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Maxillary Removal and Reinsertion in Pediatric Patients
David M. Powell, MD;
Nirav Shah, MD;
Alan Carr, DDS;
Shiva Shanker, DDS, MDS, MS;
Jerry R. Dwek, MD;
David E. Schuller, MD;
Gregory J. Wiet, MD
Arch Otolaryngol Head Neck Surg. 2002;128:29-34.
ABSTRACT
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Objective To examine outcomes after the maxillary removal and reinsertion (MRR)
approach for the treatment of anterior cranial base tumors in pediatric patients.
Design Eligible patients were identified by medical record review. Consenting
patients were studied via rhinoscopy, fiberoptic endoscopy, standard facial
photographs, and cephalometric radiographs.
Setting A tertiary care otolaryngology clinic.
Patients Inclusion criteria were age younger than 16 years at time of initial
procedure and a follow-up period of at least 6 months. Nine patients were
eligible, and 5 enrolled. All were male patients (mean age, 13.8 years; age
range, 11-15 years) treated for juvenile nasopharyngeal angiofibroma.
Main Outcome Measures History and examination were performed to evaluate occlusion, vision,
facial growth, and tumor status. Cephalograms were used to calculate 3 standard
cephalometric measurements: sella to A point, basion to A point, and condylion
to A point. Cephalograms were examined for plate migration and bony resorption.
Results and Conclusions No major long-term complications were identified in the patients after
MRR. Cephalometric analysis revealed minor abnormalities in 2 children, but
no plate migration or bony resorption was identified in the removed and reinserted
maxillae. No abnormal development patterns were detected on physical examination
or when cephalometric measurements were compared with age- and race-matched
normative data. Although further study is warranted, MRR seems safe and effective
for treatment of pediatric patients with anterior cranial base tumors.
INTRODUCTION
THE ANTERIOR cranial base, a site crowded with functionally important
structures, is a locus of various benign and malignant lesions in adults and
children. Recent advances in cranial base surgical techniques have improved
access to and repair of this complex anatomic region.1
Maxillary removal and reinsertion (MRR) is one such technique. This procedure
was reported in 1992 by Schuller and colleagues2
as a method to gain wide surgical access to the anterior cranial base for
tumor resection while preserving adjacent critical structures. Since 1992,
MRR has been performed on several pediatric patients by the members of the
Department of Otolaryngology at The Ohio State University, Columbus. Most
of these cases involved surgical treatment of juvenile nasopharyngeal angiofibroma
(JNA). Although benign, JNA is an aggressive and extremely vascular neoplasm
that is capable of bony destruction and intracranial extension.3
These characteristics make surgery the most frequently used treatment modality
for JNA, typically via transpalatal and transantral approaches.4-5
Surgery of the anterior cranial base, however, is associated with frequent
postoperative complications. In 1994, Kraus and colleagues6
reported a 31% incidence of local major complications, such as infection,
orbital injury, or neurologic injury, in 85 patients after craniofacial resection
of anterior cranial base neoplasms. For JNA, postoperative hemorrhage and
tumor recurrence are the most common complications.5
One potential complication of facial skeletal surgery in children is
injury to facial growth centers with sequelae such as malocclusion, visual
disturbance, or cosmetic deformity.7 Correction
of these sequelae may require additional surgery. The major growth centers
of the face are the mandibular condyle, the nasal septum, and, to a lesser
extent, the maxilla. Transverse facial growth is completed between the first
and second decades, but anteroposterior and vertical facial growth continue
through adolescence and into early adulthood.8
In MRR, the nasal septum is transected and the maxilla is divided, removed,
and replanted. Facial growth abnormalities that result in malocclusion, maxillary
hypoplasia or resorption, or facial disproportion, therefore, represent potential
complications of MRR when it is performed on pediatric patients.
Maxillary removal and reinsertion has never been formally evaluated
as a surgical procedure for pediatric patients with incomplete facial development
at the time of surgery. The goals of this study were to investigate the outcome
of MRR in pediatric patients and to examine postoperative maxillary position
and integrity when MRR is used to treat anterior cranial base tumors in pediatric
patients.
PATIENTS AND METHODS
Medical record review identified 9 MRR procedures performed on pediatric
patients at The Ohio State University Hospital and Columbus Children's Hospital
between 1992 and 1998. The technique is summarized in Figure 1. A detailed description of this technique has been previously
reported.2 Inclusion criteria for this study
were age younger than 16 years at the time of surgery and a follow-up period
of at least 6 months postoperatively to monitor tumor recurrence and evaluate
for postoperative facial growth asymmetries.
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Figure 1. Summary of technique. A, Drawing
of maxillary removal and reinsertion in a young male patient. Procedure begins
with partial osteotomy at nasofrontal angle to allow extended midfacial degloving.
