Because of the importance and complexity of the invasion range and the adjacent area of primary maxillary sinus cancer, and its poor biological behavior and survival rate, there is a certain difficulty in controlling the radical resection and safety margin. In view of such principles for facilitating the timely detection and treatment of postoperative recurrence of maxillary malignant tumor, the authors suggest that, for some maxillary tumors with higher malignant degree such as primary maxillary sinus cancer and osteosarcoma and combined with sinus wall damage, at the same time of performing radical tumor resection, the open repair methods of using the man-made support such as titanium mesh to maintain the appearance of the midface and wearing a prosthesis can be applied firstly, and then the surgical reconstruction can be implemented at 2 years after surgery when there is no local recurrence and distant metastasis.

After radical maxillary tumor resection, due to simultaneous defects in bone tissues such as the orbital bone, cheekbone, and nasal bone, the patient’s appearance can be affected in different degrees. With the development of CT, MRI, and endoscopic techniques, the concerns in the past that the immediate use of autologous tissue to repair and reconstruct the maxilla may affect the examination of tumor recurrence are gradually eliminated, and there is no data to support that the prognoses of patients with surgical reconstruction are poorer than those of patients without surgical reconstruction. Therefore, for patients with tumors of higher malignant degree that primarily occurred in the palate and gingiva, the lesions are relatively limited and do not invade the maxillary sinus; for patients with tumors which can be completely removed or some patients with tumors of low malignant degree, the lesions invade the maxilla but do not invade through the sinus wall; the authors advocate that the closed repair and functional reconstruction are performed at one stage, according to the defect statuses in maxilla and adjacent bones; the artificial prosthesis (biological material or titanium mesh) can be used as scaffolds to reconstruct the anatomical shape, and then the oral surface or nasal surface is covered with the free composite tissue flap to restore the alveolar crest and palate and reconstruct the nasal passage and separate the oral and nasal cavities. The implants can be transplanted immediately or delayedly to restore the patient’s chewing function finally.

The prosthodontic repair is mainly used for limited maxillary defects such as Class 1 defects of Brown classification, and the patients who are not suitable for repair with vascularized tissue flap and whose remaining teeth have enough support strength. The local tissue flaps such as palate island flap and buccal fat pad flap allow the surgeons to exchange for repair of smaller maxillary defects with minimal damage; some regional tissue flaps such as temporalis muscle flap and submental island flap have all been successfully used to reconstruct relatively larger defects in midface and maxilla. But because the regional tissue flaps often lack sufficient amount of tissue to fill the defect, as well as the length of the vascular pedicle is insufficient to reach the defect area, it is subjected to certain restrictions in application in repair and reconstruction of larger maxillary defects.

The artificial implant materials used in the reconstruction of the maxilla include titanium mesh, titanium, and biomaterials, of which the titanium mesh is most widely used and reliable. The safety of maxillary reconstruction with titanium mesh has long been recognized by the majority of scholars, because the titanium and titanium alloys have stable physical, chemical, and biological properties, good biocompatibility, light weight, high strength, corrosion resistance, and low conductivity and have the advantage of being transmitted by X-ray which other metals do not have. The application of titanium mesh in repair and reconstruction is dated back to its application in repair of defects in the skull, skull base, and orbital floor caused by tumors or trauma, and some scholars use it for reconstruction of maxillary defects, and the titanium mesh can be used alone and can also be used in combination with soft tissue flaps or free bone transplantation. Because the titanium mesh has a better image quality on CT and MRI, therefore, the use of the titanium mesh to reconstruct the mandible does not have an effect on the monitoring of tumor recurrence. Another advantage of the titanium mesh is that it has sufficient strength to support the midface and orbital contents. Tideman (1993) [3] first performed repair of maxillary defects by means of casting titanium mesh scaffold, filling it with autologous iliac bone, and wrapping it with temporalis myofascial flap; its recent application in four cases has obtained satisfactory results. But the shaping precision and flexibility of the casted titanium mesh are poor; there is a certain difficulty in making relatively great adjustment during surgery, coupled with reasons such as inadequate tissue volume in single temporalis myofascial flap; and it may result in exposure of titanium mesh after surgery; therefore, the technology has not been promoted. In addition, although the postoperative appearance of titanium mesh is generally satisfactory and the operation is relatively simple, however, if the surgeon is inexperienced and local blood supply and decreasing tension are ineffective, this can cause postoperative wound infection, fistula formation, and increase the probability of exposure of titanium mesh; it should be used with caution especially in patients with Class 3–4 defects of Brown classification or in patients who have received radiotherapy or need to have postoperative radiotherapy.

