TECHNICAL STRATEGY

Applications of Coronoid Process as a Bone Graft in Maxillofacial Surgery

Samrat Sabhlok, MDS,* Pushkar P. Waknis, MDS, and Kiran S. Gadre, MDS
Abstract: The coronoid process can be easily harvested as a donor bone by an intraoral approach during many maxillofacial surgery procedures. The purpose of this study was to evaluate the utility of autogenous coronoid process bone grafts for maxillofacial reconstructive surgery. Twelve patients, who underwent coronoid process grafts for reconstruction of maxillofacial deformities due to trauma, alveolar atrophy, or temporomandibular joint ankylosis, were included in the study. There were 3 orbital defects after extended maxillectomy, 1 blowout fracture of the orbit, 2 cases of reconstruction after temporomandibular joint ankylosis surgery, 1 case of additional chin augmentation following horizontal flip genioplasty, 1 defect of anterior wall of maxilla due to trauma, 2 mandibular defects, and 2 cases of bone augmentation for implants. We recommend the use of coronoid process of the mandible as a source for autogenous bone graft as it can provide sufficient bone in quantity and quality for selected maxillofacial reconstructions. Key Words: Coronoid process graft, autogenous bone graft, blowout fracture, TMJ ankylosis, orbital reconstruction (J Craniofac Surg 2014;25: 577Y580) of their embryological characteristics (endochondral vs intramembranous ossification), types of bone (cancellous vs cortical), morphological and physical characteristics, the morbidity associated with harvest from the specific donor site, the volume of graft to be obtained, and the rate of their resorption. The desirable characteristics of a bone graft are sufficient volume, minimal donor-site morbidity, obtaining intramembranous bone with high cortical component, proximity to the recipient site, ease of harvesting and achieving reproducible and good results, and minimal resorption rate. Coronoidectomy is a surgical procedure for a variety of indications, including oral submucous fibrosis, coronoid hyperplasia, temporomandibular joint (TMJ) ankylosis, trauma, and temporalis muscle fibrosis, as well as for surgical access.8 The use of these grafts provides sufficient bone stock for augmentation without using distant donor sites such as the iliac crest or the calvarium. If the requirements are more extensive, there is an additional, contralateral donor site available. A dry skull study found that the coronoid process can yield a triangular piece of bone measuring approximately 19 18 26 mm and 6 mm in thickness. This is similar in thickness to the outer table of calvarial bone.3 A similar study performed on the mandibular symphysis attained an average graft size of 20.9 9.9 6.9 mm.4 The ascending and anterior ramus and the coronoid process have also been used for reconstruction of postablative, segmental mandibular defects.5 The lateral mandible has been used as a source for autogenous bone for correction of posttraumatic nasal deformities as well.9 The purpose of this study was to evaluate the utility of autogenous coronoid process bone grafts for maxillofacial reconstructive surgery.

urgery involving the maxillofacial skeleton often requires bone grafting. Myriad applications of autogenous bone grafts have been reported mainly to surgically correct discontinuity and contour defects of the craniofacial skeleton and to achieve an optimal functional and aesthetic result. These defects may result from congenital malformations, alveolar atrophy, oncologic resections, or trauma. The goal in autogenous bone harvesting is the procurement of a specific quantity, quality, and contour of bone required for the reconstruction. Numerous sites are available for obtaining small to moderate volumes of bone for maxillofacial reconstruction. These include the calvarium, iliac crest, tibia, ulna, mandibular symphysis, the rib, and coronoid process.1Y7 These harvest sites differ on the basis

MATERIALS AND METHODS

Twelve patients, aged 18 to 50 years (mean, 34 years) who underwent coronoid process grafts for reconstruction of maxillofacial deformities due to trauma, alveolar atrophy, oncologic resections, or facial malformations, were included in the study. There were 3 orbital defects, one blowout fracture of the orbit, 1 defect of anterior wall of maxilla, 2 mandibular defects, 1 case of additional chin augmentation following horizontal flip genioplasty, 2 cases of bone augmentation for implants, and 2 cases of reconstruction in TMJ ankylosis patient.

From the *Department of Oral & Maxillofacial Surgery, Dr. D. Y. Patil Dental College, Pimpri; Ruby Hall Clinic and Department of Oral & Maxillofacial Surgery, Bhartiya Vidyapeeth Dental College, Pune, Maharashtra, India. Received September 23, 2013. Accepted for publication December 2, 2013. Address correspondence and reprint requests to Samrat Sabhlok, MDS, Department of Oral and Maxillofacial Surgery, Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune 411018, Maharashtra, India; E-mail: samratsabhlok@yahoo.com The work has been approved by the appropriate ethical committees related to the institution(s) in which it was performed and that subjects gave informed consent to the work. No funding was received for this study. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275

Surgical Technique
Intraoral incision is made along the external oblique ridge, and the coronoid process is exposed. A fork ramus retractor is used to engage the coronoid. A large curved Kocher clamp holds the coronoid process. The coronoid process is cut at the base with a straight fissure bur. The coronoid is separated by gentle tapping with an osteotome. The tendinous attachments of the temporalis muscle are cut with a cutting diathermy while pulling and twisting the coronoid with the aid of the Kocher clamp. Once removed, all the muscle attachments are cleared off from the coronoid. The coronoid process is now ready for transfer to the recipient site. The oral wound is closed with 4-0 Vicryl.

The Journal of Craniofacial Surgery

& Volume 25, Number 2, March 2014

577

Copyright 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Sabhlok et al

The Journal of Craniofacial Surgery

& Volume 25, Number 2, March 2014

FIGURE 3. Intraoperative photograph showing reconstruction of mandibular continuity defect with coronoid graft.