B, After extended midface degloving, left maxilla is exposed. Partial osteotomies
allow accurate plate placement before maxilla removal. C, Left maxilla has
been extracted, exposing anterior cranial base tumor. D, Photograph of extracted
left maxilla, held in anatomic orientation. E, Tumor has been extracted. F,
Maxilla restored to original anatomic position. In this photograph, maxilla
was secured with absorbable plates (LactoSorb system; W. Lorenz Surgical,
Jacksonville, Fla). Gingivobuccal incision closure, maxillary and nasal packing,
nasofrontal plate placement, and nasal casting complete the repair.
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A complete history and head and neck examination and transnasal fiberoptic
nasopharyngoscopy were performed on participating patients at The Ohio State
University Department of Otolaryngology outpatient clinic. Specifically, patients
were questioned and examined for visual disturbances (altered acuity, diplopia),
occlusion or bite abnormalities, palpable reconstruction plates, facial symmetry,
and presence or absence of residual or recurrent tumor.
Standard lateral cephalograms were obtained at The Ohio State University
School of Dentistry radiology suite. Analysis of cephalograms was performed
by calculation of 3 standard cephalometric measurements: basion (tip of clivus)
to A point (deepest point on the anterior maxillary alveolus), sella to A
point, and condylion (posterosuperior border of the mandibular condyle) to
A point. These measurements were chosen because age-, race-, and sex-matched
normative data exist for these criteria.9
Human subjects research protocol approval was obtained for this study
from the Institutional Review Board at The Ohio State University. Informed
consent was obtained from each participant and his or her legal guardian.
RESULTS
Of the 9 eligible pediatric patients who had undergone MMR, 5 consented
to participate in the study. Table 1
summarizes operative report, postoperative course, and follow-up history and
examination findings for these patients. The average age at time of presentation
was 13.8 years, the average follow-up age was 15.0 years, and the average
follow-up period was 14 months (range, 7-26 months). Treatment of JNA was
the indication for surgery in all participating patients, although 2 of the
nonparticipating patients underwent MRR for malignant tumor resection. The
average operative time was 6.9 hours, and the average blood loss was 1440
mL. Average transfusion requirement was 2.2 U of packed red blood cells per
patient. No perioperative complications were encountered in all cases.
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Table 1. Operative Record and Follow-up History and Examination Findings*
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Postoperative examination confirmed normal visual acuity and extraocular
motions in all cases; no complaints of diplopia were encountered. Facial symmetry,
assessed by examination of the maxillary alveolar arches, malar projection,
and zygomatic arch width, revealed that no grossly appreciable growth disturbances
occurred (Figure 2). Specifically,
it was not possible to determine clinically which maxilla had been removed
and reinserted until examination of the gingivobuccal sulcus revealed the
surgical scar. Occlusion was class I in all cases, and no bite abnormalities
were observed in any patient.
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Figure 2. Frontal (A), lateral (B), and
basal (C) photographs of a young male patient 27 months after left maxillary
removal and reinsertion.
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One long-term complication was encountered: epiphora in patient 5. All
patients reported some degree of postnasal drainage and/or nasal crusting
in the early postoperative course (ie, within the first 6 months postoperatively);
2 subjects had minor crusting on follow-up examination.
Table 2 summarizes cephalometric
measurements and radiographic interpretation of the standardized lateral cephalograms.
Additionally, the cephalograms were also reviewed by a pediatric radiologist
(J.R.D.) for plate migration and bony resorption. Plates were in appropriate
position in all cases. Clearly visible right and left anterior maxillary sinus
walls were identified in all 5 cases, and an absence of cortical thinning
around screws was observed in all cases. According to the pediatric radiologist,
it was not possible to determine which maxilla had been removed and reinserted
based on radiograph signal density of the anterior maxillary wall. These findings
were interpreted as adequate evidence that replanted maxillae did not resorb
and that the removed and replanted bone remained viable (Figure 3).
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Table 2. Lateral Cephalometric Analysis and Radiographic Interpretation
for Maxillary Development in 5 Patients After Maxillary Removal and Reinsertion*
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Figure 3. Lateral cephalogram (A) and detail
from cephalogram (B) of a young male patient 11 months after left maxillary
removal and reinsertion. Note absence of plate migration, absence of bony
resorption around cortical screws, and bilateral presence of anterior maxillary
sinus wall in cephalogram detail.
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COMMENT
Postoperative evaluation of pediatric patients who underwent MRR for
treatment of anterior cranial base tumors demonstrates that this procedure
provides adequate exposure for tumor removal without jeopardizing adjacent
important structures. No residual tumor, tumor recurrences, or serious complications
were identified in the 5 participating patients. However, further follow-up
will be necessary to confirm that surgery was successful in completely eradicating
the tumor in our study cohort. Although the participating patients for this
study had all undergone JNA, MRR may be appropriate for surgical treatment
of any anterior base neoplasm.10 Operative
blood loss and number of transfusions for these subjects were similar to those
reported in other series of surgically treated patients with JNA.11-12
Cephalogram analysis identified 2 patients (patients 2 and 3) who had
cephalometric measurements outside the normal distribution range. Preoperative
medical record review revealed that patient 3 had a preexisting palatal developmental
abnormality described by his primary physician several years before JNA diagnosis.
