Reconstruction of the maxilla following hemimaxillectomy defects with scapular tip grafts and dental implants

Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e6

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Reconstruction of the maxilla following hemimaxillectomy defects with scapular tip grafts and dental implants Christian Mertens*, Christian Freudlsperger, Jens Bodem, Michael Engel, Jürgen Hoffmann, Kolja Freier Department of Oral- and Cranio-Maxillofacial Surgery, Heidelberg University Hospital, Heidelberg, Germany

a r t i c l e i n f o

a b s t r a c t

Article history: Paper received 10 January 2016 Accepted 9 August 2016 Available online xxx

Background: Treatment of post-resective defects of the maxilla can be challenging and usually requires dental obturation or microvascular reconstruction. As compared to soft-tissue microvascular grafts, bone reconstruction can additionally allow for facial support and retention of dental implants. The aim of this study was to evaluate scapular tip grafts with respect to their applicability for maxillary reconstruction and their potential to retain dental implants for later dental rehabilitation. Materials and methods: In this retrospective study, 14 patients with hemimaxillectomy defects were reconstructed with free scapular tip grafts, oriented horizontally, to rebuild the palate and alveolar ridge. After bone healing, three-dimensional virtual implant planning was performed, and a radiographic guide was fabricated to enable implant placement in the optimal anatomic and prosthetic position. All patients' mastication and speech were evaluated, along with the extent of defect closure, suitability of the graft sites for implant placement, and soft-tissue stability. Pre- and postsurgical radiographs were also evaluated. Results: A good postoperative outcome was achieved in all patients, with complete closure of maxillary defects that were class II, according to the system of Brown and Shaw. Additional bone augmentation was necessary in two patients in order to increase vertical bone height. Patients were subsequently treated with 50 dental implants to retain dental prostheses. In all cases, additional soft-tissue surgery was necessary to achieve a long-term stable periimplant situation. No implants were lost during the mean observation period of 34 months. Conclusions: Due to its specific form, the scapular tip graft is well suited to reconstruct the palate and maxillary alveolar ridge and to enable subsequent implant-retained rehabilitation. Due to the limited bone volume, an accurate three-dimensional graft orientation is essential. Furthermore, most cases require additional soft-tissue surgery to achieve a long-term stable periimplant situation. © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Keywords: Reconstruction maxilla Hemimaxillectomy Scapula graft Scapula tip Microvascular bone graft Dental implants

1. Introduction Post-resective bone defects of the maxilla, especially after surgical resection of malignant tumors, are typically associated with severe functional impairment and problems with deglutition, mastication, and missing midfacial support. Depending upon the defect size and location, different therapeutic options are feasible.

* Corresponding author. Department of Oral- and Cranio-Maxillofacial Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany. Fax: þ49 6221 56 4222. E-mail address: [email protected] (C. Mertens).

Smaller defects typically can be treated by means of dental obturation, while larger defects require surgical reconstruction. For larger defects, the use of microvascular grafts is obligatory, especially in patients with adjuvant or neoadjuvant radiotherapy. Defects of the maxilla and midface can be classified by different systems (Aramany, 2001; Brown and Shaw, 2010; Cordeiro and Santamaria, 2000; Okay et al., 2001). Recent literature often uses the classification system of Brown and Shaw. According to them, class I defects are mainly treated with either dental obturators or fasciocutaneous radial forearm flaps. Class II defects can be treated similarly with dental obturators or with microvascular reconstructions. For defect sites not requiring

http://dx.doi.org/10.1016/j.jcms.2016.08.010 1010-5182/© 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Mertens C, et al., Reconstruction of the maxilla following hemimaxillectomy defects with scapular tip grafts and dental implants, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.08.010

