Download Oral Cavity Reconstruction PDF

TitleOral Cavity Reconstruction
Author
LanguageEnglish
File Size10.7 MB
Total Pages480
Table of Contents
                            Foreword
Preface
Acknowledgment
Contents
Contributors
1
	Principles and History of Oral Cavity Reconstruction
		INTRODUCTION
		EVALUATION AND PLANNING
		RECONSTRUCTIVE OPTIONS
			Non-vascularized Grafts
			Local Tissue Rearrangement
			Regional Flap Transfer
			Distant Tissue Transfer
			Implants and Biomaterials
		CONCLUSION
		REFERENCES
2
	Anatomy of the Oral Cavity and Related Structures
		INTRODUCTION
		IMPORTANCE OF STRUCTURE AND FUNCTION
			Lips
			Buccal Mucosa and Cheek
			Alveolar Ridges
			Retromolar Trigone
			Floor of Mouth
			Hard Palate
			Oral Tongue
			Mandible
			Function
		CONCLUSION
		REFERENCES
3
	Functional Aspects and Physiology of the Oral Cavity
		INTRODUCTION
		EMBRYOLOGY
		ORAL COMPETENCE
			Normal
			Abnormal
		SALIVATION
			Normal
			Abnormal
		MASTICATION
			Normal
			Abnormal
		BOLUS FORMATION AND PROPULSION
			Normal
			Abnormal
		TASTE
			Normal
			Abnormal
		CONCLUSION
		ACKNOWLEDGMENT
		REFERENCES
4
	Pathology of Neoplastic Diseases of the Oral Cavity
		INTRODUCTION
		ORAL SQUAMOUS MALIGNANCY BY ANATOMIC SITE
			Anatomic Sites
			Lips
			Buccal Mucosa
			Gingiva and Alveolar Mucosa
			Retromolar Trigone
			Floor of Mouth
			Tongue
			Palate
			Salivary Gland
		ORAL LICHEN PLANUS (OLP)
		OSTEORADIONECROSIS
		MELANOMA
		SARCOMA
		TISSUE PROCUREMENT
		CONCLUSION
		REFERENCES
5
	Benign Lesions and Tumors of the Oral Cavity
		INTRODUCTION
		Mucosa and Soft Tissue Traumatic Fibroma (Irritation Fibroma)
		Pyogenic Granuloma (Pregnancy Tumor, Lobular Capillary Hemangioma)
		Peripheral Giant Cell Granuloma (Giant Cell Epulis)
		Peripheral Ossifying Fibroma (Fibroid Epulis)
		Squamous Papilloma
		Mucocele
		Granular Cell Tumor
		Cheilitis Granulomatosa (Miescher's Cheilitis)
		Epulis Fissuratum
		Drug-Induced Gingival Hyperplasia
		Bone Central Giant Cell Lesion (Giant Cell Reparative Granuloma, Giant Cell Tumor)
		Florid Osseous Dysplasia (FOD)
		Cherubism
		Fibrous Dysplasia (FD)
		Langerhans Cell Granulomatosis [Langerhans Cell Histocytosis (LCH)]
		Osteosclerosis
		Exostosis
		Cysts
		OKC and the Nevoid Basal Cell Carcinoma Syndrome
		Traumatic Bone Cyst
		Odontogenic Tumor
		Ameloblastoma
		Adenomatoid Odontogenic Tumor
		Ameloblastic Fibroma
		Myxoma
		Odontoma
		REFERENCES
6
	Planning and Diagnostic Evaluation in Oral Cavity Reconstruction
		INTRODUCTION
		EVALUATION AND PLANNING
			History and Physical Examination
			Laboratory and Radiologic Studies
			Treatment Planning
			Surgical Planning - Incisions
			Primary and Neck Resection
		RECONSTRUCTIVE OPTIONS
		CONCLUSION
		REFERENCES
7
	Surgical Approaches to the Oral Cavity
		INTRODUCTION
		EVALUATION AND PLANNING
		RECONSTRUCTIVE OPTIONS
			Transoral Approach
			Midline Glossotomy
			Lip Split with Cheek Flap and Mandibulotomy
			Degloving Approach to the Oral Cavity
			Midface Degloving Approach
			Lingual Release Approach
			Transhyoid Approach
		CONCLUSION
		REFERENCES
8
	Lip Reconstruction
		INTRODUCTION
		PERTINENT ANATOMY
		EVALUATION AND PLANNING
		RECONSTRUCTIVE OPTIONS
			Primary Cutaneous Lip Repair
			Skin Grafts
			Vermilion Repair
		LIP REPAIR TECHNIQUES
			Technique
			Advantages/Disadvantages
			Limitations
		SIMPLE LIP ADVANCEMENT FLAPS
