Maxillary and midface reconstruction: a narrative review

Introduction

Background

Maxillary defects can significantly impact the ability to eat, swallow, speak, and breathe, impairing esthetics and function. They can also have significant impacts on self-esteem and quality of life (1). Maxillary reconstruction can be challenging, and several different treatment modalities, surgical and non-surgical, are at the surgeon’s disposal (1).

Rationale

The purpose of this narrative review is to introduce maxillofacial surgeons to techniques available to them for the reconstruction of maxillary defects. This article does not intend to provide specific recommendations. The reconstructive choice must be tailored to the individual who is being treated, the given defect, and the surgeon’s comfort with techniques.

Objective

We will review surgical options such as bone grafting, vascularized free flaps, and non-surgical and surgical prosthetic devices. This article explores the various methods for reconstructing the maxilla, the advantages and disadvantages of each approach, and discusses which types of maxillary defects each technique is amenable to. This is a complex topic that requires frequent updates due to continuously advancing technology. Regular review updates are essential to keep pace with these developments. We present this article in accordance with the Narrative Review reporting checklist (available at https://fomm.amegroups.com/article/view/10.21037/fomm-24-55/rc).

Methods

A qualitative study of relevant literature was performed. We conducted a literature search using PubMed, Google Scholar, Wiley, and ResearchGate databases. Textbooks known to the authors were also reviewed. Our review included English-language articles from April 1998–January 2025 (Table 1). No limitation on dates was set when reviewing articles for this narrative review. The literature reviewed ranged from articles to textbooks, with a preference for published textbooks for review, although no limitations were set on the authors of this narrative review (Table 2).

Classification of maxillary and midface defects

Understanding maxillary and midface defect classifications is crucial before delving into the intricacies of reconstruction. Classification systems can guide a surgeon’s treatment planning.

Brown and Shaw classification

Brown and Shaw introduced a classification system for vertical and horizontal defects in their paper “Reconstruction of the maxilla and midface: introducing a new classification”. Vertical defects range from I–VI, while horizontal defects are categorized from a–d, with increasing complexity of dentoalveolar and palatal involvement.

Vertical defect classification (classes I–VI) (2)

This classification system evaluates vertical tissue loss, examining how defects progress from the palate to the orbit (Figure 1).

• Class I: maxillectomy without oronasal fistula.
• Class II: maxillectomy without orbital involvement
• Class III: maxillectomy that involves the orbital floor and adnexa, without removal of the orbit.
• Class IV: maxillectomy with orbital enucleation or removal of orbital contents entirely.
• Class V: orbitomaxillary defects with orbital content removal.
• Class VI: nasomaxillary defects involving nasal structures, with intact palate and dental alveolus.

Figure 1 Schematic drawing of the Brown and Shaw vertical defects. (A) Class I defect that is without oro-nasal communication and maintains the integrity of the dental-bearing maxilla. (B) Class II defect that extends to the maxillary alveolus, palate, and alveolar ridge but preserves the orbital floor and rim. (C) Class III defect involving the orbital floor and possibly skull base. (D) Class IV defect, the most extensive of the vertical defects, which includes complete orbital cavity removal. (E) Orbitomaxillary defect that preserves the palate and dental alveolus. (F) Nasomaxillary defects involving nasal structures only.

Horizontal defect classification (classes a–d) (2)

This classification measures horizontal tissue loss, specifically in the palate and alveolar ridge (2) (Figure 2).

• Class a: unilateral palatal defects not crossing the midline.
• Class b: less than or equal to 1/2 of the unilateral palate.
• Class c: less than or equal to bilateral 1/2 of the palate, or transverse anterior.
• Class d: greater than 1/2 of the maxilla.

Figure 2 Schematic drawing of the Brown and Shaw horizontal defects. (A) Class a defect, unilateral palatal defect that does not cross the midline. (B) Class b defect, bilateral defect that extends across the palatal midline. (C) Class c defect limited to the anterior maxilla, less than or equal to half of the bilateral or transverse area. (D) Class d, a defect that encompasses more than half of the maxilla.

This classification framework helps clinicians evaluate maxillary and midface defect severity, enabling them to select optimal reconstructive approaches.

Treatment modalities

Brown and Shaw outline treatment options for each defect class. For class I and IIa defects, fasciocutaneous radial forearm flaps are typically successful (2). Class IIb defects respond well to obturation or reconstruction with any osteocutaneous flap (2). Surgeons generally avoid pedicled flaps due to their inability to provide dental prosthesis stability (2). For class II defects, fibula free flaps are preferred for prosthesis stability and soft tissue recontouring (2).

Class III defects are often the most challenging due to the aesthetic and functional properties of the orbital floor and rim. The deep circumflex iliac artery (DCIA) flap is commonly used for these defects due to its bone stock and soft tissue bulk (3). A soft tissue free flap plus orbital plate is another option for this defect. Class IV patients have the poorest prognosis, with larger volume soft tissue flaps like the thoracodorsal artery perforator flap, or anterolateral thigh free flap often used to obliterate the dead space and support a future orbital prosthesis (2). Osteocutaneous free flaps can also be used to rebuild the alveolar bone of the maxilla to support a dental prosthesis. Class V defects usually do not require osteocutaneous flaps, as the palate remains mostly intact (2). Class VI defects are typically repaired with a radial forearm free flap (RFFF), with or without bone, depending on nasal bone involvement or maxillofacial prosthesis (2).

Bone grafting

Nonvascular bone grafting in the maxilla is challenging and lacks substantial literature support. While viable for mandibular defects, it is problematic in the maxilla, given the proximity of the maxillary sinus and difficulty in stabilizing and sealing the graft materials. Typically, bone grafting alone would be reserved for a smaller defect, like a Brown I.

The anterior iliac crest bone graft (AICBG) has been a reliable source of bone grafting in maxillary defects such as the cleft palate defect (Figure 3). Cancellous-only or corticocancellous bone grafts can be harvested at this site. This graft is limited to defects less than 5 centimeters (4). Complications include seroma, hematoma, gait disturbances, donor site infections, anterior superior iliac spine (ASIS) avulsion or fracture of the tubercle of the ilium, and nerve injury (4). Commonly injured nerves are the lateral femoral cutaneous, iliohypogastric, and subcostal nerves (4).

Figure 3 An image series depicting anterior iliac crest harvest for avascular bone grafting at the recipient site. (A) Pre-operative image with failing implants. (B) Harvested anterior iliac crest bone graft. (C) Prepared the recipient site. (D) Placement of bone graft with titanium mesh.

Obturators

Maxillary obturators are used when soft tissue or osteocutaneous free flaps are not viable options; this is often because of patient comorbidities or lack of a viable donor site. Obturators create barriers between the oral cavity, the nasal cavity, and the maxillary sinuses and provide immediate dental rehabilitation. However, obturators have seen decreased use with the advancement of free flap surgery. Still, they remain crucial for certain defects and patients, providing immediate aesthetics, function, speech, and structural support.

Obturators are typically used for Brown I and II defects in dentate patients. They are contraindicated when the orbital floor, cranial base, cheek, or mandible is involved (5). Functional limitations of obturators primarily relate to defect size. For horizontal defects, obturators are only considered if the defect involves less than 50% of the palate. Moreno et al. found that free flap reconstruction was superior in providing intelligible speech and proper mastication for type III defects (>50% of the palate) (6). For smaller defects, speech and postoperative diet outcomes were comparable between obturators and free flaps.

Obturators offer several advantages. They can reduce morbidity in patients with large maxillary defects, decrease surgery duration, provide immediate dental rehabilitation, and are cost-effective (7). They restore mastication, aesthetics, and speech without requiring a donor site, potentially reducing hospital stays and morbidity. Obturators may also facilitate cancer recurrence monitoring through easy removal for visual inspection (8) (Figure 4).

Figure 4 Surgical resection of squamous cell carcinoma and obturator placement. (A) pT4a squamous cell carcinoma of the right posterior maxilla. (B) Resected specimen. (C) Placement of temporary surgical obturator.

However, obturators present challenges. They require intact dentition for stability and patient compliance with appointments, maintenance, and cleaning. The prosthesis may need replacement or repair due to wear and tear (5). Patients with dexterity limitations may struggle with obturator management.

Skin grafting can enhance obturator stability, support, and retention. By creating an engageable surface through scar band formation between natural mucosa and the skin graft, the obturator gains improved retention when compared to relying on sensitive nasal mucosa.

Zygomatic implants and zygomatic implant perforated (ZIP) flap technique

While local and regional flaps provide effective soft tissue coverage, they often lack the structural support needed for dental rehabilitation in Brown class II maxillectomy defects. Zygomatic implants, introduced by Brånemark in the late 1990s, offer a transformative solution by providing stable anchorage in the zygoma (9,10). These implants are particularly valuable for patients with extensive maxillary resections, as they engage the often-spared zygomatic bone, supporting prosthetic rehabilitation even when traditional maxillary implants would fail (9,10).

The primary advantage of zygomatic implants is their ability to support early prosthetic loading and achieve excellent primary stability, allowing dental prosthesis placement immediately following surgery. This is especially beneficial for patients undergoing radiotherapy, as it enables dental rehabilitation before treatment begins (9,11).

Building on this concept, the ZIP flap technique, introduced in 2017, combines zygomatic implants with a perforated soft tissue flap—typically an RFFF (Figure 5). This innovative approach allows immediate soft tissue closure of the maxillary defect, while simultaneously placing zygomatic implants that perforate the flap, providing immediate prosthetic support (9,10,12). The ZIP flap technique is particularly effective for Brown class II defects, where the maxilla is resected, but the orbital floor remains intact (11). There is often not enough bone left in these cases for traditional implants, but if a bony flap were used, there would not be enough restorative space for dental rehab.

Figure 5 Correction of oro-nasal fistula and ZIP technique for reconstruction. (A) Patient with atrophic maxilla and large oro-nasal fistula due to treatment of childhood sarcoma. (B) Inversion of palatal tissue and placement of zygomatic implants. (C) Forearm free flap inserted. (D) Placement of immediate dental prosthesis. ZIP, zygomatic implant perforated.

Studies on ZIP flap reconstruction have shown promising results, with median time to prosthesis fitting ranging from 22 to 29 days, even in cases requiring postoperative radiotherapy (11,13). This rapid rehabilitation enhances patient outcomes, allowing for a quicker return to normal function and improved quality of life. Moreover, the ZIP flap has demonstrated high survival rates for both the vascularized flap and zygomatic implants, even in irradiated fields (9,11). Case reports further illustrate the effectiveness of the ZIP flap in complex oncologic reconstructions. For example, a patient with a total maxillectomy received four zygomatic implants and an RFFF, with a fixed dental prosthesis placed 21 days post-surgery (9). Another patient with a Brown class 2b defect received two zygomatic implants, with prosthesis placement after 19 days (9).

Long-term studies confirm the ZIP flap technique’s effectiveness for complex maxillary reconstructions. One study of 35 patients demonstrated the procedure’s durability, with 100% vascularized flap survival, 98.4% zygomatic implant survival, and 97% prosthesis survival (11). Over a median follow-up of 25 months, complications were minimal—limited to minor prosthodontic issues and rare oro-nasal fistulae—all of which were manageable (11). After one year, patient-reported outcomes showed high satisfaction, with 83% rating their quality of life as good to outstanding, noting significant improvements in mastication, speech, and swallowing (11). Although patients receiving postoperative radiotherapy reported somewhat lower quality-of-life scores, overall satisfaction and functional restoration remained high, further validating the ZIP flap technique’s effectiveness for complex maxillary reconstructions (11,14).

Local and regional flaps

Various local and regional flaps are commonly used in midface and maxillary reconstruction, each with specific advantages:

• Advancement flaps: ideal for small to moderate defects (up to 3 cm) in the nasolabial fold area. It offers excellent aesthetic results by matching surrounding skin color and texture. The flap’s design enables precise local tissue advancement, minimizing scarring and maintaining natural facial contours (12,15).
• Buccal fat pad flap: popular for treating oroantral fistulas and small to moderate defects in the posterior maxilla, Brown class I and II. It is easy to harvest with minimal donor site morbidity (12). The flap’s rich blood supply promotes quick healing and integration. However, its location and volume may complicate future dental prosthetic placement (12).
• Temporalis muscle flap: suitable for larger defects involving soft tissue and some structural components, especially in the posterior maxillary region. Its bulk and reliable blood supply make it ideal for filling large voids (12). While versatile in coverage, its volume may challenge subsequent prosthetic placement, requiring careful planning and possible secondary procedures (12) (Figure 6).
• Perforator-based transposition flaps: advanced option for larger defects needing extensive reach and volume. Flaps like the facial artery musculomucosal (FAMM) system offer significant coverage while minimizing donor site morbidity and visible scarring (12). Precise harvest allows tailored flap design, optimizing functional and aesthetic outcomes (12). These flaps bridge the gap between local and free tissue transfer options.

Figure 6 Temporalis muscle flap for reconstruction of the posterior maxilla. (A) Posterior maxillary defect. (B) Harvest of the temporalis muscle flap. (C) Temporal defect after temporalis brought into the mouth. (D) Temporalis flap closing the maxillary defect.

Microvascular free flaps for maxillary and midface reconstruction

Soft tissue defects of the midface

When addressing small to moderate defects where skin grafting often proves insufficient tissue, surgeons turn to local flaps for more reliable coverage. These flaps, including rhomboid, rotation, and advancement flaps, offer the advantage of similar tissue characteristics and better blood supply (16). A prime example is the paramedian forehead flap, which remains a cornerstone in nasal reconstruction (16). This versatile flap provides excellent color and texture matching, crucial for achieving natural-looking results in the aesthetically sensitive nasal region. It is important to note that while local flaps offer numerous benefits, they also have a higher risk of complications, necessitating careful patient selection and meticulous surgical technique (16).

Soft tissue flaps

Fasciocutaneous free flaps have become the gold standard for maxillary defect reconstruction, especially after tumor resection or trauma. These flaps, comprised of skin, fascia, and sometimes subcutaneous tissue, offer reliable vascularity, versatile shaping, and adequate soft tissue bulk to restore both function and aesthetics in the midface region. Their flexibility allows surgeons to contour the flap to fill complex defects. In maxillary defect reconstruction, they can create a vital barrier between the oral cavity and sinonasal cavities (17).

RFFF

The RFFF is a powerhouse for reconstructing soft tissue and palatal defects (Figure 7). It is easily accessed and can be harvested quickly with a two-surgeon team. This flap boasts a long pedicle—averaging 10–12 cm—allowing anastomosis in many ablative sites (17). It contains multiple vessels: the radial artery, the cephalic vein, and two venae comitantes (17). While its thinness can be a disadvantage when bulk is desired, the RFFF’s pliability allows the reconstruction of large surfaces (17). However, alternatives like the anterolateral thigh, latissimus dorsi, and rectus abdominis should be considered for bulkier reconstructions. The donor site requires a split-thickness skin graft, creating an additional surgical site. Potential complications at the donor site include graft rejection, wound dehiscence, tendon exposure, and poor healing (18). The visible donor site scar on the forearm may be concerning to some patients, particularly those with darker skin tones or a predisposition to hypertrophic scarring (1,16).

Figure 7 Successful resection of maxillary lesion with treatment via radial forearm free flap. (A) Posterior maxillary adenoid cystic carcinoma. (B) Resection specimen. (C) Harvest of radial forearm free flap. (D) Healed free flap 8 months later.

RFFF use is limited by inadequate hand blood flow or radial artery dominance in hand supply. In such cases, the ulnar forearm free flap may be used. It is often more aesthetic due to decreased hair growth, and the donor site scar is easily concealed. However, its pedicle is shorter than the RFFFs (14). There is also more risk to the median nerve.

Anterolateral thigh free flap

The anterolateral thigh free flap is ideal for thicker resections and larger defects, with a potential skin paddle up to 8 cm × 25 cm and the ability to harvest vastus muscle as well as skin (19) (Figure 8). The flap’s blood supply comes from the lateral circumflex femoral artery and venous comitantes, with a pedicle length of 8 to 16 cm (19). Its advantages include versatility (fasciocutaneous or myocutaneous), multiple skin paddles, and chimeric potential (19). Two-surgeon teams can perform the harvest, reducing surgery time. Donor site morbidity is low, with primary closure possible. Disadvantages include variability in perforator location, number, and potential bulkiness (20).

Figure 8 Anterolateral thigh free flap for reconstruction of a large resection involving the skin. (A) cT4a maxillary squamous cell carcinoma with extension into skin. (B) Intraoral view of primary lesion. (C) Composite defect of face and maxilla. (D) Rolled anterior lateral thigh flap used to close both the extraoral and intraoral defect.

