Highlights On Maxillofacial Reconstruction

Highlights On Maxillofacial Reconstruction Hesham El-Hawary

Highlights On Surgical
Reconstruction & GRAFTING

ELHAWARY
• Hesham El-Hawary
• 1998
• MSc 2004
(fracture mandible children)
• DDDSc 2008
(distraction osteogenesis)
• Assoc Prof. OMFS
• Cairo University
• MSA University
• Umm Alqura University, KSA

ELHAWARY
• Email:
hesham@elhawarydentalclinic.com
• Slide share:
• www.slideshare.net/hesham_elhawary
• Department of OMFS
4th Floor - Sunday
1st Floor - Tuesday

Definitions

Reconstruction
• Restoration of form and function lost in the defective structure
Graft
• Tissue which is transplanted and expected to become part of the host
Donor
• A person or as site that donates of biological tissue or an organ of the human
body from a living or dead person to a living recipient in need of at
ransplantation.

Free graft
• A graft transplanted without its nourishing blood supply; must undergo
revascularization from the recipient bed
Vascularized graft
• The state of a graft after the recipient vasculature has been connected
with the vessels in the graft
Pedicled graft
• The soft tissue remaining on the graft attach to the donor site to
insure vascularity

function
esthetics
structure
Aim of reconstruction

Soft tissue
defect
Bony defect Combination
Nature of defect & methods of treatment

Soft tissue
defect
• Expanders
• ST grafts
Bony defect Combination

http://polyscitech.com/images/tissue_expander.jpg
Expanders

ST grafts
Local Flaps
Advanced
flaps
grafts
free
vascularized
free non-
vascularized
Soft Tissue Grafting

Soft tissue
defect
• Expanders
• ST grafts
• free grafts (VAS-
NVAS)
• Pedicled Grafts
Bony defect
• Bone graft
• implant
Combination

Bone graft
• Block
• Particulate
• both
Bone graft
• autogenous
• allograft
• xenograft
• alloplast
Bone graft
• inlay
• onlay
• sandwich

implants
Metals
St-st titanium
Alloplasts
polymers ceramics

Soft tissue
defect
• Expanders
• ST grafts
Bony defect
• Bone grafts
• Implants
Combination
• DO
• Composite grafts
• Free (VAS-NVAS)
• pedicled

Causes of defects

•Congenital deformity
•Infection e.g. osteomylitis
•Trauma
•Eradication of pathology

Assessment of patient in
need of reconstruction

• Clinical and radiographic examination to determine the
problem that might be either
• Bony defect
• Soft tissue defect
• Combined bony and soft tissue defect
• Any associated problem that affect the treatment

Assessment of hard tissue defect
• The site of the defect
• The size of the defect
• The available residual bony stump
• The muscle pull
• The continuity with the oral cavity

The soft tissue defect
• Quantity of the soft tissue
• Size of the defect
• Thickness
• Quality of the soft tissue bed
• Vascularity
• Integrity
• The site of the soft tissue defect

Goals and principles of
reconstruction

• Restoration of continuity
• Restoration of alveolar bone height
• Restoration of osseous bulk
• Restoration of appearance
• Restoration of function

Anatomy & Physiology

Blood supply of gingiva and investing
structures
1. The dental artery: a branch of the superior or inferior alveolar artery
2. Intraseptal artery: enters the tooth socket
3. Rami perforantes: terminal branches of the intraseptal artery; they penetrate the tooth socket
and enter the periodontal ligament space where they anastomose (join) with the blood vessels
from the alveolar bone and periodontal ligament
4. Supraperiosteal blood vessels: located in the free gingiva and are the main supply of the
blood to the free gingiva; these vessels anastomose with blood vessels from the alveolar
bone and periodontal ligament
5. Subepithelial plexus: branches of the supraperiosteal blood vessels located in the connective
tissue beneath the free and attached gingiva
6. Periodontal ligament vessels: supply the periodontal ligament and form a complex network of
vessels that surrounds the root
7. Dentogingival plexus: a fine-meshed network of blood vessels located in the connective tissue
beneath the gingival sulcus

http://www.you-
dentist.com/foundations_of_periodontics/blood-
supply-to-the-periodontium/

http://www.you-dentist.com/foundations_of_periodontics/blood-supply-to-the-periodontium/