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bone reconstruction, the fasciocutaneous radial forearm flap or the anterolateral thigh are described as successful options. However, these flaps do not provide sufficient support for dental reconstructions. Osteocutaneous free flaps provide good results, with the fibula, iliac crest flap with the deep circumflex iliac artery and internal oblique muscle (DCIA), and scapular grafts described in this context. Class III defects, which additionally lack orbital support, require reconstruction of the orbital rim, generally by the integration of titanium mesh. Various microvascular donor sites have been described in the literature, such as the fibula, iliac crest, or scapular grafts with skin islands. No single graft type can exclusively provide for reconstruction of this defect type. For restoration of class II and III maxillectomy defects, the scapular graft is a microvascular flap with relatively low morbidity (Clark et al., 2008; Coleman et al., 2000). Microvascular scapular grafts can be divided into two groups: lateral scapular grafts that incorporate the circumflex scapular artery, and scapular tip grafts that include the longer angular arch vessels of the thoracodorsal artery. Due to its bone morphology, the scapular tip osseomyogenous free flap has the advantage of providing midfacial support. It also can be used to reconstruct the palate and the alveolar ridge. In a recent study, computed tomography (CT) scans of the head, neck, and chests of 10 patients were analyzed, focusing on the morphology of the scapular tip and its ability to reconstruct simulated resection patterns such as total palate resection, subtotal palate resection, and hemipalate resection. The study found a close similarity between the shapes of the palate and the scapular tip (Burke et al., 2006). The use of scapular tip grafts also has been well documented in various clinical studies (Chepeha et al., 2010; Clark et al., 2008; Kakibuchi et al., 2002). However, little data has been reported regarding subsequent systematic implant treatment (Hibi and Ueda, 2012; Vinzenz et al., 2008). Some have argued that due to its limited bone quantity and quality, this type of graft does not provide sufficient bone to support implant placement. The aim of the present study was thus to evaluate the effectiveness of scapular tip flaps for the reconstruction of maxillary and midfacial defects, and to assess their efficacy at retaining dental implants to support subsequent prosthetic reconstructions.

2. Materials and methods 2.1. Patients The study protocol was reviewed and approved by the ethics committee for clinical studies of the Medical Faculty of the University of Heidelberg. All patients in this retrospective cohort study were treated in the Department of Oral and Maxillofacial Surgery of the University Hospital, Heidelberg, Germany. Records of all those who received reanastomized microvascular scapular transplants between January 2011 and January 2015 were checked for eligibility. Of the 42 patients treated, 22 had received scapular transplants in the mandible and so were excluded. Four transplants failed to heal and had to be explanted. Two patients who received maxillary scapular transplants did not subsequently receive dental implants, and for that reason were excluded from evaluation as well. Thus 14 patients with post-resective defects of the maxilla who underwent reconstruction with free microvascular reanastomized scapular tip grafts and who received subsequent implants were able to be included in the present study (Table 1). Six patients were male and eight were female; the mean age was 54.86 years (standard deviation [SD] 16.81 years, range 27e81 years). Each resection of the primary tumor was performed within free surgical margins. Nine patients received additional radiotherapy prior to reconstruction. Eleven patients underwent delayed reconstructions after expressing dissatisfaction with their dental obturators for reasons including compromised speech and/or swallowing, poor denture retention, leakage, and/or oronasal regurgitation. Three patients underwent reconstruction primarily. Depending upon the size of the defect, patients were treated according to the scheme of Brown and Shaw. All patients' general medical conditions were adequate to allow microvascular surgery. 2.2. Surgical reconstructive procedure After intraoral preparation of the recipient site, free surgical margins were ensured before beginning the reconstructive surgery. No extraoral approach (Weber Fergusson) was necessary. Prior to intraoral adaptation, the harvested bone graft was shaped extraorally on a three-dimensional printed model of the recipient site, and the tip of the scapular graft was oriented anteriorly. Fixation

Table 1 Patient characteristics. Case Age Sex Etiology (y)

Defect Reconstruction In-patient Revisional Tracheotomy Radiotherapy class period surgery

Postoperative Recipient complications artery

Recipient vein

1 2

37 40

F M

MEC Angiosarcoma

II b III b

sec. sec.

11 11

No No

No No

No No

A. facialis A. facialis

V. jugularis ext V. facialis

3 4 5 6 7 8 9

71 73 81 27 70 59 43

M F F F F F M

ACC Ameloblastoma BCC Fibromyxoma OSCC OSCC ACC

II b II b II c III b II d II d II b

sec. sec. sec. sec. sec. sec. prim

12 12 14 11 18 12 17

No No No No No No No

Yes No No No Yes No No

No Adj. radiochemotherapy Adjuvant No Adjuvant No Adjuvant Neoadjuvant Adjuvant

A. A. A. A. A. A. A.

V. V. V. V. V. V. V.

10

71

F

OSCC

II b

sec.

