae. Isolated defects can be described as those that span 1 or both maxillae and are generally seen as a palatal defect that is not continuous with the dentoalveolar process.2,10 From a surgical perspective, if the defect size is smaller than 15 cm2, palatal island local flaps can be used to close isolated defects.41,42 The surgical reconstruction of unilateral defects may require less volume of donor tissue than for bilateral defects.15,16 Depending upon the patients desires, finances, and condition of the remaining teeth, defects can be reconstructed with soft tissue free flaps or osseous flaps followed by implant placement for prosthodontic rehabilitation. Additionally, zygomatic or pterygoid implants on the defect side can be used for future prosthodontic rehabilitation.43,44 From a prosthodontic perspective, unilateral defects are simpler to manage than bilateral defects because of the increased surface area for retention and support and the reduced volume of tissues to be replaced by the prosthesis.2,10,28 However, the presence of implants and the number and quality of remaining teeth are important prognostic factors to be considered. Previous authors have discussed biomechanical considerations for the prosthodontic rehabilitation of various unilateral and bilateral defects.2,10 Prosthodontic management of an isolated defect is simpler when sufficient teeth or implants exist for adequate retention and support of the prosthesis.2,10 It is important to note that if a maxillectomy defect crosses the midline and involves the loss of even a single tooth socket on the contralateral maxilla, these defects should be described as bilateral defects. This is because the biomechanics of the resultant defect is altered, which can affect prosthodontic treatment outcomes.2,10,28 Therefore, for a fair comparison of treatment outcomes, accurate description of medial-lateral extension of the defect is necessary. The 6 previously described criteria and their corollaries (acronymous as DOC-SAM) collectively and systematically represent the various descriptive factors that have been used in 14 different maxillectomy/mid-facial defect classification systems. When considered singularly, none of the 14 classification systems satisfy all 6 criteria and thus fail to accurately describe the maxillectomy defect. This may represent the reason for lack of universal acceptance of any of the 14 classification systems. Therefore, the authors suggest that future studies on maxillectomy defects should incorporate the 6 criteria identified in this systematic review. These criteria can provide an accurate description of the maxillectomy defect and allow a realistic comparison of the pretreatment and posttreatment outcomes of surgical reconstruction and/or prosthodontic rehabilitation of the maxillectomy defect.

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1. The glossary of prosthodontic terms. J Prosthet Dent 2005;94:51. 2. Aramany MA. Basic principles of obturator design for partially edentulous patients. Part I: Classification. J Prosthet Dent 1978;40:554-7. 3. Wells MD, Luce EA. Reconstruction of midfacial defects after surgical resection of malignancies. Clin Plast Surg 1995;22:79-89. 4. Spiro RH, Strong EW, Shah JP. Maxillectomy and its classification. Head Neck 1997;19:309-14. 5. Umino S, Masuda G, Ono S, Fujita K. Speech intelligibility following maxillectomy with and without a prosthesis: an analysis of 54 cases. J Oral Rehabil 1998;25:153-8. 6. Davison SP, Sherris DA, Meland NB. An algorithm for maxillectomy defect reconstruction. Laryngoscope 1998;108:215-9. 7. Brown JS, Rogers SN, McNally DN, Boyle M. A modified classification for the maxillectomy defect. Head Neck 2000;22:17-26. 8. Triana RJ, Uglesic V, Virag M, Varga SG, Knezevic P, Milenovic A, et al. Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects. Arch Facial Plast Surg 2000;2:91-101. 9. Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg2000;105:2331-46. 10.Okay DJ, Genden E, Buchbinder D, Urken M. Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent 2001;86:352-63. 11.Yamamoto Y, Kawashima K, Sugihara T, Nohira K, Furuta Y, Fukuda S. Surgical management of maxillectomy defects based on the concept of buttress reconstruction. Head Neck 2004;26:247-56. 12.Carrillo JF, Gemes A, Ramrez-Ortega MC, Oate-Ocaa LF. Prognostic factors in maxillary sinus and nasal cavity carcinoma. Eur J SurgOncol2005;31:1206-12. 13.Futran ND, Mendez E. Developments in reconstruction of the midface and maxilla. Lancet Oncol 2006;7:249-258. 14.Rodriguez ED, Martin M, Bluebond-Langner R, Khalifeh M, Singh N, Manson PN. Microsurgical reconstruction of posttraumatic high-energy maxillary defects: establishing the effectiveness of early reconstruction. Plast Reconstr Surg 2007;120(7 Suppl 2):103S-17S. 15.Brown JS, Shaw RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol2010;11:1001-8. 16.Dalgorf D, Higgins K. Reconstruction of the midface and maxilla. Curr Opin Otolaryngol Head Neck Surg 2008;16:303-11. 17.Shrime MG, Gilbert RW. Reconstruction of the midface and maxilla. Facial Plast Surg Clin North Am 2009;17:211-23. 18.van der Sloot PG. Hard and soft palate reconstruction.Curr Opin Otolaryngol Head Neck Surg. 2003;11:225-9. 19.OConnell DA, Futran ND. Reconstruction of the midface and maxilla. Curr Opin Otolaryngol Head Neck Surg 2010;18:304-10.

