INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
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CONTENTS
Introduction
Objectives of management
Guidelines of management
Treatment methods

Enucleation & Curettage
-Ca...
INTRODUCTION
Treatment of odontogenic tumors is designed to

eradicate the lesion and restore aesthetic form and
optimal ...
Objectives of management:
Eradication of the lesion
Preservation of normal tissue to the extent possible
Restoration of...
GUIDELINES
SIZE & LOCATION OF TUMOR:
Small – Excisional biopsy
Increased size – more radical
Location – important role ...
DURATION:
When the tumor was 1st noticed
Fast growing in short duration – immediate
treatment
Prognosis depends on rate...
BENIGN Vs MALIGNANT :
Benign tumor – treat conservatively
Some benign tumors behave aggressively – radical
treatment
Be...
Factors governing the choice of
treatment method
Age and health of the patient
Clinical type of ameloblastoma
Site of t...
Treatment methods
Enucleation & curettage

- Thermal cauterization
- Carnoys solution
- Cryosurgery
Resection without co...
ENUCLEATION:
Allows the cystic cavity to be covered by a

mucoperiosteal flap & the space fills with the blood
clot which...
Indicated in:
Odontoma
Ameloblastic fibroma
Ameloblastic fibroodontoma
Adenmatoid odontogenic tumor
Cementoblastoma
...
Enucleation - procedure

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Enucleation - procedure

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ADVANTAGES:
Primary closure of the wound
Healing is rapid
Post operative care is reduced
DISADVANTAGES:
After primary ...
Curettage
Curettage - removal of the tumour by scrapping it

from the surrounding normal tissue
Currently - least desira...
INDICATIONS
Unicystic ameloblastoma
 Small tumour - a child or a young adult
Patient can be followed up for 10 years or...
Operative procedure
Intra-oral approach
Mucoperiosteal flap is reflected
Mandible - buccal aspect
Lingual access - inj...
Ameloblastoma – Enucleation & Curettage

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Adenomatoid Odontogenic tumor:

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Ameloblastic fibro odontoma

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Ameloblastic fibroma

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Compound odontoma:

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After lesion is removed - largest curette - a margin of

apparently normal bone should be removed by
aggressive scrapping...
Topical antibiotic - gauze pack.
The pack is removed approximately 2 to 3 inches

everyday until the surgical defect is ...
Cautery (desiccation)
Various types - primarily as an adjuvant to curettage,

but in some cases as a primary mode of ther...
Cautery is empirical :

(i)
how far the tumour in each case has extended
into
the cancellous bone
(ii) how far the causti...
Electrocoagulation (thermal
cautery)
Mehlisch et al (1972) - 50% recurrence rate
More effective therapy than curettage
...
Chemical cauterisation
Carnoy’s solution - a fixing agent

absolute alcohol
chloroform
glacial acetic acid
ferric chlorid...
Technique:
Teeth – extracted
Enucleation and curretage
Bony cavity is examined
Carnoys solution is applied
Cotton app...
CRYOSURGERY:
Alternative treatment modality
Excellent results in maxillo-facial region
AIM: eliminate invasive bone les...
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TECHNIQUE:
After curettage
Surrounding soft tissues are retracted & protected

away with gauze and flap retractors
Enti...
Complications - sequestration, pathological fracture,

transient anaesthesia of mandibular nerve
More extensive the free...
MARGINAL RESECTION / RESECTION WITHOUT CONTINUITY
DEFECT / PERIPHERAL OSTEOTOMY / EN BLOC RESECTION
Indicated in lesions ...
INDICATIONS:
Ameloblastoma
Calcifying epithelial odontogenic tumor
Myxoma
Ameloblastic odontoma
Squamous odontogenic ...
Procedure allows complete excision of the tumor but

at the same time a continuity f the jaw bone is
retained thus deform...
Operative procedure
Intra-oral / extra-oral approach
Intra-oral - good access and when the lesion is

anterior to third ...
Surgical approaches to maxilla:

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Surgical approaches to mandible:

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Intra-oral approach
Large mandibular lesions - a midline lip-splitting
incision
Connecting vertical incisions are made o...
Marginal Resection

www.indiandentalacademy.com
On exposure of the mandible, the bony segment is

sectioned with an air-driven saw or bur, at least 1 to
1.5 cm from the ...
Segmental (partial) mandibular
resection / hemimandibulectomy
Segmental resection - maxillectomy and

hemimandibulectomy
...
Segmental resection:

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Operative procedure
Depending on the size - a lip-splitting incision may or
may not be necessary
A submandibular incisio...
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Expose the mental neurovascular bundle, which is ligated

and sectioned.
Preservation of the marginal mandibular branch ...
Resection with disarticulation:

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Odontogenic myxoma

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The patient should be fed through a naso-gastric tube

for a week and scrupulous oral hygiene should be
maintained.
Dres...
Classification of Maxillectomies
1.

Partial Maxillectomy(Alveolectomy): Removal of lower
half of the Maxilla.

2.

Subtot...
Marginal (partial) maxillectomy
The marginal maxillectomy is the surgical procedure

most often used for tumors of maxill...
Partial Maxillectomy (Alveolectomy)

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Calcifying epithelial odontogenic
tumor:

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Extra oral procedure

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Total maxillectomy

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British Journal of Oral and Maxillofacial Surgery 45 (2007) 306–310
www.indiandentalacademy.com
RECONSTRUCTION
Radical surgeries like segmental resection,

hemimandibulectomy and maxillectomy leave the
patient with a ...
Goals of mandibular reconstruction
Re-establishment of mandibular continuity and

an osseus-alveolar base
Maintenance of...
Goals of maxillary reconstruction

 Obliteration of the defect
 Restoration of essential function of mid face
 Provisio...
Immediate Vs delayed reconstruction
IMMEDIATE
ADVANTAGES
Single stage surgery
Early retain of function
Minimal compromi...
Ideal Graft:
Restoration of ability to masticate
Acceptable esthetic appearance
Withstand physiologic forces
Non-react...
CLASSIFICATION
Depending on nature of bone
Depending on donor
Depending on the preparation
Depending on the vascularit...
Depending on nature of bone
Cancellous bone graft
Cortical bone graft
Corticocancellous grafts

. Blocks
. Chips
. Powd...
Depending on the preparation allografts and xenografts
can be again divided into:
a. Freezed bone grafts
b. Freezed dried
...
Depending on donor site:
Iliac crest graft anterior ileum
posterior ileum
trephine grafts
Rib graft
Full thickness
Split...
Depending on function
Bridging graft or inlay graft
Reconstruction graft
Contour graft – onlay graft.
Bone substitutes...
Maxillary reconstruction
Prosthesis
Obturator and splints
Local soft tissue flaps
Buccal and palatal advancement flaps
...
Regional flaps
Temporalis – myofascial / myo-osseous
Trapezius – muscle / myo-cutaneous / osseo-myocutaneous
Free flaps
...
Mandibular reconstruction
Autogenous vascularised bone by pedicled flaps
Clavicle pedicled on sternocleidomastoid
Rib pe...
Autogenous vascularised bone by free flaps
iliac crest based on deep circumflex iliac artery
fibula based on peroneal ar...
Autogenous non-vascularised bone
calvarium
iliac crest
rib
Fibula
Allografts
Xenografts
Alloplastic materials
stainle...
Fibula Free Flap

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Fibula Free Flap

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Mandible Reconstruction

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Thank you
Leader in continuing dental education
www.indiandentalacademy.com

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Management of odontogenic tumors /certified fixed orthodontic courses by Indian dental academy

