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Multiplanar and combined distraction osteogenesis for three-dimensional and functional reconstruction of unilateral large maxillary defects
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British Journal of Oral and Maxillofacial Surgery 47 (2009) 106–110
Multiplanar and combined distraction osteogenesis for three-dimensional and functional reconstruction of unilateral large maxillary defects Xue-Gang Niu a , Yi-Min Zhao b,∗,1 , Xiao-Xian Han a a b
Department of Stomatology, 252nd Hospital of Chinese PLA, Bao-ding 071000, He-bei Province, PR China Stomatological College, Fourth Military Medical University of Chinese PLA, Xi-an 710032, Shan-xi Province, PR China
Accepted 8 July 2008 Available online 29 August 2008
Abstract We have developed a new way of three-dimensional and functional reconstruction of unilateral large maxillary defects by multiplanar and combined distraction osteogenesis of the zygoma, maxillary alveolar process, and hard palate. In the first procedure we started the internal curvilinear distraction osteogenesis of the left zygoma in one patient who had had a left maxillectomy to rebuild midfacial bony support. In the second procedure, the internal curvilinear distraction osteogenesis of the maxillary anterior alveolar process and straight distraction osteogenesis of the right hard palate were used to restore the posterior alveolar process and left palate. In the third procedure, the distracted zygoma and alveolar process were connected by a small local bone graft. The important lost maxillary bony architecture was re-established three-dimensionally and resulted in a natural facial appearance, normal speech and swallowing, and good foundation for chewing. This may be the first example of three-dimensional and functional reconstruction of unilateral large maxillary defects that did not require bone grafts from other anatomical areas. © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Distraction osteogenesis; Zygoma; Alveolar process; Palate; Maxillary defect; Curvilinear distraction
Introduction
Material, patients, and methods
Maxillary defects that result from resection of tumours or congenital abnormalities are common, and can create serious cosmetic and functional handicaps. We describe a new method for the three-dimensional and functional reconstruction of unilateral large maxillary defects (Fig. 1) by distraction osteogenesis of the zygoma, maxillary alveolar process, and hard palate.
The semiburied curvilinear distractor, which is assembled from three parts: a curvilinear vector 40 mm long, 5.5 mm wide, and 5.7 mm high; a movable part that is 4 mm long, 7 mm wide, and 7 mm high; and a flexible central thread bar that is fixed at the centre of the curvilinear vector. The first two parts, which are made of medical grade titanium, have integrated fixation plates to fix them to the bone. The flexible central thread bar is made from nickel titanium wire. The distraction activator is hexagonal with a matching screwdriver. A 360◦ counter-clockwise rotation of the activator gives advancement of 0.35 mm for the movable part, and the maximum distraction length allowed by the distractor is 30 mm (Figs. 2, 3). The common semiburied straight distractor is 28 mm long, and the maximum distraction length is 15 mm.
∗
Corresponding author. Tel.: +86 13 72975585. E-mail addresses: [email protected], [email protected] (Y.-M. Zhao). 1 The work should be attributed to Yi-Min Zhao (phD), Department of Prosthodontics, College of Stomatology, Fourth Military Medical University, Xi’an 710032, Shan-xi Province, PR China.
0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.07.183
X.-G. Niu et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 106–110
107
Case report
Fig. 2. After maxillectomy the zygoma was divided and the semiburied curvilinear distractor fixed.
A 53-year-old man with ameloblastic fibroma that had occupied most of the left maxilla (Fig. 1) had a left maxillectomy followed by three operations for reconstruction. Under general anaesthesia, the first procedure began with a Weber’s incision. The whole left maxilla except the anterior alveolar bone was resected, which resulted in a large maxillary defect. The osteotomy on the zygoma was then made distal to the defect with an oscillating saw and osteotome to create the variable transport disc, which was 15 mm long, and the vector of the semiburied curvilinear distractor was fixed to the residual zygoma on the opposite side of the osteotomy. The transport disc was fixed to the movable part of the distraction device (Fig. 2). After irrigation with normal saline, the wound was closed in layers with the distraction activator passing percutaneously in the temporal region. After a latency period of 7 days, the distraction was started at 1.05 mm/day (0.35 mm three times a day) for 22 consecutive days. After 3 months of consolidation, the next step was started. In the second procedure through the original Weber’s incision the zygomatic distractor was removed, the variable transport disc on the remaining left maxillary alveolar bone (15 mm long) was created by a vertical osteotomy between the central and lateral incisor, and a horizontal one above the roots of the lateral incisor and canine. The semiburied curvilinear distractor was then fixed (Fig. 3). The posterior palatal mucoperiosteum was then reflected so that the osteotomy could be made in the right hard palate. After separation of the nasal septum, a variable transport disc 15 mm long, and 20 mm wide was made on the posterior part of the right hard palate (Fig. 4) and the semiburied straight distractor was fixed. After a latency period of 7 days, distraction was started at 1.05 mm/day (0.35 mm three times a day) for the alveolar
Fig. 3. The bone was cut between the central and lateral incisor to make the variable transport disc, and then the distractor was fixed.