			Circumoral (Karapandzic) Advancement Flaps
			Cross-Lip Flaps
			Gillies "Fan" Flap
			Melolabial (Nasolabial)
			Cheek Advancement (Von Burow-Bernard) Flaps
			Island Flaps
			Other Cervical-Based Flaps
			Temporoparietal Scalp Flap
			Laterally-Based Forehead Flap
			Deltopectoral Chest Flap
			Microvascular Free Flap Lip Reconstruction
		SUMMARY
		REFERENCES
9
	Reconstruction of the Buccal Mucosa and Salivary Ducts
		INTRODUCTION
		EVALUATION AND PLANNING
		RECONSTRUCTIVE OPTIONS (TABLE 1)
			Split Thickness Skin Grafts and Acellular Human Collagen Matrix
			Local Tissue Flaps
			Buccal Fat Pad Grafts
			Temporalis and Temporoparietal Fascia Flaps
			Cervical Pedicled Flaps (Sternocleidomastoid, Platysma, and Infrahyoid Myocutaneous Flaps)
			Regional Myocutaneous Flaps
			Free Tissue Transfer and Buccal Mucosal Reconstruction
			Lateral Arm, Latissimus Dorsi, Rectus Abdominus, and Lateral Thigh Flaps
			Combined Flaps
			Reconstruction of the Parotid (Stensen's) Duct
		SUMMARY
		REFERENCES
10
	Ventral Tongue and Floor of Mouth
		INTRODUCTION
		EVALUATION AND PLANNING
		RECONSTRUCTIVE OPTIONS
			Split-Thickness Skin Graft
			Acellular Allograft Dermal Matrix (Table 3)
			Platysma Myocutaneous Flap
			Submental Island Flap
			Nasolabial Flap
			Random Cutaneous Nasolabial Flap, Staged Repair
			One-Stage Cutaneous Nasolabial "Island" Flap
			Myocutaneous Nasolabial Flap
			Radial Forearm Free Flap
			Lateral Arm Free Flap
		CONCLUSION
		PROBLEM-BASED DISCUSSION
		REFERENCES
11
	Reconstruction of Partial Glossectomy Defects
		INTRODUCTION
		RECONSTRUCTIVE OPTIONS
			Partial Glossectomy Defects (Less Than 25% of the Anterior Mobile Tongue)
			Hemiglossectomy Defects (Less Than 50% of the Anterior Mobile Tongue)
			Subtotal Glossectomy Defects (50-100% of the Anterior Mobile Tongue)
		Other Defects
		REFERENCES
12
	Reconstruction of the Base of Tongue and Total Glossectomy Defects
		INTRODUCTION
		Anatomy and Physiology of the Tongue
		EVALUATION AND PLANNING
		RECONSTRUCTIVE OPTIONS
			Small Tongue Base Defects
			Partial Tongue Base Defects
			Subtotal or Total Tongue Base Defects
			Subtotal or Total Glossectomy Defects
			Pedicled Myocutaneous and Muscular Flaps
			Pedicled Latissimus Dorsi Myocutaneous Flap
			Pedicled Infrahyoid Flap
			Fasciocutaneous Free Flaps - Radial Forearm Free Flap
			Ulnar Forearm Free Flap
			Lateral Arm Free Flap
			Scapular and Parascapular Free Flaps
			Anterolateral Thigh Free Flap
			Lateral Thigh Free Flap
			Omental Free Flap
			Myocutaneous and Muscular Free Flaps - Rectus Abdominis Free Flap
			Latissimus Dorsi Free Flap
			Gracilis Free Flap
			Tensor Fascia Lata Free Flap
			Adjunctive Measures in Tongue Base and Glossectomy Reconstruction
		CONCLUSION The Future of Base-of-Tongue and Total Glossectomy Reconstruction
		REFERENCES
13
	Hard Palate Reconstruction
		INTRODUCTION
		EVALUATION AND PLANNING
		RECONSTRUCTIVE OPTIONS
		DECISION MAKING TIPS
		PREOPERATIVE CONSIDERATIONS
		SPECIAL SURGICAL REQUIREMENTS
		CONCLUSION
		REFERENCES
14
	Reconstruction of the Soft Palate and Velopharyngeal Complex
		INTRODUCTION
		EVALUATION AND PLANNING
		RECONSTRUCTIVE OPTIONS Prosthetic Therapy
			The Dynamic Pharyngoplasty
			Asymmetrical Pharyngeal Flap
		CONCLUSION
		REFERENCES
15
	Cleft Lip and Palate
		INTRODUCTION
		Epidemiology
		Embryology
		EVALUATION AND PLANNING
			Cleft Lip and Palate Classification