19

Yes

Yes

Adjuvant

11 12 13 14

61 29 51 55

F M M M

ACC Ossifying fibroma ACC Adenocarcinoma

II II II II

sec. prim prim sec.

11 8 21 8

No No No No

No No No No

Adjuvant No Adjuvant No

No Seroma No No Seroma No Intraoral dehiscence Intraoral dehiscence No No Seroma No

b b b b

lingualis facialis thyreoidea facialis facialis thyreoidea facialis

jugularis facialis jugularis jugularis facialis jugularis facialis

A. facialis

V. facialis

A. A. A. A.

V. V. V. V.

thyreoidea facialis facialis thyreoidea

int ext ext int

facialis facialis facialis jugularis ext

ACC ¼ adenoid cystic carcinoma; OSCC ¼ oral squamous cell carcinoma; MEC ¼ mucoepidermoid carcinoma; BCC ¼ basal cell carcinoma; Defect class according to classification Brown & Shaw; prim ¼ primary reconstruction; sec. ¼ secondary reconstruction.

Please cite this article in press as: Mertens C, et al., Reconstruction of the maxilla following hemimaxillectomy defects with scapular tip grafts and dental implants, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.08.010

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was achieved by semi-rigid osteosynthesis with miniplates and osteosynthesis screws, as the scapular graft in the maxilla was not load-bearing at the time of reconstruction. A connection was established between the bone graft and the crista zygomaticoalveolaris, the remaining alveolar bone, and the palate of the residual maxilla. The vascular pedicle was positioned through a prepared tunnel and was then connected by microvascular anastomosis to the recipient vessel of the neck (Table 1). 2.3. Implant therapy Implants were placed after an average graft healing time of 11.43 months. Based upon a prosthetic wax-up, a radiographic guide was fabricated prior to the three-dimensional analysis. Software using CT data (Simplant, Dentsply Implants, Hasselt, Belgium) was used for presurgical planning to achieve the best prosthetic position and angulation of the implants. Implant placement (Astra Tech Tx, €lndal) was performed under either local or Dentsply Implants, Mo general anesthesia in a two-stage approach. Second-stage surgery was scheduled after 3 months of implant healing. After an additional 2-week healing period, the decision was made as to whether further soft-tissue surgery was required to achieve stable periimplant gingiva. The decision regarding fixed versus removable reconstructions was dependent upon the vertical height of the suprastructure and the accessibility for the patient to accomplish good oral hygiene. Especially in cases of severe scarring after radiation or in cases of high suprastructures, a removable reconstruction was chosen.

Fig. 2. Three-dimensional CT prior to secondary reconstruction.

2.4. Follow-up procedure All patients were followed clinically and radiographically on a regular basis. Patients with malignant tumors were evaluated clinically at monthly intervals in the first year after tumor surgery, to ensure detection of any signs of tumor recurrence or periimplant softtissue inflammation. Throughout the second year, the clinical followup appointments were scheduled for every 2 months. Patients who had resection of benign tumors were seen every 6 months. All patients were evaluated clinically to assess periimplant softtissue conditions and to determine whether any adaptations or repairs of the final prosthetic restorations were necessary. After prosthetic rehabilitation, all patients were assessed for the parameters of mastication (unrestricted diet, soft diet, liquids), speech (normal, intelligible, or unintelligible), respiration (problems breathing through the nose), and oral competence (ability to achieve complete lip closure). Panoramic radiographs were taken before and after implant placement and then on an annual basis. The radiographs were assessed for marginal bone loss.

Fig. 1. Clinical situation after hemimaxillectomy prior to secondary reconstruction.

Fig. 3. Clinical situation of the maxilla after microvascular reconstruction, secondary epithelialization process of the scapular graft.

3. Results 3.1. Patients All 14 patients underwent successful reconstruction with the scapular grafts (Figs. 1e5). In all patients the resection defects had clear margins. Three patients had a tracheostomy. No transplant failed, but one revision of the graft pedicle was necessary. Three

Fig. 4. Clinical situation after completion of epithelialization process, normal oral mucosa.

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Fig. 8. Panoramic radiograph after prosthetic rehabilitation.

3.2. Implant therapy

Fig. 5. Three-dimensional CT after secondary reconstruction.

Fig. 6. Clinical situation after second-stage implant surgery.

Fig. 7. Final fixed prosthesis. Proliferative soft-tissue activity at implant 026 requiring surgical removal. There were, however, no signs of an infection such as suppuration or bleeding.

patients had minor donor-site complications (postoperative seroma), which were treated successfully by needle aspiration. One patient had a postoperative infection in the neck area. The mean in-patient period was 13.21 days (SD 3.88 days; range 8e21 days). During the postoperative healing period, the intraorally exposed muscle of the bone graft relined and transformed to regular oral mucosa.

All of the graft sites were suitable for dental implant placement (Figs. 6e8); however, additional bone augmentation had to be performed in three patients. In two of the three patients, the vertical bone height was augmented to match the bone level of the residual maxillary bone. One of these patients received onlay bone grafting with calvarial block grafts, and one received an iliac crest bone graft (Table 2). The third patient did not have a solid osseous union between the scapular graft and the remaining anterior maxilla and was thus additionally grafted with iliac crest bone to fill this gap and to allow for subsequent implant placement. The 14 patients received a total of 50 implants (range 2e6 implants per patient) (Table 3). The scapular grafts retained 44 implants, while 6 implants were retained by residual alveolar bone. All patients had opposing dentition (mean 12.79 teeth; SD 2.76; range 4e16), and 11 patients had teeth remaining in the maxilla (mean 6 teeth; SD 3.42, range 0e10). All implants were able to be inserted with good primary stability (minimum 20 Ncm) and healed subgingivally for a mean healing period of 4.1 months (range 2e7 months). The implant healing period was identical for patients who did or did not undergo irradiation. At second-stage surgery, flap debulking and recontouring were performed by excision of mucosa and fat tissue to create a sufficient vertical dimension to accommodate a dental prosthesis. All patients needed additional soft tissue surgery to achieve stable periimplant soft tissue. Vestibuloplasty was performed either with split-thickness skin grafts from the thigh (nine patients) or with free gingival grafts from the palate (five patients). The respective decision was made depending upon the amount of tissue required. No postoperative complications occurred. For final restorations, four patients received fixed prosthetic rehabilitations, and 10 received removable, implant-retained dentures (milled CAD/CAM fabricated bars, ISUS, Dentsply, Hasselt). The decision regarding fixed versus removable reconstructions was based upon the soft-tissue situation (scarring), the ability to achieve good oral hygiene (mouth opening), and the required vertical height of the prosthesis. An increased vertical dimension of the prosthesis required a removable restoration. At the completion of their treatment, all of the patients showed normal mastication (unrestricted diet), deglutition, and respiration. Speech was normal in 9 patients and intelligible in 5 patients. All patients had an oral competence, with sufficient lip height and a labial vestibule allowing for fabrication of a dental restoration. No connection to nasal cavity or maxillary sinus remained after reconstruction. No implants were lost during the mean observation period of 34 months. All implants were functionally loaded, and no prosthetic restoration had to be remade or repaired during the observation time. Throughout the follow-up appointments, which

Please cite this article in press as: Mertens C, et al., Reconstruction of the maxilla following hemimaxillectomy defects with scapular tip grafts and dental implants, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.08.010

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Table 2 Summary of treatment regimens after microvascular reconstruction. Case

Additional bone grafting

Implants in graft

Implants (total)

Implant position

Prosthetic reconstruction

Opposing dentition

Remaining teeth in maxilla (position)

