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British Journal of Oral and Maxillofacial Surgery 54 (2016) 857862

Health-related quality of life after maxillectomy: obturator


rehabilitation compared with ap reconstruction
J. Breeze a,b, , A. Rennie a , A. Morrison c , D. Dawson a , J. Tipper a , K. Rehman a , N. Grew a ,
D. Snee a , N. Pigadas a
a
b
c

Department of Oral and Maxillofacial Surgery, New Cross Hospital, Wolverhampton, England WV10 0QP
Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Birmingham B15 2SQ
Biostatistical Operations, Worldwide Clinical Trials, Isaac Newton Centre, Nottingham Science Park, Nottingham, England NG7 2RH

Accepted 22 May 2016


Available online 5 June 2016

Abstract
Health-related quality of life (QoL) reported by patients has the potential to improve care after ablative surgery of the midface, as existing
treatment algorithms still generally revolve around outcomes assessed traditionally only by clinicians. Decisions in particular relate to
reconstruction with a flap compared with rehabilitation with an obturator, the need for adjuvant treatment, and morbidity related to the size
of the defect. We prospectively collected health-related QoL assessments for 39 consecutive patients treated by maxillectomy between 01
January 2010 and 31 December 2014 using the University of Washington Quality of Life Questionnaire, and who had a mean (SD) duration
of follow-up of 14 (4). We made sub-group analyses using paired t tests and analysis of variance (ANOVA) to compare reconstruction with
a flap with rehabilitation with obturators, size of the vertical defect, and whether adjuvant treatment with radiotherapy or chemoradiotherapy
adversely affected it. Overall there was a significant decrease in health-related QoL after treatment compared with before (p < 0.001), but
there was no significant difference in the effects of any of the paired reconstructive and rehabilitation treatments on it. Obturators remain an
important option for rehabilitation in selected patients in addition to reconstruction with a flap. We found that neither increasing the size of
the vertical defect (in an attempt to ensure clear margins) nor the use of postoperative radiotherapy seemed to have any adverse effect on QoL.
More patients are required before we can conclude that the potential survival benefits of such measures may outweigh any adverse effects.
2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Maxillectomy; Cancer; Quality of Life; Surgery; Complication

Introduction
The reconstruction and rehabilitation of patients after ablative surgery of the maxilla and midface remains one of the
greatest challenges currently faced by head and neck surgeons. Ablative surgery affects physical function, particularly
speech, chewing, and swallowing. 1,2 Treatment of the maxillectomy defect should aim to minimise the facial deformity,
restore oral function, and preserve psychological wellbeing.
Corresponding author at: Department of Oral and Maxillofacial Surgery,
New Cross Hospital, Wolverhampton, England WV10 0QP.

2,3

The most common options are rehabilitation with a prosthetic obturator, or reconstruction with a flap. Each option
has its advantages and disadvantages, and there is a need to
tailor treatment to patients individually.
Obturator rehabilitation remains the most common option
worldwide, and acceptance has been greatly improved
through retention provided by implants.4,5 Provision of an
obturator is a quick surgical option, with low cost, low morbidity, and the possibility of modification according to the
patients needs, and it can supply missing teeth and support soft tissues.2 Success is related in part to the extent
of resection of the soft and hard palate, 3 with larger obtu-

http://dx.doi.org/10.1016/j.bjoms.2016.05.024
0266-4356/ 2016 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