Fig. 4. Diagram showing the variable transport disc made on the posterior part of the right hard palate for the reconstruction of the left hard palate.
Fig. 1. The axial computed tomographic view of a large tumour in the left maxilla.
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X.-G. Niu et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 106–110
Fig. 5. The three-dimensional computed tomographic view of the bony defects before distraction of the zygoma.
process and 0.8 mm/day (0.4 mm twice a day) for the right hard palate. Both continued for 19 consecutive days. Three months later, the third operation was done to remove the distractors and extract the loose lateral incisor. Transport discs of the zygoma and alveolar process were close but did not meet because of interposed connective tissue. A connection was therefore made with one piece of 3.5 mm bone harvested from the neighbouring part of the zygoma and plugged between them. Oronasal communication was closed by the attachment of the lengthened mucoperiosteum to the buccal mucosa. Three-dimensional computed tomograms and panoramic films were taken to study the results of the treatment.
Fig. 6. After three months of consolidation the newly-formed bone was evident in the distraction gap (arrow).
Results During the first procedure the three-dimensional computed tomographic view showed that before distraction, almost all the left maxilla except the anterior alveolar bone had been lost and the distractor of the zygoma was well fixed (Fig. 5). At the end of distraction, the bony transport disc was distracted about 20 mm along the curvilinear vector to the low position of maxilla with a radiolucent distraction gap. At 3 months, the newly-formed bone was evident in the distraction gap (Fig. 6), so part of the left maxilla had been reconstructed and the bony support had been set up. During the second procedure, before distraction, the posterior alveolar process of the left maxilla and the left hard palate were still missing and the distractors were well fixed (Fig. 7). After distraction, the bony transport disc of the maxillary anterior alveolar process was distracted about 18 mm along the curvilinear vector to approach the distracted bony transport disc of the zygoma; the bony transport disc of the right hard palate was distracted about 15 mm to the left (Fig. 8). At 3 months, after removal of the distractors, there was good new bone in both distraction gaps, the left maxillary alveolar process had been rebuilt, and connected to the zygoma by a small piece of bone. The framework of the hard palate had also been reconstructed. After a further 3 months the regenerated bone in the three regions was more uniform
Fig. 7. The three-dimensional computed tomographic view of the condition of the bone of the right hard palate before distraction.
Fig. 8. After distraction, the transport disc of the right hard palate was distracted about 15 mm to the left, and the distraction gap was radiolucent (arrow).
X.-G. Niu et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 106–110
Fig. 9. The panoramic view of the bony density in the distraction gap between the zygoma and the maxillary alveolar process, almost the same as that of normal bone. The maxillary alveolar process and zygoma were connected (arrows).
Fig. 10. . Postoperative oral view of the reconstruction of the palate.
and mature; the maxillary alveolar process and the zygoma had integrated completely (Fig. 9). In general, the postoperative view was almost identical to the preoperative view except for the surgical scar. The oral view showed that the integrity of the palate had been restored and the oronasal communication had been closed (Fig. 10).
Discussion The maxilla is the functional and aesthetic keystone of the midface. However, the functional reconstruction of large maxillary defects is a challenge. It is important for the prosthesis to have bony support bilaterally.1,2 However, there is often only a limited amount of bone remaining on the defective side. If bony support is lacking, the prosthesis is liable to sink and turn over during chewing, so it is better to reconstruct the lost maxilla as far as possible and rebuild the bony support on the defective side. Techniques that incorporate
109
grafts, flaps, alloplastic materials, and titanium mesh have been used for reconstruction.3–5 Some promising results have been obtained, but their use results in considerable morbidity, and the costs are high. In the case of large maxillary defects, it is difficult for the transplant to get adequate fixation from the remaining bone after a high, radical maxillectomy.5 In recent years, distraction osteogenesis has been shown to be effective in the treatment of maxillofacial defects.6,7 Our idea was to restore the midfacial contour and give bony support on the defective side, first by distraction osteogenesis of the zygoma. The zygoma and maxilla are in the midface and are connected in a curvilinear manner, so the internal curvilinear distraction osteogenesis of the zygoma should be used to reconstruct as much of the lost maxilla as possible, and avoid facial deformity. We have developed a semiburied curvilinear distraction device to fit the zygomaticomaxillary complex8 and the unilateral maxillary alveolar arch. Every part of the distractor is made from titanium alloy, and it is small and light enough to be implanted subcutaneously with only the distraction activator exposed. The central bar is made from nickel titanium alloy, which is extremely elastic, flexible, and strong. By revolving the flexible central bar, the movable part can advance along the curvilinear vector, and then the curvilinear distraction can be accomplished. Curvilinear distraction osteogenesis of the zygoma was completed smoothly with bony support set up low down in the maxilla, so that the composite fibula flap could be used to rebuild the maxillary alveolar process and close the oronasal communication. However, because of the high risk of trauma, the curvilinear distraction osteogenesis of the maxillary anterior alveolar process and straight distraction osteogenesis of the right hard palate was preferred. The left maxillary alveolar arch was reconstructed and was connected by a small piece of bone with the distracted zygoma in the area of the first molar, with the result that the zygomaticomaxillary pillar was rebuilt; this is important for the transmission of occlusal force. A good foundation for mastication was therefore set up and the implant-supported prosthesis may be fabricated in a later procedure. Using the latter, with the bony extension, the mucoperiosteum was also lengthened, and could be sutured to the buccal mucosa without tension for the rehabilitation of the palate and separation of the oral and nasal cavities. The problems of dyslalia and regurgitation before the obturation of the defect were therefore solved. However, there are still some problems. In the present case, three operations over a long period were required; in later cases distraction osteogenesis in the three regions after maxillectomy might be done at the same operation, so only two operations would be needed and duration of treatment could be reduced greatly. However, the high cost of distractors was a problem, which might be solved by outside financial assistance. Overall, the hard work of reconstruction of a unilateral large maxillary defect could be accomplished by multiplanar and combined distraction osteogenesis of the zygoma, maxillary alveolar process, and hard palate. The lost important
110
X.-G. Niu et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 106–110
bony architecture of the maxilla was three-dimensionally reestablished resulting in a natural facial appearance, normal speech and swallowing, and the ability to chew. It is probably the first example of three-dimensional and functional reconstruction of a large unilateral maxillary defect without bone grafts from other anatomical areas.
References 1. Landes CA. Zygoma implant-supported midfacial prosthetic rehabilitation: a 4-year follow-up study including assessment of quality of life. Clin Oral Implants Res 2005;16:313–25. 2. Sharma AB, Beumer III J. Reconstruction of maxillary defects: the case for prosthetic rehabilitation. J Oral Maxillofac Surg 2005;63:1770–3.
3. Muzaffar AR, Adams Jr WP, Hartog JM, Rohrich RJ, Byrd HS. Maxillary reconstruction: functional and aesthetic consideration. Plast Reconstr Surg 1999;104:2172–83. 4. Tideman H, Samman N, Cheung LK. Immediate reconstruction following maxillectomy: a new method. Int J Oral Maxillofac Surg 1993;22: 221–5. 5. Peng X, Mao C, Yu GY, et al. Maxillary reconstruction with the free fibula flap. Plast Reconstr Surg 2005;115:1562–9. 6. Rubio-Bueno P, Naval L, Rodriguez-Campo F, Gil-Diaz JL, DiazGonzales FJ. Internal distraction osteogenesis with a unidirectional device for reconstruction of mandibular segmental defects. J Oral Maxillofac Surg 2005;63:598–608. 7. Cheung LK, Zhang Q, Zhang ZG, Wong MC. Reconstruction of maxillectomy defect by transport distraction osteogenesis. Int J Oral Maxillofac Surg 2003;32:515–22. 8. Niu XG, Han XX. Evaluation of a new semiburied curvilinear distraction device in dogs. Br J Oral Maxillofac Surg 2008;46:61–3.
