J Korean Assoc Oral Maxillofac Surg.  2017 Jun;43(3):186-190. 10.5125/jkaoms.2017.43.3.186.

Tumor resection from retromolar trigone, posterolateral maxilla, and anterior mandibular ramus using lower cheek flap approach: a case report and review of literature

Affiliations
  • 1Department of Dentistry, School of Medicine and Institute of Health Science, Gyeongsang National University, Jinju, Korea. parkbw@gnu.ac.kr
  • 2Department of Oral and Maxillofacial Surgery, Changwon Gyeongsang National University Hospital, Changwon, Korea.

Abstract

A surgical approach involving the retromolar trigone, posterolateral maxilla, and pterygoid region is the most challenging in the field of maxillofacial surgery. The upper cheek flap (Weber-Ferguson incision) with subciliary extension and the maxillary swing approach have been considered as alternatives; however, neither approach provides sufficient exposure of the pterygoid region and the anterior portion of the mandibular ramus. In this report, we describe two cases in which a lower cheek flap approach was used for complete tumor resection in the retromolar trigone and the anterior mandibular ramus. This approach allows full exposure of the posterolateral maxilla and the pterygoid region as well as the retromolar trigone without causing major sensory disturbances to the lower lip. A mental nerve anastomosis after tumor resection was performed in one patient and resulted in approximately 90% sensory recovery in the lower lip. The lower cheek flap approach provides adequate exposure of the posterolateral maxilla, including the pterygoid, retromolar trigone, and mandibular ramus areas. If the mental nerve can be anastomosed during flap approximation, postoperative sensory disturbances to the lower lip can be minimized.

Keyword

Lower cheek flap; Retromolar trigone; Posterolateral maxilla; Anterior mandibular ramus; Surgical approach

MeSH Terms

Cheek*
Humans
Lip
Maxilla*
Surgery, Oral

Figure

  • Fig. 1 Preoperative clinical and radiographic views of Case 1. A. Arrow indicates the firm mass on the left side of the retromolar trigone. B, C. Positron emission tomography-computed tomography and magnetic resonance imaging show an isolated hot spot involving the anterior mandibular ramus, posterolateral maxilla, and retromolar trigone (arrows).

  • Fig. 2 Intraoperative photographs of Case 1. A. Lower cheek flap with upper vestibular incision allowing complete exposure of posterolateral maxilla, mandibular ramus, and retromolar trigone. A, B. Surgical field showing excision of the primary tumor along with a partial posterior maxillectomy and a marginal posterior (ramus) mandibulectomy. This approach also allows selective neck dissection I-III. C-E. Photographs show the surgical specimens of the selective neck dissection (C), posterior maxillectomy with pterygoid plate excision (arrow) (D), and marginal mandibulectomy with coronoid process excision (E).

  • Fig. 3 Postoperative clinical and radiographic views of Case 1. A, B. Six months after the operation, the patient showed approximately 40 mm of maximum mouth opening and an acceptable facial scar. C. Two-year postoperative panoramic view indicating an intact inferior alveolar canal and mental foramen (arrows).

  • Fig. 4 Preoperative radiographs of Case 2. A-C. Large radiolucent lesion evident in the left mandibular body and ramus (arrows).

  • Fig. 5 Intraoperative photographs of Case 2. A. During creation of the lower cheek flap, the mental nerve was ligated and marked with suture material (arrow), then it was severed and the flap was elevated. B, C. The tumor (arrow) was completely excised from the anterior mandibular ramus while preserving the inferior alveolar nerve. D. Following excision of the tumor, the mental nerve was anastomosed using 7-0 nylon suture (arrow).

  • Fig. 6 Postoperative clinical and radiographic views of Case 2. A, B. Six months postoperative, the surgical wounds had healed and a dental implant was placed at the surgical site. C, D. On panoramic and computed tomography views obtained 1-year postoperative, regenerated new bone tissue (asterisk) and an intact inferior alveolar canal were detected (arrows). In addition, a dental prosthesis was visible at the site of the left mandibular first molar.


Reference

1. Lore JM, Medina JE. Partial and radical maxillectomy. In : Lore JM, Medina JE, editors. An atlas of head & neck surgery. 4th ed. Philadelphia: Elsevier Saunders;2005. p. 236–249.
2. Balm AJ, Smeele LE, Lohuis PJ. Optimizing exposure of the posterolateral maxillary and pterygoid region: the lower cheek flap. Eur J Surg Oncol. 2008; 34:699–703. PMID: 18029135.
Article
3. Alves FRA, Granato L, Maia MS, Lambert E. Surgical approaches to juvenile nasopharyngeal angiofibroma: case report and literature review. Int Arch Otorhinolaryngol. 2006; 10:e162–e166.
4. Girish Rao S, Sudhakara Reddy K, Sampath S. Le Fort I access for juvenile nasopharyngeal angiofibroma (JNA): a prospective series of 22 cases. J Craniomaxillofac Surg. 2012; 40:e54–e58. PMID: 21458288.
5. Sumi T, Tsunoda A, Shirakura S, Kishimoto S. Partial maxillary swing approach for removal of the tumors in the retromaxillary area. Auris Nasus Larynx. 2009; 36:567–570. PMID: 19261408.
Article
6. Wei WI, Ho CM, Yuen PW, Fung CF, Sham JS, Lam KH. Maxillary swing approach for resection of tumors in and around the nasopharynx. Arch Otolaryngol Head Neck Surg. 1995; 121:638–642. PMID: 7772315.
Article
7. Fee WE Jr, Moir MS, Choi EC, Goffinet D. Nasopharyngectomy for recurrent nasopharyngeal cancer: a 2- to 17-year follow-up. Arch Otolaryngol Head Neck Surg. 2002; 128:280–284. PMID: 11886344.
8. Jian XC, Liu JP. A new surgical approach to extensive tumors in the pterygomaxillary fossa and the skull base. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003; 95:156–162. PMID: 12582354.
Article
Full Text Links
  • JKAOMS
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr