What are the options for maxillary reconstruction?

Maxillary Reconstruction Options

The optimal approach for maxillary reconstruction should be guided by the residual bone height, with standard implants for >9mm bone height, and alternative options including transalveolar or lateral window sinus floor augmentation, short implants, tilted implants, or distal cantilevers for cases with insufficient bone. 1

Assessment and Planning Considerations

• Clinical decision-making for maxillary reconstruction requires comprehensive assessment using advanced imaging (e.g., cone-beam computed tomography) to evaluate bone quality and quantity 1
• The height of the subantral bony ridge ("residual bone height") is the primary factor in determining the appropriate reconstruction approach 1
• For maxillary sinus tumors, "Ohngren's line" (running from the medial canthus of the eye to the angle of the mandible) helps define the plane through the maxillary sinus, with tumors below/before this line involving the maxillary infrastructure 1

Implant-Based Reconstruction Options

Standard Implants

• Indicated when residual bone height exceeds 9mm 1
• Provides predictable outcomes with conventional loading protocols 1

Sinus Floor Augmentation Techniques

• Transalveolar approach with simultaneous implant placement - less invasive option for moderate bone deficiency 1
• Lateral window approach with simultaneous or delayed implant placement - for more severe bone deficiency 1

Short Implants

• Alternative to sinus augmentation when residual bone height is limited 1
• Defined as implants with length <8mm 1
• Reduces surgical complexity and morbidity 1

Tilted Implants

• Allows engagement of available bone while avoiding anatomical structures 1
• Can reduce the need for bone augmentation procedures 1

Distal Cantilevers

• Single implant with cantilever extension unit can be considered for posterior maxilla 1
• Requires meticulous occlusal analysis and planning 1
• Cantilever unit should only contact in maximum intercuspal position on flat surfaces 1
• Limited evidence supports this approach in the posterior maxilla 1

Zygomatic Implants

• Anchored in the zygomatic bone, providing stability in cases of insufficient maxillary bone volume 2
• Can support upper dentures with clip-on mechanisms 2
• Offers a solution for severe maxillary atrophy without requiring bone grafting 2
• Requires sufficient mouth opening (approximately 35mm) 2

Free Flap Reconstruction

• Vascularized bone flaps are recommended for extensive maxillary defects 1
• For maxillectomy defects extending into the sinus, reconstruction can use myocutaneous flaps or osteomyocutaneous flaps 1
• Osteomyocutaneous free flaps are preferred for mandibular continuity defects 1
• Free flaps are recommended over pedicle flaps due to greater versatility and improved outcomes 1
• Fibula and iliac crest free flaps are commonly used for maxillary reconstruction 3

Special Considerations

Radiation Therapy Patients

• Prophylactic hyperbaric oxygen therapy may be considered for patients undergoing invasive dental procedures at sites where substantial volume of maxilla received >50 Gy 1
• For osteoradionecrosis management in the maxilla, segmental maxillectomy with free flap reconstruction is recommended for full-thickness involvement 1

Elderly and Cognitively Impaired Patients

• Complex maxillary reconstructions should be approached with caution in elderly patients with cognitive impairment 1
• Failed complex reconstructions can significantly impact quality of life in this population 1
• Consider simpler options like removable prostheses when appropriate 1

Pitfalls and Caveats

• When using implant-supported cantilevers, ensure the cantilever unit is only in contact in maximum intercuspal position on flat surfaces and out of contact in excursive movements 1
• For implant-supported cantilevers opposing natural teeth, maintain contact in maximum intercuspation; for those opposing implant-supported restorations, leave slightly out of occlusion 1
• Preoperative radiographic interpretation of compromised bone extent should be confirmed intraoperatively via bleeding bone endpoint when determining resection borders 1
• Contingency planning is essential when using prefabricated cutting guides 1
• For patients unfit for definitive surgical treatment, focus management on symptom control 1