Soft tissue surgery

1 2 3 4 5

Calvaria No No No Iliac crest

2 4 3 2 3

2 4 3 3 6

FGG FGG SSG SSG SSG

6 7 8

No No No

3 4 3

3 4 5

9 10 11 12 13 14

No No Iliac crest No No No

4 3 3 4 3 3

4 3 3 4 3 3

25, 11, 23, 12, 11, 22, 22, 11, 11, 26 21, 11, 24, 13, 13, 14,

26 13, 24, 14, 13, 24, 24, 22, 22,

15, 16 25 26 15, 25 26 24, 26 24, 25,

Fixed Removable Removable Fixed Removable

14 13 14 14 14

17, 21, 18, 11,

16, 22, 17, 21,

Fixed Removable Removable

14 11 12

17, 16, 15, 14, 13, 12, 11, 21

FGG FGG SSG

23, 13, 25, 14, 14, 15,

24, 25 15 26 15, 16 15 16

Removable Removable Removable Fixed Removable Removable

14 4 15 16 12 12

18, 22, 17, 11, 21, 12,

FGG SSG SSG SSG SSG SSG

17, 23, 16, 21, 22, 11,

15, 23, 16, 22,

16, 24, 15, 22, 23, 21,

14, 24, 15, 23,

15, 25, 14, 23, 24, 22,

13, 12, 11, 21, 22, 23 26 14, 13, 12, 11, 21 24, 26, 27

14, 26, 13, 24, 25, 23,

13, 27 12, 25, 26, 24,

12 11, 21, 22, 23 26, 27 27 25, 27

FGG ¼ free gingival graft of the palate; SSG ¼ split skin graft of the thigh.

Table 3 Implant distribution according to implant length and diameter (n ¼ 50). Implant length

6 8 9 11 13 Total %

Implant diameter 3.5

4

4.5

5

0 0 4 1 0 5 10.00%

0 1 3 0 0 4 8.00%

0 9 18 10 0 37 74.00%

0 0 2 2 0 4 8.00%

Total

%

0 10 27 13 0 50 100.00%

0.00% 20.00% 54.00% 26.00% 0.00% 100.00%

were scheduled at least every 6 months, stable periimplant soft tissue and bone were maintained in almost all patients. One implant exhibited a 3.5-mm marginal bone loss. However, it exhibited no clinical signs of an inflammation. Two patients initially showed proliferative activity of the periimplant soft tissues at two implant sites (one fixed restoration and one removable). There were, however, no signs of an infection such as suppuration or bleeding. After surgical removal, no further interventions were necessary, and probing depths showed normal values. The removable restoration was relined, and no further relining was necessary in this or other patients during the observation period. 4. Discussion The scapular tip free flap can be used successfully for reconstruction of type II or III (Brown and Shaw, 2010) hemimaxillectomy defects, and can provide sufficient bone volume to retain dental implants. However, graft orientation and fixation in the optimum three-dimensional position are of the utmost importance. If they are suboptimal, subsequent bone grafting is likely to be necessary prior to the implant placement and restoration. Three patients in the present study required additional grafting with extraoral bone, in two cases because of a discrepancy between the residual bone and the graft. For this reason, onlay grafting was performed. A third patient had a non-union between the graft and the residual bone that prevented implant placement in an ideal prosthetic position and required surgical revision with simultaneous grafting using a small bone block from the iliac crest. In order to achieve a precise graft orientation for the patients included in this study, the harvested graft material was adapted to the recipient sites extraorally, using printed 3D models of the recipient sites. This helped to reduce the time-consuming intraoral

adaptation time, as well as time when the graft material was without a vascular connection. A horizontal orientation of the scapular graft was chosen to reconstruct the palate and alveolar ridge; however, the literature also describes successful vertical orientation of scapular grafts (Brown and Shaw, 2010). A vertical orientation is more beneficial in class III defects, which require additional orbital and midfacial support. As compared to other microvascular bone grafts, the scapular graft has various advantages, including a relatively low donor-site morbidity (Clark et al., 2008; Coleman et al., 2000), a pedicle of good quality and diameter, and a shape that is well suited for maxillary reconstructions. Furthermore, the scapular graft has a high versatility in maxillary reconstruction. The bone can be divided into different components, allowing for independent positioning of each component, which is often very helpful for class III defects. Additionally, a skin paddle can be harvested, if necessary. This can be used to fill intraoral defects and also used in cases of midfacial or paranasal soft-tissue defects. Further advantages of scapular tip transplants are the long pedicle (up to 20 cm) (Uglesic et al., 2000) and the triangular or round shape, permitting the reconstruction of a wide variety of defects (Chepeha et al., 2010). Disadvantages include the time-consuming harvesting procedures, as simultaneous flap raising is impossible, as well as the difficult dissection of the vascular pedicle. A correct graft orientation is essential since the bone volume of the scapula is limited compared to other microvascular implants. Bone quality also tends to be lower. However, all implants in the present study were able to be inserted with good primary stability, and no implant was lost during follow-up. Compared to the scapular graft, using an iliac crest flap for maxillary reconstructions has more disadvantages. The iliac crest flap, with its deep circumflex iliac artery and internal oblique muscle, has a high donor-site morbidity, the vascular pedicle has a limited length, the skin island has a critical reliability, and the graft is very bulky (Futran and Mendez, 2006). For these reasons, this graft type is suitable only for reconstruction of patients after total maxillectomy. Another possibility for maxillary reconstruction, the fibula transplant, requires multiple osteotomies and offers less flexibility concerning soft tissue, however morbidity of this specific graftharvesting technique is relatively low (Clark et al., 2008). Avascular bone grafts, however, are not a reconstructive option for this particular defect type and location or for patients who have