British Journal of Oral and Maxillofacial Surgery 47 (2009) 106–110
Multiplanar and combined distraction osteogenesis for three-dimensional and functional reconstruction of unilateral large maxillary defects Xue-Gang Niu a , Yi-Min Zhao b,∗,1 , Xiao-Xian Han a a b
Department of Stomatology, 252nd Hospital of Chinese PLA, Bao-ding 071000, He-bei Province, PR China Stomatological College, Fourth Military Medical University of Chinese PLA, Xi-an 710032, Shan-xi Province, PR China
Accepted 8 July 2008 Available online 29 August 2008
Abstract We have developed a new way of three-dimensional and functional reconstruction of unilateral large maxillary defects by multiplanar and combined distraction osteogenesis of the zygoma, maxillary alveolar process, and hard palate. In the first procedure we started the internal curvilinear distraction osteogenesis of the left zygoma in one patient who had had a left maxillectomy to rebuild midfacial bony support. In the second procedure, the internal curvilinear distraction osteogenesis of the maxillary anterior alveolar process and straight distraction osteogenesis of the right hard palate were used to restore the posterior alveolar process and left palate. In the third procedure, the distracted zygoma and alveolar process were connected by a small local bone graft. The important lost maxillary bony architecture was re-established three-dimensionally and resulted in a natural facial appearance, normal speech and swallowing, and good foundation for chewing. This may be the first example of three-dimensional and functional reconstruction of unilateral large maxillary defects that did not require bone grafts from other anatomical areas. © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Distraction osteogenesis; Zygoma; Alveolar process; Palate; Maxillary defect; Curvilinear distraction
Introduction
Material, patients, and methods
Maxillary defects that result from resection of tumours or congenital abnormalities are common, and can create serious cosmetic and functional handicaps. We describe a new method for the three-dimensional and functional reconstruction of unilateral large maxillary defects (Fig. 1) by distraction osteogenesis of the zygoma, maxillary alveolar process, and hard palate.
The semiburied curvilinear distractor, which is assembled from three parts: a curvilinear vector 40 mm long, 5.5 mm wide, and 5.7 mm high; a movable part that is 4 mm long, 7 mm wide, and 7 mm high; and a flexible central thread bar that is fixed at the centre of the curvilinear vector. The first two parts, which are made of medical grade titanium, have integrated fixation plates to fix them to the bone. The flexible central thread bar is made from nickel titanium wire. The distraction activator is hexagonal with a matching screwdriver. A 360◦ counter-clockwise rotation of the activator gives advancement of 0.35 mm for the movable part, and the maximum distraction length allowed by the distractor is 30 mm (Figs. 2, 3). The common semiburied straight distractor is 28 mm long, and the maximum distraction length is 15 mm.
∗
Corresponding author. Tel.: +86 13 72975585. E-mail addresses: [email protected], [email protected] (Y.-M. Zhao). 1 The work should be attributed to Yi-Min Zhao (phD), Department of Prosthodontics, College of Stomatology, Fourth Military Medical University, Xi’an 710032, Shan-xi Province, PR China.
0266-4356/$ – see front matter © 2008 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2008.07.183
X.-G. Niu et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 106–110
107
Case report
Fig. 2. After maxillectomy the zygoma was divided and the semiburied curvilinear distractor fixed.
A 53-year-old man with ameloblastic fibroma that had occupied most of the left maxilla (Fig. 1) had a left maxillectomy followed by three operations for reconstruction. Under general anaesthesia, the first procedure began with a Weber’s incision. The whole left maxilla except the anterior alveolar bone was resected, which resulted in a large maxillary defect. The osteotomy on the zygoma was then made distal to the defect with an oscillating saw and osteotome to create the variable transport disc, which was 15 mm long, and the vector of the semiburied curvilinear distractor was fixed to the residual zygoma on the opposite side of the osteotomy. The transport disc was fixed to the movable part of the distraction device (Fig. 2). After irrigation with normal saline, the wound was closed in layers with the distraction activator passing percutaneously in the temporal region. After a latency period of 7 days, the distraction was started at 1.05 mm/day (0.35 mm three times a day) for 22 consecutive days. After 3 months of consolidation, the next step was started. In the second procedure through the original Weber’s incision the zygomatic distractor was removed, the variable transport disc on the remaining left maxillary alveolar bone (15 mm long) was created by a vertical osteotomy between the central and lateral incisor, and a horizontal one above the roots of the lateral incisor and canine. The semiburied curvilinear distractor was then fixed (Fig. 3). The posterior palatal mucoperiosteum was then reflected so that the osteotomy could be made in the right hard palate. After separation of the nasal septum, a variable transport disc 15 mm long, and 20 mm wide was made on the posterior part of the right hard palate (Fig. 4) and the semiburied straight distractor was fixed. After a latency period of 7 days, distraction was started at 1.05 mm/day (0.35 mm three times a day) for the alveolar
Fig. 3. The bone was cut between the central and lateral incisor to make the variable transport disc, and then the distractor was fixed.