CONCLUSION
The presence of 14 different classification systems in this systematic review reveals the challenges involved in classifying maxillectomy defects and the deficiencies of previous classification systems. It is perhaps impossible to gain universal acceptance of a single classification system that satisfies surgical and prosthodontic requirements and that is easy to remember and use. Considering the complexities of maxillary anatomy and the various permutations of the maxillectomy defect, a criteria-based description of the maxillectomy defect described in this article, appears more objective and amenable to universal use than a classification-based description.

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20.Ohngren LG. Malignant tumors of the maxillo-ethmoidal region.ActaOtolaryngol (Suppl) 1933;19:1-476. 21.Foster RD, Anthony JP, Singer MI, Kaplan MJ, Pogrel MA, Mathes SJ. Microsurgical reconstruction of the midface. Arch Surg 1996;131:960-5. 22.Cordeiro PG, Disa JJ. Challenges in midface reconstruction. Semin Surg Oncol 2000;19:218-25. 23.Santamaria E, Cordeiro PG. Reconstruction of maxillectomy and midfacial defects with free tissue transfer. J Surg Oncol 2006;94:522-31. 24.McCarthy CM, Cordeiro PG. Microvascular reconstruction of oncologic defects of the midface. Plast Reconstr Surg 2010;126:1947-59. 25.Chiapasco M, Biglioli F, Autelitano L, Romeo E, Brusati R. Clinical outcome of dental implants placed in fibula-free flaps used for the reconstruction of maxillomandibular defects following ablation for tumors or osteoradionecrosis. Clin Oral Implants Res 2006;17:220-8. 26.Mcke T, Hlzle F, Loeffelbein DJ, Ljubic A, Kesting M, Wolff KD, et al. Maxillary reconstruction using microvascular free flaps. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:51-7. 27.Cuesta-Gil M, Ochandiano Caicoya S, Riba-Garca F, Duarte Ruiz B, Navarro Cullar C, Navarro Vila C. Oral rehabilitation with osseointegrated implants in oncologic patients. J Oral Maxillofac Surg 2009;67:2485-96. 28.Taylor TD, Thomas D, editors. Clinical Maxillofacial Prosthetics. Chicago: Quintessence; 2000, p.85-120. 29.Harrison RE. Prosthetic management of maxillectomy patient. Head Neck Surg 1979;2:366-9. 30.Jacobs JR, Marunick MT. Surgical considerations in maxillofacial prosthetic rehabilitation of maxillectomy patient. J SurgOncol 1988;37:29-32. 31.Jensen OT, Brownd C, Blacker J. Nasofacial prostheses supported by osseointegrated implants. Int J Oral Maxillofac Implants 1992:7:203-11. 32.Nishimura RD, Roumanas E, Moy PK, Sugai T. Nasal defects and osseointegrated implants: UCLA experience. J Prosthet Dent 1996;76:597-602. 33.Roumanas ED, Nishimura RD, Davis BK, Beumer J 3rd. Clinical evaluation of implants retaining edentulous maxillary obturator prostheses. J Prosthet Dent 1997;77:184-90. 34.Bidra AS, Montgomery P, Jacob RF. Maxillofacial rehabilitation of a microstomic patient afterresection of nose, lip and maxilla. J Oral Maxillofac Surg 2010;68:2513-19. 35.Langstein HN, Robb GL. Lip and perioral reconstruction. Clin Plast Surg 2005;32:431-45. 36.Gandhi NK, Bhatt NA. Obturator-orbital prosthesis. J Prosthet Dent 1980;44:336-7. 37.Schmidt BL, Pogrel MA, Young CW, Sharma A. Reconstruction of extensive maxillary defects using zygomaticus implants. J Oral Maxillofac Surg2004;62(9 Suppl 2):82-9. 38.Uckan S, Oguz Y, Uyar Y, Ozyesil A. Reconstruction of a total maxillectomy defect with a zygomatic implant-retained obturator. J Craniofac Surg 2005;16:485-9.

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39.Boyes-Varley JG, Howes DG, Davidge-Pitts KD, Branemark PI, McAlpine JA. A protocol for maxillary reconstruction following oncology resection using zygomatic implants. Int J Prosthodont 2007;20:521-31. 40.Bidra AS, Huynh-Ba G. Implants in the pterygoid region: a systematic review of the literature. Int J Oral Maxillofac Surg 2011;40:773-81. 41.Gullane PJ, Arena S. Palatal island flap for reconstruction of oral defects. Arch Otolaryngol 1977;103:598-9. 42.Moore BA, Magdy E, Netterville JL, Burkey BB. Palatal reconstruction with the palatal island flap. Laryngoscope 2003;113:946-51. 43.Kreissl ME, Heydecke G, Metzger MC, Schoen R. Zygoma implant-supported prosthetic rehabilitation after partial maxillectomy using surgical navigation: a clinical report. J Prosthet Dent 2007;97:121-8. 44.Bidra AS, May GW, Tharp GE, Chambers MS. Pterygoid implants for maxillofacial rehabilitation of a patient with a bilateral maxillectomy defect. J Oral Implantol 2011 Jan 13. [Epub ahead of print] Corresponding author: Dr Avinash S. Bidra University of Connecticut Health Center 263 Farmington Avenue, L6078 Farmington, Conn 06030 Fax: 860-679-1370 E-mail: avinashbidra@yahoo.com Copyright 2012 by the Editorial Council for The Journal of Prosthetic Dentistry.

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