GOOD AFTERNOON JOURNAL CLUB

Novel Transoral Approach to the Posterolateral Maxilla and

Infratemporal Region

Dr. RAHUL TIWARIPOST GRADUATE STUDENT

DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERYSIBAR INSTITUTE OF DENTAL SCIENCES

JOURNAL, ARTICLE & AUTHOR

PII: S0278-2391(16)31174-0DOI: 10.1016/j.joms.2016.11.007Reference: YJOMS 57540To appear in: Journal of Oral and

Maxillofacial Surgery

Received Date: 14 August 2016Revised Date: 2 November 2016Accepted Date: 8 November 2016

David K. Lam

Oral & Maxillofacial Surgery, University

of Toronto, 124 Edward Street, Room

143, Toronto, Ontario,

Canada M5G 1G6

Telephone: 416-979-4922 Ext 4329

Facsimile: (416) 979-4936

Email: david.lam@utoronto.ca

INTRODUCTION

Surgical resection of maxillary tumors - posterior sinus wall & pterygoid plate.

Upper cheek flap via modified Weber-Ferguson incision with subciliary extension.

Posterolateral maxilla and pterygoid plates remains poor.

Author - Transoral approach using a curvilinear incision - temporalis myotomy & coronoidectomy - posterolateral maxilla and infratemporal region.

Easily accessible through the open mouth.

The ITF approaches are categorized as:

Anterior 1. Transfacial2. Transmaxillary3. Transoral4. Transpalatal

Lateral1. Transzygomatic2. Lateral

infratemporal

Inferior1. Transmandibula

r2. Transcervical

Transmandibular approach The lower cheek flap

CASE REPORT

58-year-old woman - 2.5 x 2.0 x 2.5 cm solid multicystic ameloblastoma - Rt. posterior maxilla, sinus & pterygoid plates.

Ipsilateral curvilinear incision - temporalis myotomy & coronoidectomy

Visualizes ipsilateral pterygoid palates and hamulus.

Partial right maxillectomy - wide local excision - supraperiosteal dissection of tumor - with a 1 cm margin of normal tissue including the pterygoid plates.

An obturator was placed to reconstruct the defect.

The patient is doing well with no evidence of recurrence at 2 years follow-up.

OPG

CT SCAN – axial & coronal

CT SCAN – Sag.

Sagittal computed tomography

views of a well-defined 2.5 x

2.0 x 2.5 cm lesion in the right

posterolateral maxilla with

extension into the maxillary

sinus and pterygoid plates.

Red arrows indicate tumor

extent.

SURGICAL TECHNIQUE

Curvilinear incision made in the

maxillary buccal sulcus starting

at the midline, carried posteriorly

to the base of the

zygomaticomaxillary buttress,

and extended inferiorly along the

buccal surface of the ipsilateral

mandibular ramus.

SURGICAL TECHNIQUE

A temporalis myotomy and

coronoidectomy is then performed

SURGICAL TECHNIQUE

For direct visualization of the

posterolateral maxilla

and infratemporal region.

SURGICAL TECHNIQUE

The posterolateral maxilla and

pterygoid muscles are readily

visible following temporalis

myotomy and

coronoidectomy to allow

transoral removal of an

ameloblastoma involving the

right maxillary sinus and

pterygoid plates.

SPECIMEN - Appearance of surgical specimen including pterygoid plates.

SURGICAL SITE

View of surgical site following

partial right maxillectomy including

removal of involved pterygoid

plates.

1= osteotomy lines,

2= zygoma,

3= lateral pterygoid muscle,

4= medial pterygoid muscle,

5= masseter muscle;

M= medial,

L= lateral,

A= anterior,

P= posterior

DISCUSSION

Transcutaneous incisions such as a modified Weber-Ferguson incision with subciliary extension or a lower cheek flap

Other approaches - coronoidectomy - retromaxillary-infracranial or parapharyngeal spaces.

These approaches and methods are often associated with significant morbidity.

The modified Weber- Ferguson incision, running from the oral commissure to the anterior aspect of the zygomatic arch, often provides suboptimal posterolateral maxilla exposure since it is limited by the presence of the infra-orbital nerve.

DISCUSSION

The subciliary incision may also result in esthetic and functional compromise due to ectropion of the lower eyelid.

Lower cheek flap incision - injury to the mental nerve branches - ipsilateral sensory disturbance.

The midline or paramedian lower lip cutaneous incision may also result in poor cosmesis due to the visible scar - marginal mandibular nerve injury - lower lip asymmetry and oral incompetence.

The addition of a paramedian mandibulotomy with the lower cheek flap improve access - result in trismus, malunion, non-union and/or malocclusion.

DISCUSSION

Another surgical approach involves utilizing a Le Fort 1 approach and down fracturing the maxilla to provide access to the posterior maxilla - challenging for tumors that may extend posterolaterally.

Restablishing the occlusion, application of rigid fixation, changes to nasal base and the increased bleeding risk from descending palatine vessels.

DISCUSSION

Transoral approach using a curvilinear incision, temporalis myotomy and coronoidectomy enables controlled resection of tumors that involve the posterolateral maxilla and infratemporal region.

Most tumors are easily accessible using this transoral approach even when the tumor is large and involves the posterior sinus and pterygoid plates.

SUMMARY

Surgical access to tumors involving the posterolateral maxilla and infratemporal region remains a considerable challenge for surgeons.

Various surgical approaches for treating posterior maxillary lesions require transcutaneous incisions, such as an upper or a lower cheek flap, but they often result in significant morbidity.

This paper describes a novel transoral approach involving a curvilinear incision, temporalis myotomy and coronoidectomy to allow direct visualization of the posterolateral maxilla and infratemporal region.

This surgical technique may be used for the surgical resection of maxillary tumors that extend into the posterior maxillary sinus wall and pterygoid plate region via a transoral approach.

REFERENCES

1. Helman J: Maxillectomy. Atlas Oral Maxillofac Surg Clin North Am 5:75, 19972. Lore J, Medina J (eds): An atlas of head & neck surgery, 4th ed. Philadelphia, Pennsylvania, Elsevier Saunders; 2005, pp. 236–2493. Balm A, Smeele L, Lohuis P: Optimizing exposure of the posterolateral maxillaryand pterygoid region: the lower cheek flap. Eur J Surg Oncol 34:699, 20084. Hadjianghelou O, Obwegeser H: Temporal bone approach to the retromaxillary-infracranialspace and the orbit in tumor surgery. Laryngol Rhinol Otol (Stuttg) 65:46, 19865. Lazaridis N, Antoniades K: Double mandibular osteotomy with coronoidectomy for tumours in the parapharyngeal space. Br J Oral Maxillofac Surg 41:142, 20036. Chatni S, Sharan R, Patel D, et al: Transmandibular approach for excision of maxillary sinustumors extending to pterygopalatine and infratemporal fossae. Oral Oncol 45:720, 20097. Symington O, Caminiti M: Le Fort 1 downfracture approach for the treatment of a posteriormaxillary ameloblastoma. J Can Dent Assoc 61:1048, 1995

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