bone graft /certified fixed orthodontic courses by Indian dental academy

BONE GRAFT

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

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
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.

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.

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.


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.

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.



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.


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.

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
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.


Type of free bone graft
Donar site


Chin



Retromolar area



Nasal aperture



Skull



Rib



Iliac graft



Tibia

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

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

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

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.



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.

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.



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)

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

-

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
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.



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

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.

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

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.


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

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.

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

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.

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

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.



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.



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.




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

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

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.

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.


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

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.

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


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.


 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.


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

 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.


 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.


Leader in continuing dental education


bone graft /certified fixed orthodontic courses by Indian dental academy

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