Discussion

In order to reduce intra-operative time, the soft tissue free flap is harvested at the same time as the implant placement and prosthodontic procedures. On raising a skin island, it is appropriate to make it a little over-sized for the required defect to ensure that tension and possible dehiscence at the surgical margins during healing is reduced.

In low-level maxillectomy (Brown class II), the need for bony reconstruction is questionable depending on the horizontal component. With the preservation of the orbital floor, zygomatic prominence and some bony support for the nose, facial appearance, in the experience of the authors and, as demonstrated by this case, is not significantly worsened despite low-level removal of the maxilla. The key issues in these low level defects are adequate clearance of tumour, dealing with the oro-nasal communication and reconstruction of the dentition. Whilst prosthodontic obturation can deal with these aspects in a simple manner, the stability of the obturator prosthesis and its ability to completely seal the oro-nasal defect has limitations. In addition, these prostheses require a significant amount of adjustments, clinic visits and on-going maintenance. The soft lining materials perish, discolour and harbour surface biofilm often resulting in some mal-odour and the need for regular replacement. For many patients, there is a psychological impact of retaining the maxillectomy defect and high anxiety related to the insertion and removal of the prosthesis as well as concerns relating to the handicap they would experience to speech, and eating should their prosthesis fracture or fail in some way. The use of implants to retain maxillary obturators certainly improves their stability and retention, but efficacy of the oro-nasal seal still requires regular maintenance and patients still often dislike the hygiene aspects of looking after the defect and their implant supra-structure within the defect.