			Secondary Palate
			Timing of Cleft Repair
			The Unilateral Cleft Lip Deformity - Pathologic Anatomy
		RECONSTRUCTIVE OPTIONS Unilateral Cleft Lip Repair
			Rotation-Advancement Repair of the Unilateral Cleft Lip Deformity
			Measurement and Flap Design
			The Bilateral Cleft Lip Deformity - Pathologic Anatomy
			Bilateral Cleft Lip Repair
			Palatoplasty
			Timing of Cleft Palate Repair
			von Langenbeck Palatoplasty
			Three-Flap Palatoplasty
			Two-Flap Palatoplasty
			Furlow Palatoplasty
			Preferred Techniques
		CONCLUSION
		REFERENCES
16
	Dental and Prosthetic Reconstruction of the Oral Cavity
		INTRODUCTION
		EVALUATION AND PLANNING
		RECONSTRUCTION OPTIONS
			Chemotherapy/Radiation Therapy (Tables 1 and 2)
			Maxillary Defects: Hard Palate (Table 3)
			Maxillary Defects: Soft Palate (Table 4)
			Mandible/Tongue Defects (Table 5)
			Complex Midface Defects
			Decision Making Tips
		CONCLUSION
		REFERENCES
17
	Mandibular Reconstruction
		INTRODUCTION
		EVALUATION AND PLANNING
		RECONSTRUCTIVE OPTIONS
			Non-Vascularized Grafts
			Vascularized Grafts
		LOCATION OF MANDIBULAR DEFECTS
			Anterior Defects
			Lateral Defects
			Posterior Defects (Condylar)
		CONCLUSION
		REFERENCES
18
	Composite Defects of the Oromandibular Complex
		INTRODUCTION
		RELEVANT ANATOMY
		EVALUATION AND PLANNING
		RECONSTRUCTIVE OPTIONS FOR THE OROMANDIBULAR COMPLEX
			Regional Tissue Transfer
			Pectoralis Major Myocutaneous Pedicled Flap (PMMF) Combined With a Reconstruction Plate
			Distant Tissue Transfer
			Fasciocutaneous Radial Forearm Free Flap Combined with a Reconstruction Plate
			Osteocutaneous Fibula Free Flap
			Osteocutaneous RFFF
			Scapula Osteocutaneous Free Flap
		MULTIPLE FLAPS FOR THE RECONSTRUCTION OF OROMANDIBULAR DEFECTS
		IMPLANTS AND BIOMATERIALS
			Mandible Substitutes
		DECISION-MAKING TIPS
		REFERENCES
19
	Secondary Oral Cavity Reconstruction
		INTRODUCTION
		EVALUATION AND PLANNING
		RECONSTRUCTIVE OPTIONS
			Reconstructive Options for Secondary Composite Defects
		DECISION-MAKING TIPS
		CONCLUSION
		REFERENCES
20
	Speech and Swallowing Rehabilitation
		INTRODUCTION
		VOCAL SUBSYSTEMS
		SWALLOWING
		EVALUATION METHODS AND OBSERVATIONS
			Instrumental Examination of Voice, Speech, and Swallowing
		VOICE, RESONANCE, AND SPEECH DISORDERS
			Treatments for Disorders of Voice, Resonance, and Articulation
		SWALLOWING DISORDERS
			Disturbed Lingual Motility
			Delayed Initiation of the Pharyngeal Swallow
			Incomplete Hyolaryngeal Excursion
			Paretic/Paralytic/Partial Intrinsic Laryngeal Valving
			Pharyngeal Paresis/Paralysis
		SWALLOWING TREATMENT STRATEGIES
			Cognitive Stimulation
			Modification of Bolus Variables
			Compensatory Postures/Positions
			Sensitization Techniques
			Compensatory Maneuvers
			Isometric Exercise
		SUMMARY
		APPENDIX A Swallowing Abnormalities Commonly Associated with Oral and Pharyngeal Cancer Resections
		REFERENCES
21
	Outcomes Research in Oral Cavity Reconstruction
		INTRODUCTION
		GLOBAL QOL INSTRUMENTS
		HEAD AND NECK INSTRUMENTS
		FUNCTIONAL STATUS AFTER RECONSTRUCTION
		QOL AFTER RECONSTRUCTION
		COST-EFFECTIVENESS ISSUES
		SUMMARY
		REFERENCES
22
	New Horizons in Oral Cavity Reconstruction
		INTRODUCTION
		DISTRACTION OSTEOGENESIS
		BONE GROWTH FACTORS
		Resorbable Implants
		TISSUE ENGINEERED ORAL MUCOSAL LINING
		CONCLUSION
		REFERENCES
Index
Back cover
                        