858

J. Breeze et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) 857862

rators causing more problems with appearance, pain, and


soreness in the mouth than reconstruction with a flap.1 Retention and stability of an obturator in particular can vary among
patients, and have the greatest impact on function and overall
acceptability.2
Reconstruction with a flap can potentially overcome the
problems associated with prosthetic obturators, particularly
nasal leakage and the need to clean and repeatedly refine the
prosthesis.1 Various flaps have been advocated, most commonly the temporalis flap; the osteocutaneous scapular, iliac
crest, and fibular flaps; and the fasciocutaneous radial forearm
and anterolateral thigh flaps. 4,5 This potentially overwhelming choice can be aided by classifying the defect into its
horizontal and vertical components.4,5 There is, however, an
appreciable potential morbidity for patients in undertaking
free flaps in terms of both the donor site, the potential for
failure, and the increased anaesthetic time and duration of
hospital stay.
Making the choice between rehabilitation with a flap or an
obturator is still not clear cut, and authors have suggested that
it is the surgeon who makes the final decision.4 The choice
varies depending on the size and shape of the defect, the
extent of disease, the requirement for postoperative radiotherapy, and the patients preference.6 Comparisons in outcome
between flap and obturator after maxillectomy have traditionally focused on measures such as intelligibility of speech and
postoperative diet.7 Although the psychological effects and
quality of life (QoL) are recognised, much less has been done
to quantify this outcome.4
Health-related QoL has become one of the primary determinants of outcome after treatment in head and neck cancer.
Unlike the more traditional measures of survival, locoregional disease control and function, QoL is assessed by
the patient independently of the clinician.8 A number of
papers have looked at it after maxillectomy, 1,57,919 with
a generally agreed reduction in overall scores in nearly
all patients.16 In patients who have had a maxillectomy
it is influenced by type and stage of tumour, skin loss,
extent of resection, postoperative radiotherapy, number and
condition of remaining maxillary teeth, and sociodemographic variables.2,3,6,913 Many different questionnaires
have been proposed for ascertaining health-related QoL
after maxillectomy,3,810,1315,1719 with the most common
being the University of Washington Quality of Life (UoWQoL).2,8,11,15 Although the Obturator Functioning Scale has
been well validated in terms of how well an obturator is
tolerated by a patient, 3,10 such a tool does not enable comparisons with outcomes after reconstruction. In addition, most of
these assessments were either retrospective, 2,3,811,15,1719 or
were not measured preoperatively. 3,9,10,13,14,17,18 We know
of only a single paper to date that has directly compared QoL
after maxillectomy between obturators and flaps.1 In addition, the effects of size of defect and the use of postoperative
radiotherapy in both groups are not clear.
The aim of this study was to ascertain the effects of differing treatments on QoL in patients after maxillectomy using a

standard questionnaire measured both before and after treatment.

Method
Assessments of health-related QoL both before and after
treatment were prospectively recorded for 39 consecutive
patients treated by maxillectomy at our centralised oncology service, covering three hospitals in the United Kingdom
(UK), between 01 January 2010 and 31 December 2014. The
University of Washington Quality of Life Questionnaire version 4 (UoW-QOL v4) was prospectively given to patients
to complete before they started treatment, and was used as
part of follow up until 18 months after treatment. 20 The
UoW-QOL v4 questionnaire consists of 12 questions, each
of which has between three and six Likert - scaled responses
rated from 0 (worst/poor) to 100 (best/excellent).20 Subjects included pain, appearance, activity, recreation, speech,
chewing, swallowing, shoulder pain, taste, saliva, mood,
and anxiety. Composite QoL functional scores were divided
into two subscales (physical compared with social-emotional
function) as suggested by Rogers and Lowe.21 These two
groups were subdivided by anatomical site and complication
rate. Scores for the physical function subscale were computed
as the simple mean of the following domain scores: chewing,
swallowing, speech, taste, saliva, and appearance. Scores for
the social-emotional function subscale were computed as the
simple mean of the following domain scores: pain; activity,
recreational, shoulder function, mood, and anxiety.
Questions were asked during a private consultation by a
clinical nurse specialist, and an interpreter was present if
required. Patients were excluded from paired analyses if they
did not have assessments after treatment, or if the assessments
were incorrectly completed. Postoperative defects were listed
using the classification suggested by Brown and Shaw, and
Peker et al, into vertical sizes.4,15

Statistical analysis
Comparison of the significance of differences between
normally-distributed continuous variables using mean composite social-emotional and physical health-related QoL
scores before and after treatment was made using a paired
t test and analysis of variance (ANOVA). Sub-group analyses were done to ascertain the significance of differences in
the effects of flap reconstruction compared with obturators,
size of vertical defect, and whether adjuvant treatment with
radiotherapy or chemoradiotherapy adversely affected QoL.
Probabilities of less than 0.05 were accepted as significant.
All statistical analyses and tables and figures were generated
using GraphPad Prism version 6.0 (GraphPad Software,
Inc., La Jolla, CA, USA).

