bone graft /certified fixed orthodontic courses by Indian dental academy


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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

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bone graft /certified fixed orthodontic courses by Indian dental academy

  1. 1. BONE GRAFT INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Bone graft in maxillofacial surgery are used to correct or replace missing bone. Bone defect can be  Consequence of congenital and developmental deformities  Originate from tumour surgery, trauma or infection  Bone graft in cosmetic surgery.
  3. 3. Types of graft a. Auto graft transplanted from one region to another in same individuals. Allograft (Homograft) – is transplated from one individual to a genetically non identical individual of same species. Xenograft (Heteorgraft) – transplant from one species to another species.] Isograft – graft exchanged between genetically identical individual such as identical things.
  4. 4. Anatomical Classification of Bone graft 1. Cortical bone (as block, chip) 2. Cancellous bone 3. Cortico cancellous bone 4. Periosteal and osteoperiosteal graft 5. Marrow graft 6. Segment of shaft of long bone such as clavicle, ribs, scapula or tibia. 7. Whole bone graft 8. Osteoarticular graft 9. Pedicle bone graft 10. Free vascularized bone graft involving microvascular ananstomosis.
  5. 5. Clinical uses and function of bone graft  Delayed and nonunion of fracture  Filling of cavities in bone  Replacement of bone and joint loss  Augmentation of skeletal deficiency in the forehead, nose, maxilla and mandible.  Fusion of growth graft cartilage Function of bone graft in mandible  Restore normal continuity and function  Restore an overall satisfactory appearance of face  Furnishes a source of viable osteogenesis cells
  6. 6. Principles of Bone graft in mandible  State of health and nutrition of patient  Aseptic technique – surgical techniques should be extra oral to prevent contamination of oral flora.  Graft Bed - tissue scar from previous wound should be excises to ensure quality and quantity of recipient site. Submandibular incision should be placed as low as possible. It will move superiorly owing to increased contour of face as a result of graft.  Handling of the graft – graft must be handled carefully to prevent contamination and mechanical injury.
  7. 7. Storage media – isotonic normal saline, tissue culture medium. Osteoprogenitor cells are hardly capable of withstanding the trauma of removal upto 4 hours.  Fixation and immobilization of the graft a. Reconstruction plate b. Maximum mandibular fixation c. If there is no teeth proximal to the canine area on side of defect a lingual splint should be fabricated with an extensive area engaging the maxillary teeth above the defect. This prevent the torque between graft host interface. Tension can be relieved by removing the coronoid process. This will eliminate temporalis muscle influence on the proximal fragment.
  8. 8.  Wound Closure Wound should be closed in layers without tension.  Antibiotic Coverage BIOLOGIC BASIS OF BONY GRAFT  Most effective form of bone grafting is cancellous cellular bone. Mechanism of bone formation in a cancellous cellular bone emanate from survival of the osteoprogenitor cells (osteoblst & marrow cells).  Transplanted osteoprogenitor cells survive within the recipient tissue for first 3-4 days by a nutritional diffusion from the surrounding vascular tissue envelop.
  9. 9.  From 3rd day – capillary buds start proliferation from surrounding tissue. This establish oxygen gradient and acidosis, lactate in the graft signals macrophages to form macrophage derived angiogenesis factor.  Between 3rd and 14th day – complete revascularization occur. Endosteal osteoblast survive transplant and proliferate neoosteoid upon the surface of the cancellous bone trabeculae. Mineral component undergoes a gradual physiologic resorption mediated by osteoclast. Osteoclasts resorbs the bony trabeculae pattern, they release bone morphogenetic protein (BMP) from non-collagenase mineral matrix of bone. BMP direct stem cells transferred within the graft, stem cell within the local tissue and circulatory stem cells to differentiate into functional bone forming cell.
  10. 10. Phase I Bone formation  It arise from the survival endosteal osteoblast and marrow stem cells transferred within the graft material which form bone in a random haphzard fashion. Phase II Bone formation  The revascularization dependent resorption of transplated bone trabeculae in the early phase I bone followed by remodeling and replacement with new bone.  Phase II Bone begins about the third week after placement of graft. Via endosteum and periosteum of bone.
  11. 11.  Importance of phase I bone arise from the knowledge that the maximum quantity of bone available to the graft is formed in this phase.  The importance of phase II bone is remodeling of phase I bone to a long lasting bone capable of self renewal.  Usually phase II bone replaces phase I bone in a one to one ratio.