Document Text Contents
Page 2

Oral Cavity
Reconstruction

DK5780_FM.indd 1DK5780_FM.indd 1 8/12/05 10:29:49 AM8/12/05 10:29:49 AM
Process CyanProcess CyanProcess MagentaProcess MagentaProcess YellowProcess YellowProcess BlackProcess Black

Page 240

artery compression is released while firm pressure remains on the radial artery
(thus duplicating the effect following ligation of the vessel). The return of blood
flow to the digits, particularly the index finger and thumb, is assessed to confirm
that rapid (less than five seconds) return of flow occurs. If repeated tests indicate
a problem with the patency, the other arm should be examined and consideration
of Doppler studies arranged to fully evaluate the system prior to harvest. The
authors routinely use Doppler examinations to fully evaluate the patency of the
arch in addition to the quality of flow in each vessel. The brachioradialis, flexor
carpi radialis, palmaris longus, radial nerve, radial artery pulse, capillary refill,
antecubital fossa, cephalic, and basilic veins should all be examined and identified
prior to the planned donor site harvest (period). Ideally, the patient’s non-
dominant extremity is that designated for the harvest site.

Techniques

Harvest:

The patient, nursing staff and anesthesiologists should understand that the arm
should not incur intravenous or arterial lines or needle sticks. A second nursing
and surgical team is ideal for the two team approach. Prior to incisions, the
arm is marked to identify landmarks including the radial artery, superficial veins
and radial nerves. A tourniquet can be applied to the upper arm prior to sterile
prep or applied sterilly after the prep but is not inflated until the arm is exsangui-
nated and the procedure is ready to begin. The arm is extended on the armboard
which is at 90� to the table allowing surgeons to sit opposite each other during the
dissection. The thigh should be prepared for skin graft harvest or appropriate
allograft material available for coverage of the donor site. The skin coverage
necessary is marked overlying the volar aspect of the forearm centered on the
donor artery. A curvilinear incision extends to the antecubital fossa for extended
length pedicle if necessary. The skin and underlying fascia is then elevated identi-
fying the distal radial nerve branches which may divide into two to five small
branches at the wrist. Care is taken to divide the fascia at the brachioradialis
and dissect deep to the vascular pedicle or the pedicle can be separated from
the cutaneous paddle if dissection does not proceed deep at this point. The dissec-
tion is then started from the ulnar aspect and elevated toward the pedicle taking
care to remain superficial to the ulnar artery and median nerve. Preservation of
the paratenon fascia overlying the tendons of the flexor carpi radialis, palmaris
longus and brachioradialis muscles is crucial to prevent tendon exposure. Some
authors advocate performing a suprafascial dissection allowing improved healing
of the graft over the tendon. The deep osseous branches are ligated when bone is
not harvested, and carefully preserved when an osteocutaneous flap is harvested.
The distal and proximal incisions are connected around the periphery of the flap
leaving the flap connected only proximally by the venous, neural and arterial sys-
tems and by only the radial artery distally. The cutaneous nerves are immediately
deep to the subcutaneous tissue proximally and usually run alongside the distal
branches of the cephalic and basilic venous system. At this point, separation of
the brachioradialis and flexor carpi radialis (FCR) allows visualization of the
proximal radial artery and paired venae comitantes to the antecubital fossa.
The deep and superficial systems will merge into a plexus of veins in the ante-
cubital fossa and beyond, often allowing the surgeon to perform fewer venous

Reconstruction of Partial Glossectomy Defects 217

Page 241

Subtotal Glossectomy Defects (50–100% of the Anterior
Mobile Tongue)