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Management of odontogenic tumors /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. CONTENTS Introduction Objectives of management Guidelines of management Treatment methods Enucleation & Curettage -Carnoys solution -Cryosurgery Marginal Resection Segmental Resection Reconstruction www.indiandentalacademy.com
  3. 3. INTRODUCTION Treatment of odontogenic tumors is designed to eradicate the lesion and restore aesthetic form and optimal function. Because of these needs and the benign nature of these lesions, a variety of surgical techniques that preserve vital structures and facial aesthetics have been developed for the treatment of odontogenic tumors. www.indiandentalacademy.com
  4. 4. Objectives of management: Eradication of the lesion Preservation of normal tissue to the extent possible Restoration of significant tissue loss, form & function Well-planned & executed resection & reconstruction serves the patient physically & emotionally better than repeated surgical procedure www.indiandentalacademy.com
  5. 5. GUIDELINES SIZE & LOCATION OF TUMOR: Small – Excisional biopsy Increased size – more radical Location – important role in post – operative morbidity Inaccessibility – responsible for inadequate surgical clearance www.indiandentalacademy.com
  6. 6. DURATION: When the tumor was 1st noticed Fast growing in short duration – immediate treatment Prognosis depends on rate of growth of tumor Slow growing – more elective treatment Fast growing – indicate malignant www.indiandentalacademy.com
  7. 7. BENIGN Vs MALIGNANT : Benign tumor – treat conservatively Some benign tumors behave aggressively – radical treatment Benign & small – enucleation Lesion involves full thickness – segmental resection Lesion is extensive – radical resection www.indiandentalacademy.com
  8. 8. Factors governing the choice of treatment method Age and health of the patient Clinical type of ameloblastoma Site of the lesion Size of the lesion Chances of recurrence Patient preference www.indiandentalacademy.com
  9. 9. Treatment methods Enucleation & curettage - Thermal cauterization - Carnoys solution - Cryosurgery Resection without continuity defect Resection with continuity defect www.indiandentalacademy.com
  10. 10. ENUCLEATION: Allows the cystic cavity to be covered by a mucoperiosteal flap & the space fills with the blood clot which will eventually organize and form normal bone. INDICATIONS: Surgical excision of tumor which tend to grow by expansion, rather than by infiltration of surrounding tissues. Lesions occurring in the bone with a distinct separation b/w the lesion & the surrounding bone. Often there is a cortical margin of bone that delineates the tumor from the bone. www.indiandentalacademy.com
  11. 11. Indicated in: Odontoma Ameloblastic fibroma Ameloblastic fibroodontoma Adenmatoid odontogenic tumor Cementoblastoma Squamous odontogenic tumor www.indiandentalacademy.com
  12. 12. Enucleation - procedure www.indiandentalacademy.com
  13. 13. Enucleation - procedure www.indiandentalacademy.com
  14. 14. ADVANTAGES: Primary closure of the wound Healing is rapid Post operative care is reduced DISADVANTAGES: After primary closure, it is not possible to directly observe the healing of the cavity Removal of unerupted teeth with the lesion Weakening of mandible making it prone to jaw fracture Damage to adjacent vital structures www.indiandentalacademy.com
  15. 15. Curettage Curettage - removal of the tumour by scrapping it from the surrounding normal tissue Currently - least desirable form of therapy Sehdev et al (1974) - cure rate of only 10%. Taylor (1968) - 63% recurrence rate Rankow and Hickey (1954) - 91% recurrence rate. Failure - nests of tumour cells extend beyond the clinical and radiographic margins of the lesion Chemical and electrical cauterisation have been used by surgeons in conjunction with curettage but they have reported only a slight improvement in cure rate. www.indiandentalacademy.com
  16. 16. INDICATIONS Unicystic ameloblastoma  Small tumour - a child or a young adult Patient can be followed up for 10 years or more. Small tumour in the body of the mandible in an elderly patient, as ameloblastoma takes several years to recur www.indiandentalacademy.com
  17. 17. Operative procedure Intra-oral approach Mucoperiosteal flap is reflected Mandible - buccal aspect Lingual access - injury to lingual nerve & mandibular neurovascular bundle Maxilla - palatal or buccal / labial approach Rongeur or surgical bur - remove sufficient bone expose the underlying tumor Angular / straight curettes - convex surface of the curette placed against the bony wall. www.indiandentalacademy.com
  18. 18. Ameloblastoma – Enucleation & Curettage www.indiandentalacademy.com
  19. 19. Adenomatoid Odontogenic tumor: www.indiandentalacademy.com
  20. 20. Ameloblastic fibro odontoma www.indiandentalacademy.com