J. Breeze et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) 857862

Results
Forty-three patients were treated by maxillectomy during
the study period, four of whom (9%) were excluded as
they did not have postoperative questionnaires completed.
Thirty-three of the remaining 39 (85%) had preoperative
questionnaires, and all 39 had at least one postoperative
questionnaire, completed. Twenty-six (67%) had a 6-month
follow up, all had a 12-month follow up, and 12 (31%) had
an 18-month follow up questionnaire completed. The mean
(SD) duration of follow up was 14 (4) months (Table 1).

Treatment
A mixture of obturators, pedicled flaps, and free flaps were
used for reconstruction and rehabilitation (Table 2). Of the
39 patients treated by maxillectomy, 16 (41%) had no adjuvant treatment, 13 (33%) had postoperative radiotherapy
alone (between 5560 Gy), and 10 (26%) had postoperative
chemoradiotherapy (all with cisplatin and 5FU).

University of Washington Quality of Life Questionnaire


(UW-QOL v4)
Overall there was a significant decrease in health-related QoL
after treatment compared with preoperatively (p < 0.001).
The three subset analyses are given below.

Flap reconstruction compared with obturator


rehabilitation on resultant health-related QoL
The comparison of QoL with flaps and obturators before
and after treatment is shown in Fig. 1. There was no significant difference in QoL after treatment between flaps and
obturators, either overall, or when analysed by physical function (mean difference 15.22, p = 0.31) and social-emotional
function domains (mean difference 7.93, p = 0.929). Similarly, when stratified by size of vertical defect using
dichotomised categories, small (Brown class 1 and 2) and
large (Brown class 3 and 4), there was no significant difference in mean QoL (p = 0.827 and p = 0.424 respectively,
Fig. 2).4

859

Table 1
Details of patients treated by maxillectomy for whom health-related quality
of life (QoL) data were available.
Variable

Flap
(n = 18)

Age and sex:


Mean (SD) age (years) at time 65 (9)
of operation
Male
10
8
Female
Analysis of scores before and after operation:
Included
15
3
Excluded*
Size and staging of tumour:
T1N0M0
0
0
T1N2bM0
5
T2N0M0
T3N0M0
1
9
T4aN0M0
1
T4aN2bM0
2
T4bN0M0
Histopathological diagnosis:
Adenocarcinoma
0
2
Adenoid cystic carcinoma
Odontogenic myxoma
0
15
Squamous cell carcinoma
1
Spindle cell carcinoma
Site of tumour:
10
Hard palate
6
Maxillary alveolus
Maxillary sinus
2
0
Nasal cavity
Adjuvant treatment:
8
Chemoradiotherapy
5
Radiotherapy
None
5
Recurrence of tumour:
Yes
5
No
13

Obturator
(n = 21)

Overall
(n = 39)

64 (5)

64 (7)

12
9

22 (56)
17 (44)

18
3

33 (85)
6 (15)

5
1
0
1
12
1
1

5 (13)
1 (3)
5 (13)
2 (5)
21 (54)
2 (5)
3 (8)

2
1
1
17
0

2 (5)
3 (8)
1 (3)
32 (82)
1 (3)

13
3
4
1

23 (59)
9 (23)
6 (15)
1 (3)

2
8
11

10 (26)
13 (33)
16 (41)

5
16

10 (26)
29 (74)

Signifies that six patients were excluded from paired analyses because
preoperative QoL questionnaires were not available. Data are expressed as
number (%).

Effect of size of vertical defect (Brown score)4 on


health-related QoL
Overall there was no significant difference in mean composite
QoL scores between vertical defect groupings either before
treatment (F(3,29) = 1.33, p = 0.283) or at last available
follow-up (F(3,29) = 0.96, p = 0.439). Results of composite
follow-up QoL results showed no evidence that larger defects
resulted in a worse QoL. While patients with Brown defects

Table 2
Reconstructive and rehabilitative options chosen for ablative defects classified according to defect size.
Defect

1
2
3
4
Total

Obturator

3
10
4
4
21

Pedicled flap

Soft tissue free flap

Temporalis

Radial forearm

Anterolateral thigh

Scapula

4
5
1
10

1
2
1
4

2
2

2
2

Composite free flap

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J. Breeze et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) 857862

Fig. 1. Health-related quality of life scores for each of the University of Washington questionnaire domains comparing flaps with obturators.

