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INDIAN DENTAL ACADEMY
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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.
Types of graft
Auto graft transplanted from one region to another in same
Allograft (Homograft) – is transplated from one individual to a
genetically non identical individual of same species.
(Heteorgraft) – transplant from one species to
Isograft – graft exchanged between genetically identical individual
such as identical things.
Anatomical Classification of Bone graft
Cortical bone (as block, chip)
Cortico cancellous bone
Periosteal and osteoperiosteal graft
Segment of shaft of long bone such as clavicle, ribs, scapula
Whole bone graft
Pedicle bone graft
Free vascularized bone graft involving microvascular
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
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.
- 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.
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
Wound should be closed in layers without tension.
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 &
Transplanted osteoprogenitor cells survive within the
recipient tissue for first 3-4 days by a nutritional diffusion from the
surrounding vascular tissue envelop.
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
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.
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.
Importance of phase I bone arise from the knowledge that the
maximum quantity of bone available to the graft is formed in this
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
Type of free bone graft
Ilium is major source of graft for maxilllofacial reconstruction.
Anatomy of Iliac
iliac muscle, ceacum, ascending colon
Abductor muscle of hip (gluteas muscle)
Lateral Femoral nerve innervate lateral
Subcostal nerve over anterior iliac spine
Iliohypogastric nerve over iliac tubercle
Approach to Iliac crust
Lateral approach stripping tensor fascia lata and gluteas
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
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
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
Increased incidence of post operative ileus.
Increase post operative pain from disruption of abdominal
Guideline to length of incision is depend on the maximum
width of bone to be harvested.
Types of 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.
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
VARIOUS APPROACH TO PARTICULATE CANCELLOUS
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.
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.
Incision is 2cm in length
No medial lateral stripping and incision carried down to iliac
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.
Approach to posterior Iliac Bone
Posterior approach is used when a greater quantity of
particulate bone is required.
More cancellous bone is available – approx. 2 to 2.5times the
quantity taken from anterior iliac.
Less bleeding, less gait pain and disturbance
Overall operative time increased
Nerve damage (cluneal nerve)
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
Principles and indication
Rib graft -
Combined orbital floor and medial orbital wall.
Zygomatic arch and body reconstruction
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.
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
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
Lateral part of the wound, slips of seratus anterior can be
seen inserting on to the rib.
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.
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
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.
Defect in orbital floor
Skull consists of inner and outer table and a separated by
Graft is taken from posterior part of skull, in the region of
parietal and occipital bone
Approach – bicoronal or hemicoronal flap
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.
Radial forearm flap – Chinese flap
Scapula flap – French flap
History – in 1972 McGregor describe gran flap based on
IAN TAYLER – explained iliac crest has primary vascular anatomy
of descending circumflex iliac artery.
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.
External iliac artery.
Technique of identifying DCIA
Ascending branch of DCIA from internal oblique muscle
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
Fibers of internal oblique and transverse abdominals muscles
are divided at the same level least to identification of external iliac
On the medial site bone cut is made 1cm below the DCIA
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
Contralateral crest – pedicle is positioned anteriorly and is
positioned for vessel in apposide of the neck.
Hernia formation is 12% in osteocutaneous flap and 4% pure
Iliac provides 6-16cm graft in length which allows three
dimensional carving the shape of hemimandible.
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
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.
Fibula head articulated with tibia 2cm below the knee joint.
A fibula is 40cm long bone this provide upto 26cm for
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.
Anterior to fibula – extensor hallucis longus muscle and
extensor digitorium longus muscle.
Peroneus longus and peroneus brevis
Soleus muscle and centrally flexor
Peroneus brevis muscle
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.
Posterior crural septum –
Fibula is accessed by dissection
on the front or rear surface of the
posterior crural septum.
peroneus and flexor lodge
Fibula is situated at the point
of attachment of triceps fermoralis
Straight line connecting the
fibula head and lateral malleolar mark
the posterior crural septum.
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.
Short vascular pedicle
Low height of bone
Low height of recipient site for endosteal implant
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
Anterior wall of maxillary (orbital rim and floor are maintain)
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.
It is ideal for elderly patient with an edentulous mandible with vertical
height of 13 cm.
Inadequate bone for mandibular reconstruction
Two weak to withstand normal masticatory force.
Limbs is immobilized for 8 weeks
Incision on forearm hypertrophy and unsighty.
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
Minimal donor site morbidity
Minimal amount of bone stock available
Associated morbidity of craniotomy
Serratus rib free osteocutaneous flap
Described by ostrup and Fredrickson in 1974.
a clinical free rib graft for mandibular reconstruction.
Serratus pedicle flap is based on thoracodorsal vessel and muscle
belly receive is best supply from the lateral thoracic artery.
Serratus anterior muscle orginate from 6 – 10 ribs and insert on to
the costal of surface of medial aspect of scapula.
Anterior approach is most reliable as vascular pedicle may be
length by relying on the intercostal vessel, which branches from
internal mammary artery.
Damage blood supply to the thoracolumbar spinecord.
Used for reconstruction of rib and syphyseal defect
Less amount of corticocancellous bone
Weak to handle funcdtional masticatory post
Poorly suited for implant reconstruction
Skin vascular pedicle is unreliable
Winged scapular deformity
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.
SCM has tripartiat blood supply
Easy flap for one stage immediate reconstruction of
Exposure of great vessel of neck after mobilization and resulting
contour deformity of neck.
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
Intercostal muscle between 5th and 6th rib are dissected
Rib is section at lateral and medial extent with rib cutter
Increase mobilization of flap is gained by dividing humeral,
sternal and clavicular attachment.
Ease of harvest
Vesatile and durable flap containing long pedicle
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
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
Superior viability of bone
Greater bone availability
Minimal associated morbidity and cosmetic effect
Poor anterior mobilization
Donar site volume defect that may affect jaw function and ranging
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