Wound healing
Wound Healing And Suturing

Definition
• The process by which the body is trying to achieve anatomical
integrity of the injured part and to restore full function
• As a secondary consideration, this should be combined with an
attempt to produce as perfect a cosmetic result as possible

Normal sequence of wound healing

Normal sequence of wound healing
Phases of wound healing
Days Weeks Months
Hemostasis
Inflammation
Proliferation
Maturation & Remodeling

http://en.wikipedia.org/wiki/File:Wound_healing_phases.png

Bone anatomy and histology

The structure of bone
The 4 characteristics of bone tissue are
1. Dense matrix containing deposits of calcium salts
2. bone cells within lacunae, which are organized around blood vessels
3. Canaliculi form pathways for blood vessels to exchange nutrients and
wastes
4. Outer surfaces of bones are covered by periosteum consisting of outer
fibrous and inner cellular layers

Bone
Inorganic
component
65%
hydroxylapatite
Organic
component
35%
Collagen Blood Vessels
Cells
(2% of the mass)

The functional unit of Bone
• It consists of cylindrical shaped
lamellar bone that surrounds
longitudinally oriented vascular
channels called haversian canals
• Horizontally oriented canals
(Volkmann canals) connect adjacent
osteons
• The mechanical strength of cortical
bone depends on the tight packing
of the osteons

Surgical principles of bone
grafting procedures

Principles of treatment of maxillofacial
trauma
• Reduction
• Restoration of anatomical form
• Restoration of function
• Establish proper occlusion
• Fixation (Immobilization)
• Stabilization
• Prevention of infection

• Control of the residual segments
• Restore the continuity
• Restore the occlusion
• Restore the condylar position
• Fixation (Immobilization)
• Stabilization
• Provide good soft tissue bed for the graft
• Improve the soft tissue bed
• Remove the scare tissue
• Flap rest on sound tissue
• Aseptic environment
• Prevention of infection

Biological basis of
reconstruction

• The healing of grafts is unique among connective
tissues because new bone formation arises from
tissue regeneration rather than from simple tissue
repair with scar formation (Marx, Saunders 1986)

• Two phase theory
• Transplanted cells proliferation
• Angeogenesis and fibroblasts proliferation from graft bed
• Immune response
• Autogenous grafts : recognized as self
• Allografts:
• Latent period depend on similarity
• Cell mediated immune response
• Methods to decrease graft rejection
• Immunosuppression drugs
• Alteration of the antigenicity of graft by
• Freezing, boiling, dry heating, irradiation

PHYSIOLOGY OF BONE REPAIR
AND FUSION
Understanding Peri-Implant Bone Healing
(Bone Biology & Osseointegration)

Principles of bone regeneration
• Osteogenic:
The material contains active osteoblasts or will stimulate
predetermined osteoprogenitor cells and mature osteoblasts to form
bone. Osteogenic materials will advance cell proliferation.
Examples: Bonemarrow, autologous bone-
transplant, demineralized bone matrix (DMB), or
TGB- (transforming growth factor)

• Osteoinductive:
The material will stimulate non-predetermined cells, (i.e. mesenchymal
stemcells) to convert into chondroprogenitor or osteoprogenitor cells.
Osteoinductive materials will advance cell differentiation.
Examples: BMP (bone morphogentic proteins), bonemarrow (contains
BMP), autologous bone (contains BMP), and demineralized bone
matrix (DMB)

• Osteoconductive:
The material will function as a matrix for the ingrowth of bloodvessels,
cells, formation of cartilage and deposit of mineralized tissue.
Osteoconductive materials support osseous regeneration by the
matrix effect.
Examples: Demineralized bone matrix (DMP), bone transplantat,
hydroxylapatite, and tricalcium phosphate

Timing
Early Vs Secondary

• Most operators prefer 2ry reconstruction
• Factors govern the choice are
• Irradiation
• Infection
• Recurrence
• Amount of soft tissue
• Patient health condition
• For malignancies wait 2 years before reconstruction except for chin to
avoid backward retraction that leads to suffocation

Available Grafts

Extra-oral donor site
• Cranial bone grafts
• Costochondral grafts
• Iliac crest graft
• Tibial bone graft
• Fibular graft
• Scapula

Intra-oral donor site
• Chin graft
• Retromolar graft
• Tuberosity

Thank you

Highlights On Maxillofacial Reconstruction

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