2 and 3 reported significantly lower follow-up QoL scores in


both the physical and social-emotional domains, patients with
a level 2 defect reported slightly more loss of physical function than social-emotional function (-13.66 compared with
-10.78, Table 3, respectively).

Fig. 2. Last available follow-up composite health-related quality of life


scores for patients with flaps compared with obturators, grouped by size
of vertical defect. Vert 1 = resection of alveolar bone, but not causing an
oronasal fistula; Vert 2 = maxillary resection not involving the orbit; Vert
3 = maxillary resection involving the orbit but preserving the eye; and Vert
4 = orbital enucleation or exenteration.4 .

Effect of postoperative adjuvant treatment on


health-related QoL
There was no significant difference in mean composite QoL
scores by vertical defect groupings at the last available
follow-up between patients given adjuvant treatment compared with no adjuvant treatment (F(6,25) = 0.87, p = 0.534).
Composite follow-up scores showed no evidence that the use
of postoperative adjuvant radiotherapy or chemoradiotherapy
resulted in significantly lower QoL scores in either functional
domain (Table 4).
Discussion
Outcomes reported by patients, such as health-related QoL,
are becoming increasingly important measures to facilitate

Table 3
University of Washington health-related quality of life scores showing the postoperative effects of the size of the vertical defect. Data are expressed as mean
(SD) except where otherwise stated.
Domain
Physical function domain:
Vertical Brown score 1 (n = 5)
Vertical Brown score 2 (n = 18)
Vertical Brown score 3 (n = 6)
Vertical Brown score 4 (n = 4)
Social-emotional function domain:
Vertical Brown score 1 (n = 5)
Vertical Brown score 2 (n = 18)
Vertical Brown score 3 (n = 6)
Vertical Brown score 4 (n = 4)

Treatment

Last available follow-up

Mean difference

95% CI

p value

98.9 (2.53)
92.4 (8.98)
99.1 (2.31)
96.5 (4.66)

84.8 (13.70)
79.0 (16.75)
74.6 (18.05)
80.7 (13.21)

-14.03
-13.46
-24.47
-15.83

(-33.15 to 5.09)
-23.35 to -3.57
-43.40 to -5.54
-35.13 to 3.46

0.111
0.011
0.021
0.080

98.0 (2.74)
93.2 (11.84)
98.4 (4.01)
93.0 (9.31)

81.2 (12.94)
82.4 (10.67)
73.7 (14.57)
86.6 (10.67)

-12.63
-10.78
-24.61
-6.38

-25.35 to 0.08
-17.55 to -4.00
-42.25 to -6.97
-18.33 to 5.58

0.051
0.004
0.016
0.188

Vertical Brown scores: 1 = resection of alveolar bone but not causing an oronasal fistula; 2 = maxillary resection not involving the orbit; 3 = maxillary resection
involving the orbit but preserving the eye; and 4 = orbital enucleation or exenteration.

J. Breeze et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) 857862

861

Table 4
University of Washington health-related quality of life scores for operation alone compared with postoperative radiotherapy or chemoradiotherapy.
Domain/adjuvant treatment
Physical function domain:
Radiotherapy or chemoradiotherapy (n = 17)
Surgery alone (n = 16)
Social-emotional function domain:
Radiotherapy or chemoradiotherapy (n = 17)
Surgery alone (n = 16)

Before treatment

Last available follow-up

Mean difference

95% CI

p value

96.2 (8.08)
94.0 (6.83)

80.0 (15.09)
78.5 (16.95)

-16.24
-15.42

-26.06 to -6.41
-24.60 to -6.23

0.003
0.003

95.0 (11.45)
94.7 (7.49)

80.7 (13.25)
83.0 (9.69)

