**7. Pediatric reconstruction**

tissue base that resists abrasion and reduces mucus secretion, minimizing poor hygienic environments. The opposing mandibular ridge is important to the stability of the obturator. Prosthetic rehabilitation of the maxillectomy patient is performed in three phases. Stage one starts with the placement of the surgical packing and surgical obturator, which is retained for 5 to 7 days by screw or wire fixation. This helps re-establish oral contours and allows the patient to start a liquid diet almost immediately postoperatively, bypassing the need for nasogastric feeding. In the second stage, the surgical obturator is removed and modified with a tissue conditioner. As the obturator is modified, the patient learns how to swallow less forcefully, and leakage around the prosthesis decreases. The third stage can be anywhere from 3 months to over a year after maxillectomy, when the definitive obturator prosthesis is fabricated [172]. In maxillectomy patients, osseointegrated implants may be placed in the residual alveolar ridge or horizontal palate. An edentulous maxillectomy defect has the poorest prognosis for accepting an obturator. It is impossible to achieve retention of a complete maxillary denture. Thus, endosseous implants may aid in retention, stability, and support of the obturator prosthesis; a bar and clip, magnet, and ball-0-ring gasket-type keeper are widely used in these situations. The bar and clip assembly provides the obturator prosthesis with improved stability and retention. For patients with significant extraoral tissue loss, the facial prosthesis also has limitations related to retention and stability. The extraoral application of implants has been a

significant advance in maxillofacial prosthetics (Figure 32).

698 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 32. Orbit prosthesis** 

**Figure 32.** Orbit prosthesis

**Pediatric Reconstruction** 

For example, implants placed in the mastoid bone or the temporal bones allow an auricular implant to be fixated via bar splinting. A nasal prosthesis can use a similar retention technique and have its fixtures placed in the floor of the nose. And in situations in which tumor ablation included the orbit, implants can be placed in the supraorbital rim region [173]. As with intraoral dental implants, extraoral sites require proper hygiene practices to ensure tissue health.

**Postoperative Evaluation** 

of pediatric orofacial defects following extensive tissue losses.

dental implants, extraoral sites require proper hygiene practices to ensure tissue health.

Mandibular reconstruction and rehabilitation in a 7-year-old with osteosarcoma were recently reported by Richardson and Cawood [174]. They made every effort to maintain the functional matrix so as not to disturb the normal growth processes of the face. After tumor ablation with a partial mandibulectomy, immediate reconstruction with a titanium mesh tray was performed without bone graft. This technique allowed the tray to function as a space maintainer. When the patient approached the onset of puberty, the tray was removed and a composite circumflex iliac crest free flap was used to restore the continuity and soft tissue deficiencies. Microvascular anastomosis of the donor and recipient sites was used. Two years later, osseointegrated implants were placed, with a subsequent vestibuloplasty with a split-thickness skin graft. They concluded that the multidisciplinary approach to the care of this patient, along with the introduction of revascularized free tissue transfer with osseointegrated implants, revolutionized the reconstruction

The postoperative care and management of complications require an understanding of osseous wound healing and the potential causes of failure. Loss of skeletal stability as a result of loss of fixation allows for motion at the wound interface, with secondary impairment of vascularization. Early recognition of flap compromise is associated with improved chances of flap salvage. The ideal flap monitoring technique should be reliable, reproducible, easily interpretable, inexpensive, noninvasive, rapidly responsive to changes in microcirculation, and able to provide continuous monitoring in the immediate postreconstructive period. The clinical examination should focus on capillary refill time (>3 seconds is the cutoff), which provides information on the adequacy of the arterial supply. Early venous outflow obstruction results in capillary refill that is too brisk. The color of a flap can also provide information about arterial insufficiency. A pale flap signifies poor flap perfusion, whereas one with outflow obstruction is congested and hyperemic. Skin temperature can assess the adequacy of circulation in digits but is of little use when applied to

51

Mandibular reconstruction and rehabilitation in a 7-year-old with osteosarcoma were recently reported by Richardson and Cawood [174]. They made every effort to maintain the functional matrix so as not to disturb the normal growth processes of the face. After tumor ablation with a partial mandibulectomy, immediate reconstruction with a titanium mesh tray was performed without bone graft. This technique allowed the tray to function as a space maintainer. When the patient approached the onset of puberty, the tray was removed and a composite circumflex iliac crest free flap was used to restore the continuity and soft tissue deficiencies. Microvascular anastomosis of the donor and recipient sites was used. Two years later, osseointegrated implants were placed, with a subsequent vestibuloplasty with a split-thickness skin graft. They concluded that the multidisciplinary approach to the care of this patient, along with the introduction of revascularized free tissue transfer with osseointegrated implants, revolution‐ ized the reconstruction of pediatric orofacial defects following extensive tissue losses.