The vascularized free tissue flap can be used to reconstruct simultaneously the compound and complex defects in maxilla and midface and is not affected by the location of the donor site, and the vascularized free tissue flap includes two types such as soft tissue flap and hard tissue flap. The soft tissue flap mainly plays roles in covering or filling the defects and eliminating the dead space, but the soft tissue flap cannot be used for bone reconstruction of the maxillary defect and therefore cannot achieve the purpose of implanting artificial tooth for repair. The new alveolar crest repaired by soft tissue flap is relatively blunt, and at the same time, it is more difficult to restore the shapes of the buccal gingival sulcus and palatal arch, showing a trampoline-like form, and most patients are unable to wear partial or half mouth denture. In addition, although the recent results are often unsatisfactory, because of factors such as muscle atrophy and gravity action, the long-term effect of soft tissue flap reconstruction, especially the recovery of appearance, will be far less than expected. Since the 1990s, along with the application of vascularized composite bone muscle (skin) flaps in reconstruction of maxillary defects by various scholars worldwide, the vascularized composite bone muscle (skin) flap combined with the planting techniques are extensively used, which opens up a new era for repair and reconstruction of maxillary defects. The advantage of vascularized composite bone muscle (skin) flap is that it can reconstruct the osseous pillar and appearance of the midface and make up the shortcoming that the soft tissue flap cannot serve as the support due to the long-term atrophy; the chewing function can be reconstructed combined with the implant denture technique, so as to achieve the true meaning of the functional reconstruction of maxilla.

Although the vascularized composite bone flap has played a dominant role in the reconstruction of maxillary defects, for bone graft shaping and facial appearance reconstruction, except on the basis of skull specimens, the previous operators always carried out estimation according to individual clinical experience, whose subjectivities can be imagined, so that the repeatability was poor, and it was difficult to recover the ideal appearance of the midface, which had a certain distance from the requirements for reconstruction of maxillofacial appearance and function. Therefore, how to achieve the optimum combination and have a good construction and prediction before surgery? The appearances and the application of technologies such as the rapid prototyping and computer-aided design (CAD)/computer-aided manufacturing (CAM) provide reliable guarantees for reconstructing new ideal morphology of the maxilla to restore its original appearance and function and realize individualized reconstruction in the true sense. The rapid prototyping is a high-tech manufacturing technology which started to be commercialized at the end of the 1980s. Since the CAD/CAM system had characteristics such as precision, visualization, and strong operability, this technology was introduced into surgery soon and gradually showed its advantages in the field of oral and maxillofacial surgery. For example, Tideman et al. (1993) performed immediate repair for the defect after maxillectomy using combined methods such as pure titanium mesh scaffold casted by CAD/CAM technology, filling with autogenous iliac bone block and the transfer of temporalis myofascial flap to cover the inner and outer layers of the scaffold, which recently received satisfactory results. Since 2000, the author [10, 11] had been applying the CAD/CAM technology as the means of model surgery for reconstruction of large maxillary defects (Class 2–3 defects of Brown classification), had been using the preoperative prefabricated titanium mesh to recover the appearance of the maxilla, and thus had achieved a good reconstruction effect through reconstructing the anatomical shape of the maxilla. The specific surgical approach will be detailed later.

The application of CAD/CAM technology in the reconstruction of maxillary defects has the following advantages compared with the traditional method: First, it can more accurately recover the appearance of the maxilla and thus effectively carry out anatomical reconstruction. Secondly, the osteotomy guide is designed preoperatively according to the model to determine the fixed locations of osteotomy line, titanium mesh, and titanium plate, which is conducive to guiding the accurate placement of the bone graft and the axial direction of implant placement during surgery to prevent postoperative deviation, in addition, which can effectively save time and attain the result with half effort. But it still has disadvantages such as longer production cycle, weakened bone area which is not conducive to stent bending, and slightly higher costs.

The radial forearm skin flap was formed initially by a Chinese scholar Professor Yang Guofan (1978). Because it has advantages such as long vascular pedicle, thick diameter, larger area for harvesting the skin and fascia, and simpler preparation, it is considered to be a good choice for the reconstruction of oral mucosa and has been widely used. In the reconstruction of maxilla, the radial forearm skin flap is used previously to mainly reconstruct the soft palate defects and the limited Class 1 defects of Brown classification. Since 2000, the author had been applying the CAD/CAM technology as the means of model surgery for reconstruction of large maxillary defects – Class 2–3 defects of Brown classification – and had been using the preoperative prefabricated titanium mesh to recover the appearance of the maxilla. The anatomic structure of the maxilla at one stage was reconstructed with the method of folding the free radial forearm skin flap to repair the oral and nasal wounds, and thus the functions such as chewing, speaking, and ventilation were restored. To 2002, it had been clinically applied in 19 cases, and the satisfactory results had been obtained. This method makes the three-dimensional reconstruction of large maxillary defects more accurate and more individualized. This method will be introduced in the following paragraph through taking the reconstruction of Class 3 defects of Brown classification for an example.