-14.32
-11.68

-22.43 to -6.21
-18.11 to -5.24

0.002
0.002

patient-centred care, to screen for physical and psychological problems, and to monitor a patients progress over
time.22 QoL is a valuable measurement of outcome that
extends beyond the traditional clinician-judged measurements of outcome such as mortality and morbidity for patients
with cancer.16 However, it is difficult to measure because
it is multidimensional, subjective, and changes with time
and circumstances.23 In this study we aimed to use an
internationally-recognised and well-validated scale to try to
compare different treatments prospectively as well as to judge
the effect of the size of the maxillectomy defect on QoL.
The choice between flap reconstruction and provision of
an obturator remains controversial and is highly operatordependent. Moreno et al7 described what is to our knowledge
the largest comparative series to date (73 patients with
obturators and 40 reconstructed with flaps) and found that
reconstruction provided a better outcome for swallowing and
speech, particularly for larger defects in the horizontal or
dental component of the maxilla. The results did not differ significantly in the vertical dimension, but questionnaires
were not used and aesthetics (more likely to be a problem
in this dimension) were not measured. Previous studies also
reported no difference in health-related QoL between obturators and reconstruction for Class I and II defects.1,4,5 We
found no significant difference between flaps and obturators in terms of QoL at one year. Treatment must always
be tailored to an individual patients needs, but findings such
as ours confirm that obturators, particularly if retained with
implants, remain an acceptable option for rehabilitation in
selected patients.
The three-dimensional visualisation of invasion into the
midface, and the complex anatomy, can make obtaining clear
margins difficult. There is also an understandable desire to
maintain function and form whenever possible, such as by
preserving the eye. Invaded margins may necessitate adjuvant postoperative radiotherapy or chemoradiotherapy,24
and not all patients are likely to tolerate this so clinicians
have understandable concerns that it may adversely affect
their QoL for only a limited benefit in terms of survival.
For example, the strongest predictor of adverse effects on
QoL after obturator treatment is known to be postoperative
radiotherapy.2,12,14,15,18,21 In addition, the size of the defect
after maxillectomy, particularly the extent of resection of the
hard and soft palate, has been shown to affect the function of
the obturator and the QoL, with most studies reporting that

the larger the defect the worse the outcome.2,7,10 The limited
evidence for patients not treated with an obturator also suggests that larger defects result in worse QoL.1 We found that
neither increasing the size of the vertical defect in an attempt
to ensure clear margins, nor postoperative radiotherapy,
seemed to have an adverse effect on the health-related QoL.
We recognise that our study does have a number of
potential limitations. Mean (SD) time of follow up was
14 (4) months, and it may be that significant differences
between groups would have developed given more time.
However, studies that have evaluated QoL in patients with
tumours of the head and neck have shown that the most
important changes in QoL happen during the first year after
diagnosis.20,25 We also gave no detail on formal completeness of oral rehabilitation and made no objective tests, such
as measurement of trismus. We also had a sample size that
was insufficient to compare particular subgroups, such as the
effect of placement of implants in patients with obturators
compared with those that did not. We hope that by continued
prospective data gathering we will also be able to compare
the effects of subtypes of flaps used for different sizes of
defects on QoL. A multicentre trial would increase numbers of patients, and such a collaboration is currently being
attempted between units in our region.
The three general questions at the end of the UoW healthrelated QoL questionnaire reflect overall QoL and therefore
may include morbidity at donor sites. However, the use of
the UoW questionnaire since the inception of this study has
enabled the surgeons in our unit to tailor their surgical practice
to patients concerns. There has been gradual trend away
from use of the temporalis local flap because both clinicians
and patients dislike it, but there were too few of these flaps
to permit individual analysis of this subgroup. There were
also no fibular or DCIA flaps during this particular period,
which was purely a matter of chance and not the choice of
the operator. It is likely that had a larger group of patients
been studied then these bone flaps would have been used.
Despite these limitations we think that these results will add
to the evidence about decision-making in the treatment and
rehabilitation of patients after maxillectomy.

Conict of interest
We have no conflicts of interest.

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J. Breeze et al. / British Journal of Oral and Maxillofacial Surgery 54 (2016) 857862

Ethics statement/conrmation of patients permission


Health-related quality of life assessments are incorporated
into the management of our centralised head and neck oncology service and used to focus consultations to the patients
needs. All responses have been anonymised and patients data
kept strictly confidential.

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