Genden EM, Okay D, Stepp MT, Rezaee RP, Mojica JS, Buchbinder D, Urken ML. Comparison of Functional and Quality-of-Life Outcomes in Patients With and Without Palatomaxillary ReconstructionA Preliminary Report. Arch Otolaryngol Head Neck Surg. 2003;129(7):775-780. doi:10.1001/archotol.129.7.775
Orodental rehabilitation of hemipalatomaxillectomy defects can be accomplished by using a prosthetic obturator or a vascularized bone-containing free flap. Whereas prosthetic obturation offers several advantages, including the opportunity for immediate dental restoration without the need for further surgery, vascularized bone grafts provide permanent closure of the oronasal communication and bone sufficient for the placement of osseointegrated implants.
To compare the functional and quality-of-life (QOL) outcomes in patients rehabilitated with a prosthetic obturator with defect-matched patients who underwent reconstruction with a vascularized bone-containing free flap.
Four hemipalatomaxillectomy patients rehabilitated with a tissue-borne prosthetic obturator were compared with 4 defect-matched hemipalatomaxillectomy patients who underwent reconstruction with a vascularized bone-containing free flap. All of the patients were objectively assessed for speech, mastication, and QOL. Functional status was assessed by mastication testing, voice analysis, and nasorhinometry. Swallowing-related QOL was assessed using a patient-reported, validated swallowing QOL questionnaire, and donor site morbidity was assessed using upper extremity and lower extremity questionnaires.
Patients who underwent reconstruction with a vascularized bone-containing free flap achieved higher mastication and speech assessment scores with less oronasal reflux than defect-matched patients rehabilitated with a prosthetic obturator. Swallowing QOL and donor site assessments demonstrated that compared with their prosthetic counterparts, reconstruction patients enjoyed a better QOL without incurring significant donor site morbidity.
Although palatomaxillary reconstruction with vascularized bone-containing free flaps requires a second operative site, this method of orodental rehabilitation of the hemipalatomaxillectomy defect can achieve superior functional and QOL outcomes relative to defect-matched patients rehabilitated with a prosthetic obturator.
REHABILITATION OF the postmaxillectomy defect has traditionally been accomplished with a prosthetic obturator; however, recent literature1,2 suggests that vascularized bone-containing free flaps (VBCFFs) may offer a significant advantage for orodental rehabilitation. Traditionally, prosthetic obturation has been touted as the gold standard for palatal reconstruction because it allows for immediate orodental rehabilitation without the need for a second operative site, and it permits careful surveillance of the maxillectomy cavity for recurrent disease.
Although prosthetic obturators provide a simple reconstructive solution for smaller palatal defects, extensive palatomaxillary defects represent a significant functional and aesthetic reconstructive challenge. Palatal defects that require resection of the ipsilateral canine often lead to problems with prosthetic retention and stability that may compromise speech and mastication.1 Similarly, defects involving the orbital rim, zygomatic body, or both can result in a significant cosmetic deformity of the orbit and the malar eminence that is poorly managed with a prosthetic obturator. Furthermore, elderly patients with compromised manual dexterity or patients with poor eyesight may have difficulty placing a prosthesis on a daily basis. Failure to maintain vigilant daily prosthetic hygiene can lead to crusting and malodor. Other such complaints include the social stigma associated with a prosthesis. Patients often express discontent with having to wear a prosthesis to perform such simple tasks as answering the telephone or drinking a glass of water. Such limitations can negatively affect a patient's quality of life (QOL) and activities of daily living.
In an effort to address these shortcomings, surgical reconstruction of the palatomaxillary complex has been reported using a variety of local,3,4 regional,5 and free tissue flaps.6- 8 Soft tissue flaps may provide a permanent partition between the oral and nasal cavities, but bulky flaps may preclude the retention of a tissue-borne obturator. Similarly, soft tissue flaps tend to give way to gravity, and although early postoperative results may demonstrate a suitable cosmetic augmentation of the midface and orbit, inevitably the soft tissue migrates inferiorly, resulting in a suboptimal long-term result. In addition, placement of a soft tissue flap eliminates the critical retentive properties of the defect such as the midline palatal shelf and the scar-band that forms the interface of the skin graft and mucosa. The VBCFFs offer the advantage of providing a bone graft that is suitable for reconstruction of the maxilla and placement of osseointegrated implants. This is particularly important in extensive defects that involve the orbital rim, the zygomatic body, or half of the hard palate.
Reconstruction using VBCFFs and placement of osseointegrated implants have been shown to significantly improve orodental rehabilitation in mandibular reconstruction compared with nonreconstructed mandibular defects9; however, the function and QOL of patients after VBCFF reconstruction of the maxilla have not been evaluated. This study was performed to assess and compare the function and QOL of hemipalatomaxillectomy patients after VBCFF reconstruction vs prosthetic obturation.
Eight defect-matched patients were administered a battery of mastication, speech, and QOL assessments. Patients were included in this study if they had previously undergone a hemipalatomaxillectomy, including resection of at least 1 canine tooth and no more than half of the hard palate (class II).1 Assessments of mastication, swallowing, and speech were performed in patients rehabilitated with a prosthetic obturator, patients who underwent reconstruction with a VBCFF, and nonsurgical controls. The controls remained constant throughout the study. Functional mastication was assessed by chewing performance; swallowing was assessed using a patient-reported, validated swallowing QOL survey (SWAL-QOL)10; and speech was assessed by nasometry, nasality, nasal emission, and speech intelligibility scoring. The patient's perception of his or her speech was also assessed using a short questionnaire. Donor site assessment questionnaires were administered to all of the participants to assess the effect of donor site morbidity on QOL.
Chewing performance is defined as the percentage of a given quantity of test food that a patient can chew to sufficient size such that it passes through a standard sieve after a given number of strokes.11 The 8 study patients and 4 control patients were each given 8 g of dry-roasted, unsalted peanuts to place in their mouths as a single bolus. They were then asked to chew 20 strokes, without swallowing, and then to expectorate the particles into a sieve with a mesh size measuring 2.36 mm (US Standard Sieve Series No. 8). Particles were collected in a second, smaller mesh measuring 1.12 mm (US Standard Sieve Series No. 4). The patients then rinsed their mouths 3 times with 20 mL of water, which was also expectorated into the sieve. Tap water was run through the upper sieve to collect any remaining small particles. This collected material was air-dried for 4 hours at ambient temperature and then weighed. Chewing performance was calculated as a percentage of the original 8-g bolus that passed through the sieve.
Nasality, nasal emission, and speech intelligibility were assessed in 4 patients who received obturators, 4 patients who underwent surgical reconstruction, and 4 controls. Speech performance was assessed by 4 licensed speech pathologists who were asked to rate the subjective intelligibility and resonance tasks. Speech samples for subjective rating of intelligibility and resonance were audiotaped. Participants were fitted with a head-mounted microphone placed at the level of the mouth and just lateral to the eye. Recording volume was adjusted to avoid peak clipping and to provide a constant sound level across participants. All participants were required to read the "rainbow" passage and to give a 1-minute monologue about their first job.
Speech samples were then digitized and presented via computer to the raters. A digital audiotape recorder coupled with a high-density linear A/D converter (model SBM-1; Sony Corp, New York, NY), a microphone preamplifier, and a head-mounted microphone (model 420; AKG Acoustics, Vienna, Austria) were used to record the resonance and intelligibility task samples. They were presented to the raters in a sound-treated booth. The samples for the intelligibility and resonance tasks were randomized, and the raters were presented with the intelligibility samples first and were asked to rate the degree of intelligibility of the monologue on a scale from 1% to 100%. Next they were asked to rate the resonance task with respect to the degree of hypernasality or hyponasality and the presence of nasal emission. The terms hypernasality, hyponasality, and nasal emission were defined so that it was clear that all raters were familiar with these terms. Nasality was rated on an 11-point scale, with –5 representing severe hyponasality, 0 representing normally balanced resonance, and 5 representing severe hypernasality. Nasal emission was rated on a 3-point scale, with 0 representing no nasal emission, 1 representing inconsistent nasal emission, and 2 representing consistent nasal emission. Scores were recorded and reported as means.
Patient-reported subjective speech perception was evaluated by administering to each patient a short questionnaire for rating his or her own level of communication in 6 different social situations. Each participant was asked whether he or she had difficulty speaking (1) to a known listener, (2) to an unknown listener, (3) in a noisy situation, (4) in a quiet situation, (5) face to face, and (6) on the telephone. Scores ranged from 5 ("never" experience difficulties with communication in public) to 1 ("always" experience difficulties). Scores were recorded for each patient, and the mean was calculated for each group.
A nasometer (model 6200; Kay Elemetrics Corp, Lincoln Park, NJ) was used to assess nasalance data. All participants were presented with 3 stimulus passages: (1) the "zoo" passage,12 which contains no nasal phonemes; (2) the rainbow passage,13 which contains 11% nasal phonemes; and (3) the "nasal" passage,14 which contains 35% nasal phonemes. Before testing each participant, the nasometer was calibrated according to manufacturer guidelines. All patients practiced reading the 3 stimulus passages aloud to gain familiarity with the passages and reduce the potential for mistakes. Once the patient was comfortable with the passages, the headset was placed as directed by the manufacturer. The passages were presented in the same order for all participants (rainbow, then zoo, and then nasal). Mean nasalance values were obtained for all passages.
Quality of life related to swallowing was assessed by administering the validated 44-item SWAL-QOL10 to all 4 obturator patients and all 4 VBCFF patients. Patients were asked to complete the survey to the best of their ability. The scores were generated and reported as means.
In an effort to elucidate the role of donor site morbidity on QOL, the upper extremity and hip were assessed using the validated Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire15 and the American Association of Orthopedic Surgeons (AAOS) Hip and Knee questionnaire, respectively. The DASH questionnaire was administered to assess the effect of a scapular harvest on QOL and function. A DASH questionnaire score of 0 indicates normal, pain-free function of the upper extremity and shoulder, and a score of 100 indicates complete impairment of the upper extremity. The AAOS Hip and Knee questionnaire was modified to consist of 14 questions related to pain, stiffness, and swelling of the knee and hip on ambulation (items 45-49). The AAOS Hip and Knee questionnaire was administered to assess the effect of an iliac crest–internal oblique free flap harvest on function and QOL. A score of 0 reflects no pain associated with either the hip or the knee during ambulation, and a score of 70 reflects extreme pain during ambulation. The questionnaires were administered to all 4 obturator patients and all 4 VBCFF patients. The scores were generated and reported as means.
Data in this study are presented as mean ± SD. For all nonparametric data, a 1-way analysis of variance was performed as an initial test, followed by a post hoc test. The Tukey test was performed for pairwise comparison of the control group and the 2 treatment groups (P<.05). A statistical software program (Statistica version 5.0; Statsoft Inc, Tulsa, Okla) was used for all data analysis.
Four patients (age range, 32-51 years; mean age, 42 years) who had undergone a hemipalatomaxillectomy followed by rehabilitation with a tissue-borne prosthetic obturator at least 1 year before evaluation (range, 1.1-4.4 years) were compared with 4 patients (age range, 18-69 years; mean age, 51.5 years) who had undergone a hemipalatomaxillectomy followed by VBCFF reconstruction and dental restoration at least 2.5 years before evaluation (range, 2.5-6.5 years) (Table 1). None of the patients had undergone resection of any portion of the soft palate. Two of the 4 obturator patients and 2 of the 4 VBCFF patients were treated with postoperative external beam radiotherapy that was completed before this study, and 1 obturator patient and 1 VBCFF patient had been treated with adjuvant chemotherapy that was completed before this study. All of the VBCFF patients underwent resection and primary reconstruction by the same surgical team.
Chewing performance in the control group (20.31 ± 3.12) was significantly better than that in the VBCFF group (13.27 ± 1.15) and the obturator group (10.15 ± 4.67) (Table 2) (P<.001). Although the chewing scores for the VBCFF group were higher than those for the obturator group, there was no statistically significant difference in function between these groups (P<.001).
Evaluation of resonance tasks (nasality and nasal emission) demonstrated that the obturator group performed with a greater degree of nasality (1.00 ± 1.00) and nasal emission (0.75 ± 0.84) than the VBCFF group (0.56 ± 1.14 and 0.50 ± 0.45) and the control group (0.01 ± 0.54 and 0.18 ± 0.23) (Table 3). Similarly, the VBCFF group demonstrated a higher speech intelligibility score (96.8 ± 2.56) than the obturator group (75.50 ± 35.14) (Table 2).
Subjective speech assessment scores reflected that the obturator group was less comfortable with tasks such as speaking to another individual face to face and on the telephone than the VBCFF group (2.80 ± 1.27 vs 4.25 ± 0.48) (Table 2).
Mean nasometry values from 3 passages demonstrated that the obturator group scored lower on the zoo (40.81 ± 24.28), nasal (72.24 ± 6.7), and rainbow (53.87 ± 12.15) passages than the VBCFF group (20.72 ± 12.35, 60.09 ± 5.4, and 37.43 ± 8.8, respectively) and the control group (9.02 ± 0.80, 58.6 ± 4.3, and 31.0 ± 3.7, respectively) (Table 3). Although these values suggest an increase in oral nasal reflux (nasalance) during speaking in the obturator group relative to the VBCFF and control groups, there were no statistical significances among the groups (P<.001).