  12. 12. Type of free bone graft Donar site  Chin  Retromolar area  Nasal aperture  Skull  Rib  Iliac graft  Tibia
  13. 13. ILIAC GRAFT Ilium is major source of graft for maxilllofacial reconstruction. Anatomy of Iliac Medially - iliac muscle, ceacum, ascending colon Laterally - Abductor muscle of hip (gluteas muscle) Nerves - Lateral Femoral nerve  innervate lateral thigh. Subcostal nerve  over anterior iliac spine Iliohypogastric nerve  over iliac tubercle
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  15. 15. Approach to Iliac crust  Lateral approach stripping tensor fascia lata and gluteas medius  Medial approach stripping iliac muscle  Crystal approach splitting or removing proportion of iliac crest Disadvantages of Lateral Approach  Dissection of tensor fascia lata muscle laterally create gait disturbance.  Difficult to the strip muscle from the lateral aspect of ilium  Failure to appose the muscle to the ilium can results in gait disturbance. In extreme situation dragging limp or gluteal gait occur
  16. 16. Disadvantages of Crestal Approach  In long term will usually result in irregularity of crest - below the age of 20. Disadvantages of Medial Approach  It is associated with greater risk of damage to lateral fermoral cutaneous nerve of thigh. Meralgia paraesthesia in the upper lateral thigh.  Increased incidence of post operative ileus.  Increase post operative pain from disruption of abdominal wall musculature
  17. 17. Surgical Approach  Guideline to length of incision is depend on the maximum width of bone to be harvested. Types of Incision  Lateral incision  Medial incision Lateral Incision Approach  Incision is less likely visible than medial incision  Incision are made lateral to crest to avoid lateral fermoral nerve, 1cm posterior to anterior ilia spine to avoid subcostal nerve, extend upto 2cm posterior iliac tubercle.
  18. 18.  Incision carried down through – skin, subcutaneous fact, scarpa’s fascia to the muscular aponeurosis.  Iliac bone is approach 1cm below the crest in young. (Where the crest is cartilaginous and growth is expected) and 5mm below in adult. VARIOUS APPROACH TO PARTICULATE CANCELLOUS BONE MARROW  Clamshell approach – expand medial and lateral cortex to gain access to cancellous bone.  Trap door approach – pedicle the medial or lateral cortex on muscle to gain access.
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  20. 20. Tschopp approach – pedicle the iliac crest on the external oblique muscle to gain access.  Tessier approach – pedicle the medial and lateral portion of the crest by mean of oblique osteotomy.  TREPHINE TECHNIQUE  Incision is 2cm in length  No medial lateral stripping and incision carried down to iliac crest. Trephine is used to perforate iliac crest and cancellous bone is harvested upto depth of 3cm using a rotatary action.  Trephine is angulated 30° to vertical proceed between medial and lateral cortex. 
  21. 21. Approach to posterior Iliac Bone Posterior approach is used when a greater quantity of particulate bone is required.  Advantage More cancellous bone is available – approx. 2 to 2.5times the quantity taken from anterior iliac.   Less bleeding, less gait pain and disturbance Disadvantage  Overall operative time increased  Nerve damage (cluneal nerve)
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  23. 23. Approach Incision is made at well defined bone prominence laterally, where gluteaus maximumus inserts.  Curvilinear incision course medially about 3cm lateral to midline ending at length of about 10cm.  Direct approach avoid damage to superior cluneal and middle cluneal nerve.  RIB GRAFT Principles and indication  Rib graft - Combined orbital floor and medial orbital wall. Zygomatic arch and body reconstruction
  24. 24. - Nasal bridge reconstruction - Chondral cartilage is an ideal reconstruction for the mandibular condyle. - Split rib used for brain coverage Anatomy of Rib  There are 12 ribs on each side of thorax  Seventh is longest rib  Eleven and Twelve rib are not attach anteriorly  Eighth, Ninth and Tenth do not join the sternum directly but articulate with each other costal cartilage.
  25. 25.  Vascular supply by internal mammary (internal thoracic)  Cartilages is a relatively inert tissue and therefore resorp slowly. Cartilage has inherent stress which are not manifest immediately. Cartilage should be carved the left out of the body for thirty minutes to deform prior to final carving and placement in the recipient site. Surgical Approach  A 5cm long incision is made in the submammary crease, starting approximately 4mm from the midline.  Muscles encountered first is the lower edge of pectoralis major.  Lateral part of the wound, slips of seratus anterior can be seen inserting on to the rib.
  26. 26.  Curved Doyen rib raspatory used to strip full length of the rib.  Tudor Edward rib shear are introduced with their protector and slid along the surface of the rib to make the lateral cut first.  When cartilages harvested in continue with rib then a diamond of periosteum and perichondrium is left attached to the anterior surface of the adjacent rib and costeal cartilage to prevent disarticulation of bone and cartilage.  If large volumes of ribs are required a posterolateral thorocohomy incision is used.