Patient 2 was diagnosed as being "small for age," but otherwise deemed proportionate
and bilaterally symmetrical by the author who performed cephalometric analysis
(S.S.), based on a comparison of the measurements to the available normative
data. Although normative data provide a helpful context for loose interpretation
of cephalometric measurements, further analysis of measurements obtained longitudinally
during the postoperative period will provide more valid information on the
nature of postoperative facial growth.
Radiographic interpretation of cephalograms revealed several important
findings. A bilateral anterior maxillary wall was identified in all subjects,
and bone adjacent to screws and plates showed no sign of cortical thinning
(Figure 3). These data strongly
suggest that replanted maxillae are not resorbed and that they remain viable
or possibly serve as a template for replacement by adjacent viable bone.
Normally, anteroposterior and vertical facial growth continue into late
adolescence and early adulthood.8 Thus, continued
growth of replanted maxillae, which could prevent late cosmetic or functional
deformity, may represent a benefit of primary facial skeletal reconstruction
aside from the immediate restoration of normal facial contours. Admittedly,
the small number of patients limits the power of this study, and serial cephalograms
collected at regular intervals would provide further data regarding midface
growth and the fate of replanted maxillae after MRR is performed in pediatric
patients. Although our series of participating patients is admittedly small,
this study provides important evidence that MRR is safe and effective and
does not result in serious cosmetic or functional impairment when it is performed
on pediatric patients.
Maxillary removal and reinsertion has undergone considerable changes
at our institution since its inception. Early in our experience with this
procedure, patients occasionally complained of palpable facial plates at the
nasal dorsum and maxilla.10 The procedure was
subsequently modified by placing 1.0-mm microplates, rather than larger miniplates,
at osteotomies where thin skin appeared to predispose to plate palpation,
specifically, the nasal dorsum and medial maxilla. This modification has eliminated
this complication (Table 1).
Recent investigations of facial plating have heightened awareness of
other potential complications of MRR. Resnick and colleagues13
reported a 10% reduction in cranial growth when miniplates were placed across
craniofacial suture lines in juvenile rabbits. Although we did not identify
facial growth disturbance on cephalogram or physical examination in our patients,
inhibited growth remains a theoretical concern because miniplates and microplates
are placed across nasofrontal and zygomaticomaxillary sutures in MRR. Additionally,
recent studies14 have demonstrated the incidence
of intracranial migration of microplates in juvenile animals. Although this
concerning phenomenon appears to occur primarily in neonates, one may consider
absorbable plates such as the LactoSorb system (W. Lorenz Surgical, Jacksonville,
Fla) to minimize the likelihood of growth inhibition or plate migration when
performing MRR in pediatric patients (Figure
1F). Absorbable plating systems have been used successfully by multiple
investigators for craniofacial surgery, most commonly in pediatric patients.15-17
CONCLUSIONS
Maxillary removal and reinsertion is safe and provides adequate access
for surgical removal of anterior cranial base tumors in pediatric patients.
Postoperative facial examination and lateral cephalometric measurements suggest
that MRR does not negatively affect subsequent facial growth and development
in pediatric patients and provide evidence that removed and replanted maxillae
remain viable.
AUTHOR INFORMATION
Accepted for publication August 24, 2001.
This study was supported in part by grant P30 CA16058 from the National
Cancer Institute, Bethesda, Md (Dr Schuller), The Ohio State University Comprehensive
Cancer Center Head and Neck Oncology Program, and the Arthur G. James Cancer
Hospital and Research Institute, Columbus.
Presented as a poster at the 13th Annual American Society of Pediatric
Otolaryngology Meeting, Palm Beach, Fla, May 12-14, 1998. Recipient of the
First Place Award for Clinical Research.
We thank Cheri Young, administrative assistant of The Ohio State University
Department of Otolaryngology, for her invaluable assistance in the preparation
of the manuscript.
Corresponding author and reprints: David M. Powell, MD, Department
of Otolaryngology, 4100 U.H.C., 456 W 10th Ave, Columbus, OH 43210.
From the Department of Otolaryngology (Drs Powell and Schuller) and
The School of Dentistry (Drs Carr and Shanker), The Ohio State University,
and the Departments of Radiology (Dr Dwek) and Otolaryngology (Dr Wiet), Columbus
Children's Hospital, Columbus; and the Department of Otolaryngology, Temple
University, Philadelphia, Pa (Dr Shah).
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