  21. 21. Ameloblastic fibroma www.indiandentalacademy.com
  22. 22. Compound odontoma: www.indiandentalacademy.com
  23. 23. After lesion is removed - largest curette - a margin of apparently normal bone should be removed by aggressive scrapping.  After thus removing 1 to 3 mm of surrounding bone, all margins are smoothened with a rongeur or a large round bur.  Adjunctive treatment like cauterisation may be employed at this stage. Irrigation with normal saline Small wounds - closed primarily Large wounds - packed with gauze impregnated with compound tincture of benzoin, balsam of Peru or Whitehead’s varnish www.indiandentalacademy.com
  24. 24. Topical antibiotic - gauze pack. The pack is removed approximately 2 to 3 inches everyday until the surgical defect is filled with granulation tissue. Oral hygiene is maintained. Complications Numerous complications - particularly extensions to vital structures Curettage procedure breaks the cortical barrier, thus paving the way for residual tumour to grow into the soft tissues, which then becomes more difficult to treat. www.indiandentalacademy.com
  25. 25. Cautery (desiccation) Various types - primarily as an adjuvant to curettage, but in some cases as a primary mode of therapy. Chemical agents: -Carnoy’s solution -Electrocautery -Cryotherapy Cauterisation is basically an attempt to eradicate the tumour that has infiltrated beyond the clinical and radiographic margins of the tumour www.indiandentalacademy.com
  26. 26. Cautery is empirical : (i) how far the tumour in each case has extended into the cancellous bone (ii) how far the caustic agent (heat / chemicals) penetrates into the cancellous bone (iii) how effective is the agent in eradicating the tumour cells and (iv) the possible harmful effects to normal tissue www.indiandentalacademy.com
  27. 27. Electrocoagulation (thermal cautery) Mehlisch et al (1972) - 50% recurrence rate More effective therapy than curettage Secondary ischaemia & necrosis - may destroy the invading tumour cells. Cautery frequently been employed as an adjuvant to other methods of therapy to give a better result (Gardner and Pecak – 1980) Mehlisch et al - no recurrences www.indiandentalacademy.com
  28. 28. Chemical cauterisation Carnoy’s solution - a fixing agent absolute alcohol chloroform glacial acetic acid ferric chloride (modification) Stoelinga and Bronkhorst (1988) - unicystic ameloblastoma and reported no recurrences Depth of penetration - cancellous bone up to 1.5 mm after 5 minutes and up to 1.8 mm after 1 hour (Voorsmit et al – 1981) Use of Carnoy’s solution appears to be harmless and has the potential of reducing recurrences after curettage. www.indiandentalacademy.com
  29. 29. Technique: Teeth – extracted Enucleation and curretage Bony cavity is examined Carnoys solution is applied Cotton applicator / ribbon guaze – 3 minutes Copious irrigation with saline BIPP inserted & wound kept open BIPP replaced periodically Recurrence – 10% www.indiandentalacademy.com
  30. 30. CRYOSURGERY: Alternative treatment modality Excellent results in maxillo-facial region AIM: eliminate invasive bone lesion without necessarily involving the problems of conventional anatomic radical surgery Advantage of cryotherapy is that it is possible to devitalise the tissue with liquid nitrogen to a depth of 1.5 cm The jaw can be frozen through its entire thickness if necessary. www.indiandentalacademy.com
  31. 31. www.indiandentalacademy.com
  32. 32. TECHNIQUE: After curettage Surrounding soft tissues are retracted & protected away with gauze and flap retractors Entire bony cavity – frozen with liquid nitrogen spray Solid frost is observed 3 freezing cycles Each cycle - 1 minute Gap b/w each cycle – 5 minutes Mucoperiosteal flap were sutured www.indiandentalacademy.com
  33. 33. Complications - sequestration, pathological fracture, transient anaesthesia of mandibular nerve More extensive the freezing, the greater the risk Another method which has been described (Weaver and Smith-1963, Bradley-1978) in which the affected segment of bone is excised, frozen in liquid nitrogen to devitalise the tissue, and then reimplanted as an autogenous graft. www.indiandentalacademy.com
  34. 34. MARGINAL RESECTION / RESECTION WITHOUT CONTINUITY DEFECT / PERIPHERAL OSTEOTOMY / EN BLOC RESECTION Indicated in lesions which are known for recurrence Lesions that tend to grow beyond their surgically apparent capsule Treatment - when the lesion does not extent closer than 1 cm to the inferior border of the mandible.  Margin of 1 to 2 cm - minimum acceptable margin. Various authors - good results with en bloc resection Lesions of the maxilla - en bloc resection is not as successful and recommend segmental resection www.indiandentalacademy.com
  35. 35. INDICATIONS: Ameloblastoma Calcifying epithelial odontogenic tumor Myxoma Ameloblastic odontoma Squamous odontogenic tumor www.indiandentalacademy.com