Fig. 4. Diagram showing the variable transport disc made on the posterior part of the right hard palate for the reconstruction of the left hard palate.
Fig. 1. The axial computed tomographic view of a large tumour in the left maxilla.
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X.-G. Niu et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 106–110
Fig. 5. The three-dimensional computed tomographic view of the bony defects before distraction of the zygoma.
process and 0.8 mm/day (0.4 mm twice a day) for the right hard palate. Both continued for 19 consecutive days. Three months later, the third operation was done to remove the distractors and extract the loose lateral incisor. Transport discs of the zygoma and alveolar process were close but did not meet because of interposed connective tissue. A connection was therefore made with one piece of 3.5 mm bone harvested from the neighbouring part of the zygoma and plugged between them. Oronasal communication was closed by the attachment of the lengthened mucoperiosteum to the buccal mucosa. Three-dimensional computed tomograms and panoramic films were taken to study the results of the treatment.
Fig. 6. After three months of consolidation the newly-formed bone was evident in the distraction gap (arrow).
Results During the first procedure the three-dimensional computed tomographic view showed that before distraction, almost all the left maxilla except the anterior alveolar bone had been lost and the distractor of the zygoma was well fixed (Fig. 5). At the end of distraction, the bony transport disc was distracted about 20 mm along the curvilinear vector to the low position of maxilla with a radiolucent distraction gap. At 3 months, the newly-formed bone was evident in the distraction gap (Fig. 6), so part of the left maxilla had been reconstructed and the bony support had been set up. During the second procedure, before distraction, the posterior alveolar process of the left maxilla and the left hard palate were still missing and the distractors were well fixed (Fig. 7). After distraction, the bony transport disc of the maxillary anterior alveolar process was distracted about 18 mm along the curvilinear vector to approach the distracted bony transport disc of the zygoma; the bony transport disc of the right hard palate was distracted about 15 mm to the left (Fig. 8). At 3 months, after removal of the distractors, there was good new bone in both distraction gaps, the left maxillary alveolar process had been rebuilt, and connected to the zygoma by a small piece of bone. The framework of the hard palate had also been reconstructed. After a further 3 months the regenerated bone in the three regions was more uniform
Fig. 7. The three-dimensional computed tomographic view of the condition of the bone of the right hard palate before distraction.
Fig. 8. After distraction, the transport disc of the right hard palate was distracted about 15 mm to the left, and the distraction gap was radiolucent (arrow).
X.-G. Niu et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 106–110
Fig. 9. The panoramic view of the bony density in the distraction gap between the zygoma and the maxillary alveolar process, almost the same as that of normal bone. The maxillary alveolar process and zygoma were connected (arrows).
Fig. 10. . Postoperative oral view of the reconstruction of the palate.
and mature; the maxillary alveolar process and the zygoma had integrated completely (Fig. 9). In general, the postoperative view was almost identical to the preoperative view except for the surgical scar. The oral view showed that the integrity of the palate had been restored and the oronasal communication had been closed (Fig. 10).