Please cite this article in press as: Mertens C, et al., Reconstruction of the maxilla following hemimaxillectomy defects with scapular tip grafts and dental implants, Journal of Cranio-Maxillo-Facial Surgery (2016), http://dx.doi.org/10.1016/j.jcms.2016.08.010

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undergone irradiation. Studies evaluating the success of avascular and microvascular bone grafts for mandibular continuity defects showed success rates of 95% for microvascular bone grafts (Pogrel et al., 1997) but only 76% for nonvascular bone grafts (Handschel et al., 2011; Pogrel et al., 1997; van Gemert et al., 2009). Furthermore microvascular bone grafts show lower bone resorption rates than avascular bone grafts (Mertens et al. 2013, 2014). If a dental obturator can provide sufficient stability and sealing of the defect, it is the treatment of choice. Depending upon the number of teeth remaining in the maxilla, the defect size, and the configuration, it may be possible to retain an obturator solely by using the remaining teeth. The literature shows results with good masticatory function (Andrades et al., 2011; Koyama et al., 2005). A factor negatively affecting the results of dental obturators, however, is postradiation xerostomia. Such hyposalivation can lead to reduction of the defect sealing, resulting in reduced speech and swallowing abilities. Furthermore, nasal leakage when drinking liquids can occur. As most patients in the present study had received radiotherapy, this may have been a factor in influencing patients' choice of the particular reconstructive procedure. In general, the disadvantages of microvascular flap surgery are increased risk of surgical complications, longer recovery and treatment time, higher costs of the procedure, and the need to find a highly specialized surgical center. The decision as to which therapy to perform will always depend highly upon the general medical and oncologic condition of the patient. The result of the present study demonstrates that scapular tip bone dimensions are well-suited to retain dental implants. Radiographic studies analyzing the scapular bone volume also support this (Burke et al., 2006). In the present study, restoration with an implant-retained rehabilitation was possible in all cases, although in three cases additional bone-augmentation procedures were necessary. After reconstructive surgery and implant placement, a need for additional soft-tissue surgery also may often arise. Despite the fact that the muscle covering the scapular graft transforms into oral mucosa, scar tissue and periimplant tissue mobility in the present study made soft-tissue surgery obligatory to ensure periimplant soft-tissue stability. All treated patients required flap debulking during second-stage surgery and a subsequent vestibuloplasty. Vestibuloplasty was either combined with a free gingival graft of the palate or a split-thickness skin graft from the thigh. The goal was to achieve a stable soft-tissue situation, permitting insertion of a fixed or removable prosthetic restoration. Preservation of the shaped soft-tissue situation was achievable by design of the final denture. Due to their more flexible design, better access for cleaning, and better ability to compensate for large vertical discrepancies, removable restorations were preferred. Despite all pretreatments, both groups (fixed and removable) each had one implant for which proliferative soft tissue had to be removed. Although the results of the present study are promising, the follow-up time of the treated patients (34 months) was relatively limited. However, no implant losses have yet occurred. 5. Conclusion For patients after hemimaxillectomy, the scapular tip graft provides an excellent therapeutic option, permitting reconstruction of both the alveolar ridge and the palate and subsequent implant-