Rectus abdominis free flap

The rectus abdominis free flap offers another option for large, bulky defects. Its major blood supply is the deep inferior epigastric artery, with an average pedicle length of 13 cm (8). Advantages include reliable soft tissue, a long pedicle, multiple harvestable skin paddles, a two-surgeon approach potential, primary closure, and adequate vessel diameter (8). Complications can include subcutaneous hematoma and ventral wall hernias. This flap is contraindicated in patients with previous abdominal surgeries or hernia repairs. Obese patients may face an increased risk of fat necrosis due to the shearing of skin perforators during surgery (20).

Osteocutaneous free flaps

Osteocutaneous free flaps, such as the fibula free flap, DCIA, scapula free flaps, and osteocutaneous radial forearm, combine vascularized bone with soft tissue. This makes them ideal for complex reconstructions involving both bony and soft tissue deficits. These flaps are particularly useful in reconstructing midface and maxillary defects where structural support and soft tissue bulk are required (2,21). These flaps can be raised without a skin paddle as a bone flap only when bone restoration is the only goal. These flaps provide vascularized bone to support facial contours and dental prosthetics (2,22,23).

Fibula free flap

The fibula free flap is the true workhorse of maxillofacial reconstruction due to its robust blood supply, long pedicle, and ability to undergo multiple osteotomies, making it highly adaptable to the complex three-dimensional needs of maxillary reconstruction (2,21). The fibula free flap excels in cases where large portions of the maxilla are resected. It can be shaped to recreate the maxillary contour and provide sufficient bone for dental implants. Its versatility allows for the restoration of vertical and horizontal components of the maxilla, making it ideal when the dental alveolus is resected along with the maxillary bone. Virtual surgical planning (VSP) has significantly enhanced fibula flap use, enabling precise osteotomies and dental implant placement during the same surgery (2). This improves reconstruction accuracy, reduces ischemia and total operating time, and can reduce the number of surgeries needed for functional rehabilitation (1,2).

DCIA free flap

The DCIA free flap, which can be raised with a skin paddle or a large cuff of the internal oblique muscle, is well-suited for large maxillary defects requiring robust bone for facial projection and orbital content support. The inclusion of additional soft tissue is beneficial for closing oronasal fistulas and other soft tissue defects (2). The DCIA flap is preferred when the maxilla’s anterior segment is involved, as it provides better facial projection than soft-tissue-only reconstructions, and its large bone stock allows for future dental implants (2,22).

Scapula free flap

The scapula free flap offers a versatile option, particularly for defects involving the maxilla and midface. It provides a large surface area of vascularized bone and soft tissues. It can support the orbital contents, nasal structure, and maxillary alveolus. Additionally, due to its large soft tissue components, it is ideal for composite defects. The scapula flap’s ability to restore three-dimensional structure and its ease of shaping makes it particularly useful for orbitomaxillary reconstructions, where bone and soft tissue are often lost (2,8).

Radial forearm osteocutaneous flap

The radial forearm osteocutaneous flap is a variation of the soft tissue flap that includes harvesting a portion of the radius. It is best used in short-segment maxillary and mandibular reconstruction (Figure 9). Although it is a lower quantity bone stock compared to other osseous free flaps, it can provide an adequate arch thickness for implant placement (24). The bony harvest can provide up to 10 cm in length and a width that is 40% the circumference of the radius (9). Candidacy of this flap is determined by the perfusion of the distal extremity with only the ulnar artery supplying it (24) and is determined by an Allen test. The advantages of this flap are a thin skin paddle, flexibility of the skin paddle, long vascular pedicles, and reliable anatomy (24). The disadvantages are related to donor site morbidity and include ischemia, reduced strength of the operated wrist, scar contracture, and fracture of osteotomized bone (24).

Figure 9 Radial forearm free flap and bone graft to reconstruct premaxilla. (A) Defect after removal of necrotic premaxilla. (B) Harvest of osteocutaneous radial forearm free flap. (C) Plating of radial bone into the premaxilla. (D) Non-vascular bone graft packed around the site.