  36. 36. Procedure allows complete excision of the tumor but at the same time a continuity f the jaw bone is retained thus deformity, disfigurement & need for secondary cosmetic surgery & prosthetic rehabilitation are avoided. ADVANTAGE: Not violating the tumor margins during resection which might provide the possibility of tumor seeding in the surgical site. DISADVANTAGE: Does not discriminate b/w tumor tissue & vital structures in close approximation such as inferior alveolar nerve. www.indiandentalacademy.com
  37. 37. Operative procedure Intra-oral / extra-oral approach Intra-oral - good access and when the lesion is anterior to third molar region Extra-oral approach - lesion involves the ramus of the mandible or when immediate reconstruction is planned www.indiandentalacademy.com
  38. 38. Surgical approaches to maxilla: www.indiandentalacademy.com
  39. 39. Surgical approaches to mandible: www.indiandentalacademy.com
  40. 40. Intra-oral approach Large mandibular lesions - a midline lip-splitting incision Connecting vertical incisions are made on the buccal and lingual Incisions - extend deep into buccal and lingual folds. The teeth bordering the surgical margin should be extracted Horizontal incisions connecting the lower ends of vertical incisions are made. The buccal and lingual mucoperiosteal flaps are then developed, but not reflected superiorly over the region of bone to be removed. www.indiandentalacademy.com
  41. 41. Marginal Resection www.indiandentalacademy.com
  42. 42. On exposure of the mandible, the bony segment is sectioned with an air-driven saw or bur, at least 1 to 1.5 cm from the radiographic margin of the lesion Haemorrhage - controlled by crushing the bone over small blood vessels with a blunt instrument or by using bone wax The mucoperiosteum is then undermined both lingually and facially to relieve tension. They are approximated with interrupted silk sutures. www.indiandentalacademy.com
  43. 43. Segmental (partial) mandibular resection / hemimandibulectomy Segmental resection - maxillectomy and hemimandibulectomy Least number of recurrences. Indications: Infiltrative lesions Lesions – posterior/ inferior border of mandible Lesions with high recurrence rate www.indiandentalacademy.com
  44. 44. Segmental resection: www.indiandentalacademy.com
  45. 45. Operative procedure Depending on the size - a lip-splitting incision may or may not be necessary A submandibular incision - join the vertical lip incision Intra-orally - horizontal incision is made through the mucoperiosteum The facial and lingual flaps are advanced below the horizontal incision using a periosteal elevator. The lingual flap is raised as deep as to expose the mylohyoid attachment. A vertical mucoperiosteal incision is made 0.5 cm proximal to the anticipated anterior bony cut. www.indiandentalacademy.com
  46. 46. www.indiandentalacademy.com
  47. 47. www.indiandentalacademy.com
  48. 48. Expose the mental neurovascular bundle, which is ligated and sectioned. Preservation of the marginal mandibular branch of the facial nerve Using an air-driven saw, bur or a Gigli saw, a vertical cut is made through the mandible anterior to the lesion. Using bone forceps, the proximal part of the mandible is rotated laterally, exposing the inferior alveolar nerve and vessels, at the lingula of the mandible. They are ligated and cut adjacent to the mandibular foramen. The capsule is cut with a scalpel and the segment of mandible is disarticulated and removed using boneholding forceps. Bleeding - controlled by digital pressure, coagulation or ligation, depending on the size of the bleeding vessel. www.indiandentalacademy.com
  49. 49. Resection with disarticulation: www.indiandentalacademy.com
  50. 50. Odontogenic myxoma www.indiandentalacademy.com
  51. 51. The patient should be fed through a naso-gastric tube for a week and scrupulous oral hygiene should be maintained. Dressings should be changed daily. Removal of drain depends on the amount of drainage. Alternate skin sutures are removed after 4 days and the remaining ones, after 6 days. After that, the naso-gastric tube may be removed and oral feeding may be begun. www.indiandentalacademy.com
  52. 52. Classification of Maxillectomies 1. Partial Maxillectomy(Alveolectomy): Removal of lower half of the Maxilla. 2. Subtotal Maxillectomy:: lesions which extend beyond the confines of Antrum 3. Medial Maxillectomy: Medial wall of antrum, inferior & middle Turbinates, ethmoidal air cells, Lamina papyracea (one side) 4. Total Maxillectomy: complete removal of Maxilla. www.indiandentalacademy.com
  53. 53. Marginal (partial) maxillectomy The marginal maxillectomy is the surgical procedure most often used for tumors of maxilla when the maxillary sinus is not involved. Operative procedure Intra-oral approach Mucoperiosteal incision - 1 to 2 cm in all directions from the underlying tumour. It may be necessary to extract one or more teeth to complete these incisions. www.indiandentalacademy.com