retained rehabilitation. Due to the limited bone volume, the graft material must be positioned in an accurate three-dimensional orientation. Furthermore, in most cases, additional soft-tissue surgery is necessary to achieve a long-term stable periimplant situation. Financial disclosure All authors have no relevant financial relationships to disclose. This particular research received no external funding. References Andrades P, Militsakh O, Hanasono MM, Rieger J, Rosenthal EL: Current strategies in reconstruction of maxillectomy defects. Arch Otolaryngol Head Neck Surg 137: 806e812, 2011 Aramany MA: Basic principles of obturator design for partially edentulous patients. Part I: classification. 1978 [classical article]. J Prosthet Dent 86: 559e561, 2001 Brown JS, Shaw RJ: Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol 11: 1001e1008, 2010 Burke CS, Roberts CS, Nyland JA, Radmacher PG, Acland RD, Voor MJ: Scapular thicknesseimplications for fracture fixation. J Shoulder Elbow Surg 15: 645e648, 2006 Chepeha DB, Khariwala SS, Chanowski EJ, Zumsteg JW, Malloy KM, Moyer JS, et al: Thoracodorsal artery scapular tip autogenous transplant: vascularized bone with a long pedicle and flexible soft tissue. Arch Otolaryngol Head Neck Surg 136: 958e964, 2010 Clark JR, Vesely M, Gilbert R: Scapular angle osteomyogenous flap in postmaxillectomy reconstruction: defect, reconstruction, shoulder function, and harvest technique. Head Neck 30: 10e20, 2008 Coleman SC, Burkey BB, Day TA, Resser JR, Netterville JL, Dauer E, et al: Increasing use of the scapula osteocutaneous free flap. Laryngoscope 110: 1419e1424, 2000 Cordeiro PG, Santamaria E: A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 105: 2331e2346, 2000 discussion 2347e2338 Futran ND, Mendez E: Developments in reconstruction of midface and maxilla. Lancet Oncol 7: 249e258, 2006 Handschel J, Hassanyar H, Depprich RA, Ommerborn MA, Sproll KC, Hofer M, et al: Nonvascularized iliac bone grafts for mandibular reconstructionerequirements and limitations. In Vivo 25: 795e799, 2011 Hibi H, Ueda M: Interfaces of titanium implants and a vascularized osteocutaneous scapular graft revised with distraction osteogenesis. J Craniofac Surg 23: 1549e1550, 2012 Kakibuchi M, Fujikawa M, Hosokawa K, Hikasa H, Kuwae K, Kawai K, et al: Functional reconstruction of maxilla with free latissimus dorsi-scapular osteomusculocutaneous flap. Plast Reconstr Surg 109: 1238e1244, 2002 discussion 1245 Koyama S, Sasaki K, Inai T, Watanabe M: Effects of defect configuration, size, and remaining teeth on masticatory function in post-maxillectomy patients. J Oral Rehabil 32: 635e641, 2005 Mertens C, Decker C, Engel M, Sander A, Hoffmann J, Freier K: Early bone resorption of free microvascular reanastomized bone grafts for mandibular reconstructionea comparison of iliac crest and fibula grafts. J Craniomaxillofac Surg 42: e217e223, 2014 Mertens C, Decker C, Seeberger R, Hoffmann J, Sander A, Freier K: Early bone resorption after vertical bone augmentationea comparison of calvarial and iliac grafts. Clin Oral Implant Res 24: 820e825, 2013 Okay DJ, Genden E, Buchbinder D, Urken M: Prosthodontic guidelines for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent 86: 352e363, 2001 Pogrel MA, Podlesh S, Anthony JP, Alexander J: A comparison of vascularized and nonvascularized bone grafts for reconstruction of mandibular continuity defects. J Oral Maxillofac Surg 55: 1200e1206, 1997 Uglesic V, Virag M, Varga S, Knezevic P, Milenovic A: Reconstruction following radical maxillectomy with flaps supplied by the subscapular artery. J Craniomaxillofac Surg 28: 153e160, 2000 van Gemert JT, van Es RJ, Van Cann EM, Koole R: Nonvascularized bone grafts for segmental reconstruction of the mandibleea reappraisal. J Oral Maxillofac Surg 67: 1446e1452, 2009 Vinzenz K, Holle J, Wuringer E: Reconstruction of the maxilla with prefabricated scapular flaps in noma patients. Plast Reconstr Surg 121: 1964e1973, 2008

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