Discussion The maxilla is the functional and aesthetic keystone of the midface. However, the functional reconstruction of large maxillary defects is a challenge. It is important for the prosthesis to have bony support bilaterally.1,2 However, there is often only a limited amount of bone remaining on the defective side. If bony support is lacking, the prosthesis is liable to sink and turn over during chewing, so it is better to reconstruct the lost maxilla as far as possible and rebuild the bony support on the defective side. Techniques that incorporate
109
grafts, flaps, alloplastic materials, and titanium mesh have been used for reconstruction.3–5 Some promising results have been obtained, but their use results in considerable morbidity, and the costs are high. In the case of large maxillary defects, it is difficult for the transplant to get adequate fixation from the remaining bone after a high, radical maxillectomy.5 In recent years, distraction osteogenesis has been shown to be effective in the treatment of maxillofacial defects.6,7 Our idea was to restore the midfacial contour and give bony support on the defective side, first by distraction osteogenesis of the zygoma. The zygoma and maxilla are in the midface and are connected in a curvilinear manner, so the internal curvilinear distraction osteogenesis of the zygoma should be used to reconstruct as much of the lost maxilla as possible, and avoid facial deformity. We have developed a semiburied curvilinear distraction device to fit the zygomaticomaxillary complex8 and the unilateral maxillary alveolar arch. Every part of the distractor is made from titanium alloy, and it is small and light enough to be implanted subcutaneously with only the distraction activator exposed. The central bar is made from nickel titanium alloy, which is extremely elastic, flexible, and strong. By revolving the flexible central bar, the movable part can advance along the curvilinear vector, and then the curvilinear distraction can be accomplished. Curvilinear distraction osteogenesis of the zygoma was completed smoothly with bony support set up low down in the maxilla, so that the composite fibula flap could be used to rebuild the maxillary alveolar process and close the oronasal communication. However, because of the high risk of trauma, the curvilinear distraction osteogenesis of the maxillary anterior alveolar process and straight distraction osteogenesis of the right hard palate was preferred. The left maxillary alveolar arch was reconstructed and was connected by a small piece of bone with the distracted zygoma in the area of the first molar, with the result that the zygomaticomaxillary pillar was rebuilt; this is important for the transmission of occlusal force. A good foundation for mastication was therefore set up and the implant-supported prosthesis may be fabricated in a later procedure. Using the latter, with the bony extension, the mucoperiosteum was also lengthened, and could be sutured to the buccal mucosa without tension for the rehabilitation of the palate and separation of the oral and nasal cavities. The problems of dyslalia and regurgitation before the obturation of the defect were therefore solved. However, there are still some problems. In the present case, three operations over a long period were required; in later cases distraction osteogenesis in the three regions after maxillectomy might be done at the same operation, so only two operations would be needed and duration of treatment could be reduced greatly. However, the high cost of distractors was a problem, which might be solved by outside financial assistance. Overall, the hard work of reconstruction of a unilateral large maxillary defect could be accomplished by multiplanar and combined distraction osteogenesis of the zygoma, maxillary alveolar process, and hard palate. The lost important
110
X.-G. Niu et al. / British Journal of Oral and Maxillofacial Surgery 47 (2009) 106–110
bony architecture of the maxilla was three-dimensionally reestablished resulting in a natural facial appearance, normal speech and swallowing, and the ability to chew. It is probably the first example of three-dimensional and functional reconstruction of a large unilateral maxillary defect without bone grafts from other anatomical areas.
References 1. Landes CA. Zygoma implant-supported midfacial prosthetic rehabilitation: a 4-year follow-up study including assessment of quality of life. Clin Oral Implants Res 2005;16:313–25. 2. Sharma AB, Beumer III J. Reconstruction of maxillary defects: the case for prosthetic rehabilitation. J Oral Maxillofac Surg 2005;63:1770–3.
3. Muzaffar AR, Adams Jr WP, Hartog JM, Rohrich RJ, Byrd HS. Maxillary reconstruction: functional and aesthetic consideration. Plast Reconstr Surg 1999;104:2172–83. 4. Tideman H, Samman N, Cheung LK. Immediate reconstruction following maxillectomy: a new method. Int J Oral Maxillofac Surg 1993;22: 221–5. 5. Peng X, Mao C, Yu GY, et al. Maxillary reconstruction with the free fibula flap. Plast Reconstr Surg 2005;115:1562–9. 6. Rubio-Bueno P, Naval L, Rodriguez-Campo F, Gil-Diaz JL, DiazGonzales FJ. Internal distraction osteogenesis with a unidirectional device for reconstruction of mandibular segmental defects. J Oral Maxillofac Surg 2005;63:598–608. 7. Cheung LK, Zhang Q, Zhang ZG, Wong MC. Reconstruction of maxillectomy defect by transport distraction osteogenesis. Int J Oral Maxillofac Surg 2003;32:515–22. 8. Niu XG, Han XX. Evaluation of a new semiburied curvilinear distraction device in dogs. Br J Oral Maxillofac Surg 2008;46:61–3.