  54. 54. Partial Maxillectomy (Alveolectomy) www.indiandentalacademy.com
  55. 55. Calcifying epithelial odontogenic tumor: www.indiandentalacademy.com
  56. 56. Extra oral procedure www.indiandentalacademy.com
  57. 57. Total maxillectomy www.indiandentalacademy.com
  58. 58. British Journal of Oral and Maxillofacial Surgery 45 (2007) 306–310 www.indiandentalacademy.com
  59. 59. RECONSTRUCTION Radical surgeries like segmental resection, hemimandibulectomy and maxillectomy leave the patient with a thoroughly incapacitating aesthetic and functional deficit www.indiandentalacademy.com
  60. 60. Goals of mandibular reconstruction Re-establishment of mandibular continuity and an osseus-alveolar base Maintenance of oral functions and proper occlusion with maxillary arch. To achieve minimal impairment of function Correction of soft-tissue defects To achieve good aesthetic results. www.indiandentalacademy.com
  61. 61. Goals of maxillary reconstruction  Obliteration of the defect  Restoration of essential function of mid face  Provision of adequate structural support.  Aesthetic reconstruction of external features. www.indiandentalacademy.com
  62. 62. Immediate Vs delayed reconstruction IMMEDIATE ADVANTAGES Single stage surgery Early retain of function Minimal compromise of esthetics DISADVANTAGES Recurrence Time consuming Infection DELAYED ADVANTAGES Good result Less recurrence Good planning DISADVATAGES Fibrosis Wound contraction 2nd surgery www.indiandentalacademy.com
  63. 63. Ideal Graft: Restoration of ability to masticate Acceptable esthetic appearance Withstand physiologic forces Non-reactive in tissues Sterile Readily available www.indiandentalacademy.com
  64. 64. CLASSIFICATION Depending on nature of bone Depending on donor Depending on the preparation Depending on the vascularity Depending on donor site: Depending on function www.indiandentalacademy.com
  65. 65. Depending on nature of bone Cancellous bone graft Cortical bone graft Corticocancellous grafts . Blocks . Chips . Powder Marrow graft Depending on donor Autogenous bone graft – from same individual Isogenic bone graft – from genetically related individual Allogenic – allograft – from another individual of same species Xenografts from different species www.indiandentalacademy.com
  66. 66. Depending on the preparation allografts and xenografts can be again divided into: a. Freezed bone grafts b. Freezed dried c. Demineralised d. Antigen extracted autolysed Depending on the vascularity autografts can be divided into: Non vascularised Vascularised bone transfer attached on soft tissue, pedicle, microvascular free transfer. www.indiandentalacademy.com
  67. 67. Depending on donor site: Iliac crest graft anterior ileum posterior ileum trephine grafts Rib graft Full thickness Split rib graft Calvarial graft Full Split Fibula www.indiandentalacademy.com
  68. 68. Depending on function Bridging graft or inlay graft Reconstruction graft Contour graft – onlay graft. Bone substitutes www.indiandentalacademy.com
  69. 69. Maxillary reconstruction Prosthesis Obturator and splints Local soft tissue flaps Buccal and palatal advancement flaps Cheek flaps Buccal pad of fat www.indiandentalacademy.com
  70. 70. Regional flaps Temporalis – myofascial / myo-osseous Trapezius – muscle / myo-cutaneous / osseo-myocutaneous Free flaps Rectus abdominus Radial forearm Iliac crest Omentum www.indiandentalacademy.com
  71. 71. Mandibular reconstruction Autogenous vascularised bone by pedicled flaps Clavicle pedicled on sternocleidomastoid Rib pedicled on pectoralis major Scapula pedicled on trapezius Calvarium pedicled on temporalis Rib pedicled on latissimus dorsi www.indiandentalacademy.com
  72. 72. Autogenous vascularised bone by free flaps iliac crest based on deep circumflex iliac artery fibula based on peroneal artery scapula based on circumflex scapular artery radial forearm based on radial artery rib based on intercostal artery second metatarsal calvarium based on superficial temporal artery www.indiandentalacademy.com
  73. 73. Autogenous non-vascularised bone calvarium iliac crest rib Fibula Allografts Xenografts Alloplastic materials stainless steel reconstruction plate hydroxyapatite www.indiandentalacademy.com
  74. 74. Fibula Free Flap www.indiandentalacademy.com
  75. 75. Fibula Free Flap www.indiandentalacademy.com
  76. 76. Mandible Reconstruction www.indiandentalacademy.com
  77. 77. www.indiandentalacademy.com
  78. 78. www.indiandentalacademy.com
  79. 79. www.indiandentalacademy.com
  80. 80. www.indiandentalacademy.com
  81. 81. www.indiandentalacademy.com
  82. 82. Thank you Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com

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