On the SWAL-QOL, the VBCFF group scored 207 and the obturator group scored 107, suggesting that the VBCFF group has an improved QOL regarding swallowing.
The DASH questionnaire and the modified AAOS Hip and Knee questionnaire scores demonstrated no detectable donor site deficit in the VBCFF group compared with the obturator group. The VBCFF group mean DASH questionnaire score was 18 (range, 0-31), indicating mild impairment. The mean DASH questionnaire score for the obturator group was 29 (range, 0-58), also indicating mild impairment. The mean AAOS Hip and Knee score for the VBCFF group was 35 (range, 19-48), and the mean score for the obturator group was 39 (range, 29-41), also demonstrating equivalent levels of function.
The unique 3-dimensional infrastructure of the maxillary skeleton serves functional and aesthetic roles. Functionally, the palate, the alveolus, and the paired maxillary buttresses provide a platform for the dentition and an opposing arch for the mandible. Aesthetically, the maxilla provides support for the orbit and a framework for the nose and midface. The complex nature of the maxilla discouraged surgeons from reconstruction, and in the past, restoration of the maxilla was largely accomplished with a prosthetic obturator. For limited defects, prostheses offer a simple method for separating the oral and nasal cavities and provide immediate dental restoration without the need for a second surgery. However, stability and retention of prosthetic devices can be significantly compromised after an extensive resection in which the remaining maxillary bone has been diminished or the terminal abutment tooth is insufficient for long-term clasping. In such cases, the overwhelming tipping forces often result in a compromise in mastication and an increase in oronasal reflux. In addition, defects that involve a significant portion of the vertical maxilla such as the orbital rim or zygomatic body are not appropriately addressed, and failure to support these structures commonly leads to a progressive distortion of the globe and midface contour.
In an effort to address the shortcomings of prosthetic management of extensive palatomaxillary defects, early surgical reconstruction was achieved using a variety of soft tissue flaps.16- 18 Although a permanent separation between the oral and nasal cavities could be achieved, often the bulky nature of a soft tissue flap prevented the retention of a tissue-borne denture. Free bone grafts have been introduced in an effort to lend structure and form to the upper jaw19; however, the use of free bone grafts is often insufficient to accommodate osseointegrated implants. Eventually, Reideger20 and others7,21 introduced VBCFFs for the 1-stage reconstruction of the maxilla. Reconstruction of the bony infrastructure of the maxilla was a significant improvement over previous efforts to restore the midface; however, it was not until Urken et al9 demonstrated the functional advantage of osseointegrated implants for orodental rehabilitation after mandible reconstruction that this concept was applied to maxillary reconstruction.2,6,22 Reconstruction of the palatomaxillary complex using VBCFFs enables restoration of the bony alveolus, the orbital rim, and the zygomatic body. Although it seems intuitive that composite-free tissue reconstruction of the palatomaxillary complex offers patients a functional advantage relative to prosthetic rehabilitation, this study represents the first attempt, to our knowledge, to comparatively evaluate each technique.
In this study, we demonstrated that VBCFF reconstruction of extensive hemipalatomaxillary defects can result in near-normal mastication. Whereas 3 of the 4 VBCFF patients underwent rehabilitation with implant-borne dentures, 1 patient refused implants and was rehabilitated with a tissue-borne denture, demonstrating the advantage of VBCFF reconstruction for tissue-borne dental rehabilitation for patients who may never receive osseointegrated implants. In contrast, patients who underwent prosthetic rehabilitation consistently functioned at a lower level than their VBCFF counterparts. This group often complained of poor prosthetic stability during mastication testing. Similarly, nasality, nasal emission, and nasometry scores demonstrated persistent oronasal reflux, highlighting the advantage of a permanent tissue closure of the palatal defect. The clinical significance of the nasometry scores is reflected in lower resonance task and speech intelligibility scores in the prosthetic group.