Free flap long-term outcomes and prosthetic rehabilitation

Reconstruction with osteocutaneous free flaps provides superior long-term outcomes, particularly in facial contour, prosthetic rehabilitation, and restoration of mastication and speech. Combined with dental implants, these flaps enable full dental rehabilitation, which is essential for restoring oral function. Including soft tissue in the flap reduces the risk of wound breakdown and fistula formation, which are more common with non-vascularized bone grafts (1,2). Vascularized grafts are also the gold standard in patients who have had or are planning to undergo radiation therapy (5,25).

Immediate jaw replacement (IJR)

IJR or the “jaw in a day” procedure enables simultaneous reconstruction of maxillary defects using osteocutaneous flaps and immediate dental implant placement (Figure 10). This innovative approach offers patients fewer surgical procedures, faster recovery, improved function, and immediate aesthetic results. Traditional prosthetic devices often prove challenging for patients after major reconstruction, and the anxiety of waiting months for a fixed prosthesis can be significant.

Figure 10 Jaw in a day to reconstruct maxillary defect. (A) Maxillary myxoma accessed via Weber-Ferguson. (B) Harvest of fibula free flap plated to the resected model for pick up. (C) Placement of an immediate prosthesis.

The placement of osseointegrated implants during surgery and immediate prosthesis insertion has revolutionized patient care. Before IJR, surgeons had to wait for a bony union between the flap and native bone before implant placement and oral rehabilitation. This union typically takes three months, during which patients without prosthetics may suffer physically, socially, and psychologically (26). Recent advancements in digital dentistry and 3D surgical planning have streamlined the surgical process. Fibula cutting guides can now be manufactured with pre-planned implant guide holes.

The advantages of IJR include a reduced number of surgeries, enhanced patient quality of life, and improved function. Surgeons can easily access the harvested osteocutaneous graft for implant placement while still attached to the vascular pedicle, ensuring better visibility for proper angulation and positioning, all while reducing ischemia time. Immediate implant loading is safe. However, as IJR is a relatively new procedure, first performed in 2007, further research is needed to evaluate long-term outcomes. Potential drawbacks include high costs and the risk of flap failure due to compromised blood flow in the flap from the implants after significant emotional and financial investment in an immediate prosthesis (21).

Although IJR is a great option, many patients who receive reconstruction do not have dental rehabilitation. It is estimated that between 23.7% and 51.6% of patients received complete dental rehabilitation (27). Ritschl et al. found that dental implants were inserted in 37.3% of patients, but only 23.7% of them achieved rehabilitation. In this study, they found that patients with malignancies were less satisfied with their prosthesis, but 79.9% of patients overall were satisfied with their postoperative results (28).

Patient specific preprosthetic implants

Restoring function and aesthetics in patients with maxillary defects is crucial. While osteocutaneous free flaps with or without implants are often the go-to solution, they are not suitable or desired by all patients. For large defects, a novel technique has emerged: IPS preprosthetic implants by KLS Martin (Tuttlingen, Germany). This innovation offers streamlined maxillary reconstruction through patient-specific, subperiosteally placed, multi-vector anchored implants. An example of the VSP for this method can be seen in Figure 11. This approach spares patients from osteocutaneous flap reconstruction, which requires a much longer hospital stay, anticoagulation, and a donor site, and can provide same-day temporary prosthesis insertion.

Figure 11 Virtual surgical planning of osteotomy and preprosthetic implant placement. (A) Virtually planned surgical resection of the right maxilla. (B) Virtually planned preprosthetic reconstruction.

Unlike traditional implants that depend on adequate bone stock for osseointegration, IPS prostheses can be fixed to the best quality bone in the maxilla or midface. They allow for strategic post emergence, regardless of screw location, giving surgeons and prosthodontists unprecedented flexibility. The implants’ multi-vector screw retention design ensures primary stability and permits direct loading (20). While an osteocutaneous flap is not necessary, adequate soft tissue coverage post-maxillectomy remains essential for aesthetic emergence profiles and prosthetic support. Like the ZIP flap, a soft tissue free flap should be utilized in cases with poor soft tissues, and the implant posts can be perforated through the soft tissue flap. Studies have reported positive outcomes with short-term stability, but as a new modality, longer-term studies will be needed before we can comment on their long-term stability. A study tracking four patients for up to 68 months post-operatively reported no implant failures or screw loosening (20). Another study by Korn et al. followed 20 implants in 19 patients over 26 months and found no evidence of implant loosening. Major complications were limited to patients with poor soft tissue conditions, while minor issues like mucositis and framework exposure did not significantly impact implant stability or outcomes (29).