When the entire anterior tongue requires resection, the primary problems incurred
are articulation dif�culties and oral bolus manipulation of foods. The pharyngeal
swallow and prevention of aspiration are not nearly as problematic in these anterior
defects as occurs in base of tongue resections. The key to functional and aesthetic
anterior total tongue reconstruction includes the use of a �ap that can be ��hinged��
on the base of tongue providing some movement to this ��static�� anterior neotongue.
It is also crucial to provide enough bulk to allow for the anterior neotongue to
approach the palate to assist in both speech and swallowing. In fact, the shape of
the reconstructed tongue and �ap may play a role in swallowing outcomes (66).
Unfortunately, it is not as easy to generalize to a particular �ap that is ideal for
all of these defects; rather it often depends upon the individual patient and, their
respective body habitus and associated surgical defects.

anastamoses but allowing �ow through both systems. When all of the proximal
vessels are skeletonized and ready for ligation, the distal radial artery is then
clamped with a temporary clamp while the tourniquet is released con�rming �ow
to the digits through the palmar arches. It is then safe to ligate the distal radial
artery and transfer the �ap when the recipient site is prepared. The forearm should
be closed with a split thickness skin graft although allograft material is gaining
popularity (58). A prefabricated forearm splint is placed to secure the graft mate-
rial for �ve to seven days and monitoring of the vascular supply to the hand con-
tinues throughout the post-operative period.

Complications following radial forearm �ap harvest may include skin graft
loss, sensory de�cits, hand cold intolerance and motor strength de�cits (51,52,56),
although there have been rare cases of anomalous forearm vascular supply which
must be considered prior to the radial forearm harvest to prevent ischemia to the
hand (59�61). Preservation of the paratenon cannot be overemphasized as this is
the enveloping fascia that allows vascular ingrowth from adjacent tissues and
grafts (48,51,54,62,63). When this is removed, it is helpful to advance adjacent
muscle or adipose to cover any exposed tendon prior to grafting.

Physical and occupational therapy with wrist and hand range of motion
exercises should commence within weeks following the procedure to ensure
adequate motor function.

The branches of the radial nerve should be identi�ed early in the dissection to
prevent accidental transaction or trauma and permanent numbness although some
patients do have resultant sensory loss when these branches are preserved (51).

The contraindications to the radial forearm �ap include generalized coagu-
lopathic states and other medical conditions which prevent all free tissue transfers,
while contraindications unique to this �ap include anomalous palmar arch anat-
omy, radial or ulnar agenesis or thrombosis and prior surgery or trauma to the
forearm area. Patient function, occupation and avocation may also preclude
the use of this donor site.

Post-harvest grafting techniques have included split thickness skin graft,
dermal graft, purse-string with grafting, wound-vac assisted closure and allograft
materials, although controversy remains as to the best type of material and
technique (55,58,63�65).

218 Skoner et al.

Page 479

Tumors
adenomatoid odontogenic tumor, 72
ameloblastic fibroma, 72–73
ameloblastoma, 71–72
myxoma, 73
odontogenic 71
odontoma, 74
oral cavity, benign, 59–74
traumatic bone cyst, 70–71

Two-flap technique, palatoplasty, 301

Ulnar forearm free flap, in tongue base
reconstruction, 241–243

Unilateral cleft lip deformity, 291–292
Unilateral cleft lip repair
Millard rotation-advancement cleft lip

repair, 293
reconstruction options, 292–296
rotation-advancement technique, 293–296

Vascularized grafts
free flaps, 332–337
mandibular reconstruction, 331–337

[Vascularized grafts]
pedicled osteomyocutaneous flaps,

331–332
Velopharyngeal complex reconstruction

asymmetrical pharyngeal
flap, 279–281

dynamic pharyngoplasty, 276–279
evaluation and planning, 274–275
options, 275
prosthetic therapy, 275–276
soft palate reconstruction, 273–281
velopharyngeal dysfunction, 273

Velopharyngeal dysfunction, symptoms of,
273–274

Ventral tongue, floor of mouth lesions,
177–200

Vermilion repair, in lip reconstruction,
125–129

V-lip repair technique, 129–132
Vocal subsystems, oropharyngeal cancer

post-treatment factors, 392
speech rehabilitation, 391–393

Von Burnow-Bernard flaps. See Cheek
advancement flaps.

von Langenbeck, palatoplasty, 299–300

456 Index

Similer Documents