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  28. 28. POST OPERATIVE CARE  Respiratory , pulse and blood pressure should be carried out every 15mins for first two hours then every 30mins for four hours.  Pain is controlled initially with Bupivacaine injection via epidural cannula. Complication  Plural tear - detect by placing water the wound and then exert positive pressure ventilation to see any bubbling in the wound.  If there is an air leak, a temporary chest drain inserted low in the anterior axillary line.
  29. 29. SKULL BONE Indication 1. Defect in orbital floor 2. Zygomatic prominence Anatomy  Skull consists of inner and outer table and a separated by vascular diploe.  Graft is taken from posterior part of skull, in the region of parietal and occipital bone  Approach – bicoronal or hemicoronal flap
  30. 30. Complication  Extra dural haematoma  Direct intracerebral damage  Counter coup injury  Osteomyelitis may develop in complete removal of cranial bone and it is treated by titanium cranioplasty.
  31. 31. MICROVASCULAR GRAFT  Iliac graft  Fibula graft  Radial forearm flap – Chinese flap  Scapula flap – French flap ILIAC GRAFT  History – in 1972 McGregor describe gran flap based on superficial iliac
  32. 32. IAN TAYLER – explained iliac crest has primary vascular anatomy of descending circumflex iliac artery. Anatomy  Iliac graft is based on vascular pedicle of DCIA and DCIV DCIA originate laterally from the external iliac artery and passes laterally on the deep surface of inguinal ligament.  Surgical Landmark  Iliac crest  Pubic tubercle  Inguinal ligament  External iliac artery.
  33. 33. Technique of identifying DCIA  Inguinal ligament  Ascending branch of DCIA from internal oblique muscle Surgical Technique  Skin is incised around the circumference of the flap and edge is elevated at the level of external oblique fascia towards a obligatory abdominal muscular cuff.  Incision extended to tubercle passing 1-2cm above the inguinal ligament.  Fibers of internal oblique and transverse abdominals muscles are divided at the same level least to identification of external iliac artery.  On the medial site bone cut is made 1cm below the DCIA
  34. 34. ILIAC GRAFT FOR MANDIBULAR RECONSTRUCTION  Iliac crest to form the lower border of the mandible  Anterior superior iliac spine – angle of the mandible  Anterior inferior iliac spine - condyle  Ipsilateral iliac crest is harvested pedicle emerges from the newly constructed angle to recipient vessels in the same side of the neck.  Contralateral crest – pedicle is positioned anteriorly and is positioned for vessel in apposide of the neck.
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  38. 38. Complication  Hernia formation is 12% in osteocutaneous flap and 4% pure osseous flap. Advantages  Iliac provides 6-16cm graft in length which allows three dimensional carving the shape of hemimandible. Disadvantage  Iliac crest is not ideal for angle to angle defect  Intra oral defect is not handle well by the bulk is skin paddle  Color match of iliac skin to fascia skin is poor
  39. 39. FIBULA GRAFT First reported by Ueba and Fujikawa in Japan and O’Brien & Morrison in Melbourne in 1977.  Hidalgo was the first to describe fibula transplantation for reconstruction of the mandible.  Surgical Anatomy  Fibula head articulated with tibia 2cm below the knee joint. A fibula is 40cm long bone this provide upto 26cm for transplantation.  Peroneal nerve run around the fibula head. Damage to the peroneal nerve are avoided by leaving 8cm of cranial fibula and angle joint by leaving 8cm of distal end. 
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  41. 41. Anterior to fibula – extensor hallucis longus muscle and extensor digitorium longus muscle.   Laterally - Peroneus longus and peroneus brevis muscle.  Dorsally - Soleus muscle and centrally flexor hallucis  Distally - Peroneus brevis muscle Vascular supply  Fibula is supply by peroneal artery It is a branch of posterior tibial artery and it run dorsal to intraosseous membrane and medial to fibula between tibialis posterior muscle and flexor hallucis longus muscles. 
  42. 42. Anterior  between crural peroneus septum and – extensor lodge  Posterior crural septum –  Fibula is accessed by dissection on the front or rear surface of the posterior crural septum. peroneus and flexor lodge Incision  Fibula is situated at the point of attachment of triceps fermoralis tendon.  Straight line connecting the fibula head and lateral malleolar mark the posterior crural septum.