Common complaints from irradiated patients include redness, pain, and the need for analgesics (30). Irradiated patients typically had better success in the upper jaw with fewer complaints of soreness, aching, difficulty with eating, dry mouth, and discomfort than those with IPS implants in the lower jaw (30). Like conventional implant dentures, patients prefer a fixed prosthesis (31).

The IPS-Preprosthetic^® system boasts several advantages: primary stability, immediate loading, shorter surgeries, no donor site morbidity, patient-specific designs, and prosthesis planning independent of bone quality (Figure 12). However, it is not without drawbacks. These include higher costs, ongoing prosthesis maintenance, longer pre-surgical wait times due to custom manufacturing, and the potential for mucositis, infection, and hardware failure. Despite these challenges, IPS Implants^® Preprosthetic (KLS Martin) remains a valuable tool for maxillary defect rehabilitation, particularly when osteocutaneous flaps are not feasible.

Figure 12 Pre-prosthetic implant placement to repair a previously reconstructed lesion. (A) Atrophied radial forearm free flap after radiation to the maxilla. (B) Placement of pre-prosthetic implant and ulnar free flap. (C) Placement of an immediate prosthesis.

Orbital reconstruction

Orbital defects pose complex reconstruction challenges. Effective reconstruction often combines flaps with reconstructive plates or mesh. The approach varies depending on whether the globe is preserved or the orbital contents are exenterated. Surgeons may use autologous bone grafts, titanium frameworks/mesh, and soft tissue flaps individually or in combination for optimal outcomes (Figure 13). Currently, there are no standardized recommendations for orbital reconstruction in the literature (32).

Figure 13 Reconstruction of maxillary defect involving the orbital floor. (A) Placement of orbital floor plate and pre-prosthetic implant. (B) Resected recurrent maxillary ameloblastoma with invasion through the orbital floor.

The temporalis myofascial flap is a safe and reliable rotational option for orbital reconstruction. Surgeons split the temporalis coronally and tunnel the anterior portion of the muscle subcutaneously into the orbit (13). This flap offers several advantages: it is well-vascularized, easily visualized for resection, and can be raised quickly, reducing surgery time. The main drawbacks are post-operative temporal hollowing, which may require additional cosmetic correction, and a limited rotational arc (33).

Vascularized bone flaps provide excellent orbital stability during the reconstruction of the orbital floor and rims and can reduce secondary complications (32). When orbital implants are used without vascularized bone flaps, the risk of infection and material exposure increases (15). However, using vascularized bone grafts increases operative time and the complexity of the surgery.

Strengths and limitations

This narrative review offers insight into the surgical approaches to maxillary reconstruction reported across the literature. Its primary strength is its ability to provide a broad and cohesive overview of the techniques. However, narrative reviews lack a systematic search strategy and standardization of inclusion criteria. It is important to note that current literature is mostly limited to case series, case reports, and small retrospective reviews, with a scarcity of randomized control trials. Without a critical appraisal of study quality or quantitative synthesis, this review must be interpreted cautiously and supplemented by systematic reviews or comparative studies when available. Because of the evolving nature of surgical fields and the scarcity of randomized controlled trials on this topic, continued research to optimize patient care is necessary.

Conclusions

In conclusion, this review delves into the multifaceted techniques and innovations in maxillary and midface reconstruction, shedding light on the importance of tailored surgical strategies that cater to facial defects. As the field continues to evolve, driven by technological advancements and deeper clinical insights, the potential for restoring physical and psychological well-being and quality of life for patients has and will continue to increase.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://fomm.amegroups.com/article/view/10.21037/fomm-24-55/rc

Peer Review File: Available at https://fomm.amegroups.com/article/view/10.21037/fomm-24-55/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://fomm.amegroups.com/article/view/10.21037/fomm-24-55/coif). J.T. elected to be ROAAOMS District IV Representative in 2025-2026. D.G. received grant from ITI, Straumann. N.F.C. received consulting fees from KLS Martin and SORG North America and is the Leadership of Osteoscience Vanguard Committee. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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