The functional speech studies were helpful in assigning hard data to inquiry regarding function; however, the subjective speech assessment and the SWAL-QOL were used to better define the intangible impact of treatment on function and QOL as it specifically relates to swallowing. Subjective speech assessment revealed the effect of a prosthesis on one's self-confidence. The prosthetic group consistently demonstrated difficulty speaking in public and a general fear of being misunderstood during conversation. Others communicated a concern regarding halitosis related to the prosthesis and maxillary cavity odor. Although subjective speech assessment was performed using a nonvalidated questionnaire, it was helpful in understanding the effect of an unreconstructed maxillary cavity on a patient's psychosocial state and the effect of an obturator on QOL. The SWAL-QOL was used to define the patient's QOL regarding swallowing. Scores on the SWAL-QOL demonstrated that VBCFF patients had a superior swallowing QOL relative to the obturator group.
Finally, we applied the DASH and AAOS Hip and Knee questionnaires to assess the effect of donor site morbidity on function and QOL. Although the functional studies suggest that patients who undergo reconstruction with a VBCFF perform at a higher level than patients who undergo rehabilitation with a prosthetic obturator, the aim of the donor site assessments was to weigh the morbidity associated with a free flap harvest against the benefit of a composite tissue reconstruction. The scores on both assessments demonstrated no appreciable difference in extremity function or QOL between the 2 groups, suggesting that the functional benefit gained after VBCFF reconstruction is not diminished by the morbidity of a free tissue harvest.
Although smaller palatal defects are well managed with a prosthetic obturator and total palatomaxillary defects nearly always require free tissue transfer reconstruction, we chose to examine a controversial class of defects: the hemipalatomaxillectomy defect. The traditional approach has been to prosthetically reconstruct these defects; however, function and aesthetics can be significantly impaired in patients who are edentulous, require postoperative radiotherapy, or sustain a resection of the orbital rim or zygomatic body. Edentulous patients or patients with poor-quality dentition cannot use dental clasping and therefore are more susceptible to prosthetic instability and poor retention. Although placement of osseointegrated implants may offer a solution in some cases, often the patient is restricted financially or the remaining midface bone is insufficient for implants. Similarly, patients who require postoperative radiation therapy will sustain pain and difficulty tolerating a prosthesis throughout the course of radiotherapy. In our experience, primary reconstruction has allowed patients to maintain an oral diet throughout radiotherapy without the need for refitting a prosthesis because the tissues of the oral cavity succumb to the effects of irradiation. Although we did not assess the effect of cosmesis, it is clear that the ability to reconstruct the zygoma and support the orbit is an advantage that is unique to VBCFF reconstruction.
Although this study demonstrates some of the advantages of composite tissue reconstruction of the palatomaxillary defect, there are also limitations to this approach. Patient factors such as age, comorbidities, motivation, and financial restraints must be considered before embarking on such an elaborate reconstructive effort. In patients with such restrictions, prosthetic rehabilitation of small- to medium-sized defects is adequate. Similarly, defect factors such as the biological features of the primary tumor, previous radiation exposure, and extensive facial-cutaneous involvement will have an effect on the restorative decision-making process. An aggressive primary tumor with an associated poor prognosis represents a limitation to VBCFF reconstruction, and it may require months before the functional advantages can be realized. In contrast, a patient previously treated with external beam radiation followed by a salvage resection may have substantial radiation mucositis or poor dentition. Such patients are often poor candidates for prosthetic restoration and dental clasping. A VBCFF, in select cases, may improve function and QOL for the patient. Finally, patients who have undergone a palatomaxillectomy in addition to an extensive facial-cutaneous resection, for example, a rhinectomy or an extensive cheek defect, should be critically evaluated. Although a combination palatomaxillary and total rhinectomy defect represents a reconstructive challenge, this type of reconstruction requires a coordinated plan by the surgeon and the pros-thodontist. A VBCFF reconstruction of the palatomaxillary defect can complement the prosthetic restoration by providing the bone needed for an implant-borne prosthetic nasal restoration.
The small number of patients in this study is an inherent shortcoming; however, a consistent trend in all of the assessments suggests an advantage in swallowing-related QOL for patients who underwent reconstruction with a VBCFF. Furthermore, our findings suggest that patients who undergo a VBCFF reconstruction of a palatomaxillary defect do not sustain a compromise in QOL related to donor site morbidity.
Corresponding author and reprints: Eric M. Genden, MD, Department of Otolaryngology–Head and Neck Surgery, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029 (e-mail: email@example.com).
Accepted for publication November 7, 2002.
This study was presented at the annual meeting of the American Head and Neck Society, Boca Raton, Fla, May 11, 2002.
We thank Kelly Dunphy, BA, and Laura George, BA, for their assistance with this study.