  43. 43.  Detachment of anterior crural septum is followed by detachment of extensor digitorium longus and extensor hallucis longus as far as intraosseous band.  Peroneal artery is ligated and is dissected with the bone in lateral dorsal direction. Advantage  Constant topography  Long bone  High stability
  44. 44. Disadvantage  Short vascular pedicle  Low height of bone  Low height of recipient site for endosteal implant Complication  Damaged peroneal nerve will result in foot drop, loss of arches of the foot. Flaccid foot Radial forearm flap - Chinese flap  Flap originate in China, it was used to cover burn surface.  It was introduces to Western country by Muhlbauer
  45. 45. Indication  Mandible  Anterior wall of maxillary (orbital rim and floor are maintain)  Palatal defect Anatomy  Flap depends on ascending vascular radicals from radial artery to the over line fascia and skin and descending branch to the underlying periosteum of the radius.  Venous – superficial cutaneous vein and comitants accompanying the radial artery.  Radial osteocutaneous flap provide upto 16cm.
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  48. 48. Advantages It is ideal for elderly patient with an edentulous mandible with vertical height of 13 cm. Disadvantages  Inadequate bone for mandibular reconstruction  Two weak to withstand normal masticatory force.  Limbs is immobilized for 8 weeks  Incision on forearm hypertrophy and unsighty.
  49. 49. PEDICLE GRAFT  Parietal osteofascial free pedicle flap  Serratus rib free osteocutaneous flap  Sternocleidomastoid osteomyocutaneous flap  Pectoralis major rib osteocutaneous flap  Temporals osteomuscular flap PARIETAL OSTEOFASCIAL FREE PEDICLE FLAP Flap is based on superficial temporal vessel Partial or full thickness parietal calvarial bone is transferred with an apron of galea and parieto temporal fascia for restoration of upper and middle facial defect. arch of rotation of pedicle. Removal of zygomatic arch increase the
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  51. 51. Advantages Minimal donor site morbidity Disadvantages Minimal amount of bone stock available Associated morbidity of craniotomy Serratus rib free osteocutaneous flap Described by ostrup and Fredrickson in 1974. Mckee performed a clinical free rib graft for mandibular reconstruction. Anatomy Serratus pedicle flap is based on thoracodorsal vessel and muscle belly receive is best supply from the lateral thoracic artery.
  52. 52. Serratus anterior muscle orginate from 6 – 10 ribs and insert on to the costal of surface of medial aspect of scapula. Approach  Anterior approach is most reliable as vascular pedicle may be length by relying on the intercostal vessel, which branches from internal mammary artery. Posterior approach  Damage blood supply to the thoracolumbar spinecord. Advantages  Used for reconstruction of rib and syphyseal defect
  53. 53. Disadvantages  Less amount of corticocancellous bone  Weak to handle funcdtional masticatory post  Poorly suited for implant reconstruction  Skin vascular pedicle is unreliable  Winged scapular deformity Sternocleidomastoid osteomyocutaneous  Described by Conely and Gullan  Technique for raising SCM flap is to use contralateral muscle and bone for reconstruction.  Two third clavicle may be harvested.
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  55. 55.  SCM has tripartiat blood supply -Thyrocervical -Superior thyroid -Occipipal artery Advantages  Easy flap for one stage immediate reconstruction of oromandibular defect. Disadvantages  Exposure of great vessel of neck after mobilization and resulting contour deformity of neck.
  56. 56. Pectoralis major rib osteocutaneous flap  Described by Cuono – Ariyan  PM flap depends on vascular supply of thoraco acrominal artery, lateral thoracic artery and perforating braches from 1 to 6 intercostal by internal mammary artery. Incision – Inframammary incision  Skin island is chosen to lie in a transverse axis over 5th rib  Muscle dissected from 6th, 7th, 8th and proceed cephalad toward 5th and 6th intercostal.  Lateral flap is dissected from pectoralis minor to expose vascular pedicle.  Intercostal muscle between 5th and 6th rib are dissected
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  58. 58.  Rib is section at lateral and medial extent with rib cutter  Increase mobilization of flap is gained by dividing humeral, sternal and clavicular attachment. Advantage  Ease of harvest  Vesatile and durable flap containing long pedicle Disadvantags  Increase risk of pleural tear and pneumothorax formation Temporal osteomuscular flap  Described by Conley  McCarthy and Zide designed in the flap for orbital and frontal reconstruction.
  59. 59.  Flap depend on deep temporal artery  Dissection done through sub galeal plane to expose superficial artery and vein.  Full or partial thickness bone graft are harvested with bur Advantages  Superior viability of bone  Greater bone availability  Minimal associated morbidity and cosmetic effect Disadvantages  Poor anterior mobilization  Donar site volume defect that may affect jaw function and ranging of motion.
  60. 60. Leader in continuing dental education