Palatal Flap Unit in Anterior Maxillary Reconstruction

Thursday, October 10, 2013
Cesar Guerrero DDS, cDirector, Santa Rosa Maxillofacial Surgery Center, Caracas, Venezuela., caracas, Venezuela
Marianela Gonzalez DDS,MS,MD, Oral & Maxillofacial Surgery, Texas A&M University System/BCD/ Baylor University Medical Center Dallas, Dallas, TX
Mariana Henriquez DDS, Santa Rosa Maxillofacial Surgery Center, Caracas, Venezuela
Elena Mujica DDS, Santa Rosa Maxillofacial Surgery Center, Caracas, Venezuela
Statement of the problem: Severe anterior maxillary defects generally show poor results after multiple surgical attempts. The main problem is the lack of covering soft tissues and vascularity. A new palatal flap design is developed for anterior maxillary reconstruction, based on the anterior palatine arteries and veins; the hard palate soft tissues are elevated and brought forward to extensively cover the anterior maxillary reconstruction, based on bone grafts and immediate implant insertion.

Material and Method: Four patients, ages 32, 5 y.o. (from 26.4 to 35.2 y.o.) underwent 3-D maxillary reconstruction based on  simultaneous anterior maxillary bone grafting and dental implants, adequately covered with the newly designed palatal flap. The bone grafts were obtained from the mandibular ramus or palatal torus and completed with cancellous local bone and from the suction tramp. Under general anesthesia, an incision is made at the depth of the vestibule in the anterior nasal spine area, underneath the periosteum, continuing around the teeth and posteriorly to the junction between the hard and soft palate, a through and through incision is made on the palatine bone across the palate, to avoid disturbing the velo-pharyngeal mechanism, the whole flap is only attached to the vessels, which are meticulously elongated to allow better flap mobilization. The palatal unit could be rotated or advanced according to the individual needs and it is fixated with 7 or 9 mm screws to the bone and then multiple individual 3.0 vycril sutures to complete the fixation. A compressive gauze is fixated over the palate with sutures for bleeding control and is removed 7 days later. The implants are uncovered at six months and continue with dental rehabilitation.

Method of data analysis: Evaluation included: clinical analysis, photographs and radiographs (panoramic, lateral and P-A cephalic). All patients were followed for a minimum of 12 months. Dental models were measured before and after implant uncoverage.

Results: The flaps healed without complications, the uneven keratinized surface was superficially shaved at implant exposure phase. The posterior hard palate defect was 6 mm wide +/- 2.5 mm exposing the palatine bone and healed by secondary epithelialization with no traces of surgery, the vertical augmentation was 7 mm +/- 4 mm. One bony exposure was seen at the vestibule level and close with a small rotating flap. All implants were rehabilitated and minor soft tissue adjustments were necessary to obtain ideal symmetry and have inconspicuous crowns emerging from the gingiva.

Conclusions: Palatal flap unit allowed this group of patients to be ideally treated, 3-D reconstructing the anterior maxilla with excellent functional and esthetics results; no implants were lost and fixed prosthesis were fabricated to patients satisfaction.

References:

Millard DR Jr, Seider HA: The versatile palatal island flap: Its use in soft palate reconstruction and nasopharyngeal and choanalatresia. Br J Plast Surg 30:300, 1977

Veau V, Borel-Maisonny S. Division Palatine. Anatomie Chirurqie, Phonetique. Paris: Masson; 1931