FIGURE 1. Preoperative photograph showing a swelling in the right infraorbital region requiring resection of the orbital floor (published with the patients consent).

In the cases where the orbital floor was resected for oncologic clearance, the coronoid process was easily accessible through the Weber-Ferguson incision. The coronoid was sectioned at the base and pedicled over the temporalis, and the orbital floor was reconstructed, thereby maintaining the ocular level (Fig. 1). Because the coronoid is pedicled, it shows minimal resorption and maintenance of its intraoperative position (Fig. 2). Blowout orbital fractures with minimal displacement of orbital floor and entrapment of muscle yet causing diplopia are an indication for orbital exploration. In such cases, a thick volume of bone graft from the ilium may not be necessary, but reconstruction is warranted. In such cases, we feel that the coronoid process can avoid ilium grafting yet can restore the orbital volume and provide a stable orbital floor. In oral implantology, where the buccal cortical plate has been damaged because of traumatic extraction or trauma, the coronoid process can be utilized to recontour the buccal cortical plate and is fixed with two 1.5-mm titanium screws. The intervening space can be obliterated by the use of suitable bone graft material such as

Novobone putty or BioOss. These screws are removed after 6 months during implant placement. In cases of trauma where there are small continuity defects in the mandible or comminution of zygomaticomaxillary buttress, the coronoid process can easily bridge the gap, thereby restoring continuity (Fig. 3). In cases of TMJ ankylosis, the coronoid process is elongated and needs removal for optimal mouth opening. This can be shaped by means of a bur to resemble the condyle and fixed to the mandible by titanium screws of suitable length (Figs. 4 and 5). Another application of the coronoid process is found in unilateral TMJ ankylosis cases for additional augmentation of the chin following horizontal flip genioplasty to correct the symmetry of the face (Fig. 6).

RESULTS
All cases of maxillofacial reconstructions in this series were successful. There were no complications such as the extrusion of grafts, infection, excessive resorption, or functional disturbance in any of the patients. All patients showed good uptake of the graft. The demographic data of all the patients are presented in Table 1. In cases of orbital reconstruction, there was no residual enophthalmia or diplopia. Trismus was present for 1 to 2 weeks in 3 of the 4 orbital reconstruction cases but resolved thereafter. In the 2 cases of mandibular augmentation for implants, the implant surgery was carried out 6 months after the grafting

T1

FIGURE 2. Postoperative photograph showing reconstructed orbital floor and maintenance of ocular level (published with the patients consent).

FIGURE 4. Three-dimensional computed tomography scan showing elongated coronoid process.

578

* 2014 Mutaz B. Habal, MD

Copyright 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery

& Volume 25, Number 2, March 2014

Coronoid Process as a Bone Graft

TABLE 1. Demographic Data for 12 Patients

Patient 1 2 3 4 5 6 7 8 9 10 11 12 Age, y 18 40 23 25 35 30 32 18 19 50 20 38 Sex Female Male Male Male Male Male Female Female Male Male Male Male Recipient Site Orbit Orbit Orbit Maxilla Mandible Mandible Mandible Mandible Mandible Orbit Mandible Mandible Indication Resection Resection Trauma Trauma Trauma Atrophy Atrophy TMJ ankylosis TMJ ankylosis Resection TMJ ankylosis Trauma Follow-up, mo 60 60 36 24 24 36 12 12 12 6 16 18

FIGURE 5. Maintenance of ramal height with coronoid graft.

procedure. All the implants placed in grafted bone were done as a 2stage procedure. Reconstruction by bridging the defect with coronoid grafts after maxillary and mandibular trauma gave good contour and functional results. One patient with mandibular trauma needed implant removal after 2 years because of local infection. In cases of reconstruction in TMJ ankylosis patients, the radiographs showed that the grafted coronoid process existed in the glenoid fossa, and no nonunion was observed. No evidence of reankylosis was seen in either of the 2 cases. At the 1-year follow-up period, both the patients had an adequate mouth opening of 32 and 34 mm, respectively.

DISCUSSION
Autogenous bone remains the criterion standard in maxillofacial reconstructive surgery. It provides a predictable solution in ridge augmentation surgery required in a variety of clinical situations. The ideal donor site for harvesting sufficient volume of bone should therefore be readily accessible and provide a sufficient bulk of bone to allow shaping and contouring according to the recipient site requirements. Furthermore, the procedure should have minimal morbidity, be cost-effective to the patient, and have a proven success

FIGURE 6. Additional chin augmentation after horizontal flip genioplasty in unilateral TMJ ankylosis.

record. In 1907, Axhausen10 coined the term creeping substitution, which is accepted until today. This theory describes the physiology of cortical bone graft incorporation into its new recipient site. First, the new secured bone graft is engulfed in a hematoma from the surrounding disrupted tissues. Only the most peripheral cells at this point remain viable and osteogenic. As the inflammatory process continues and organizes, the dense fibrous stroma becomes highly vascular, and the graft begins its revascularization process at approximately day 10. This vascular ingrowth is responsible for the osteogenic potential of the graft. Autogenous grafts of intramembranous lineage offer faster revascularization and healing and undergo resorption at a slower rate than bone from endochondral origin. An additional advantage of cortical block grafts is that even if the bone graft is exposed to the oral environment, it is more resistant to failure than grafts from mostly cancellous origin (ilium, rib, tibia, etc).11 In the reconstruction of orbital floor fractures, it is well documented that autogenous bone grafting is superior to alloplastic and homologous sources, because it is the most physiologic of the various materials.12 Autogenous bone grafts from the antral wall,13 ilium, calvarium, rib,14 and mandible15,16 have been used in orbital floor repair. The quality of the bone grafts from the antrum is variable because of the different thickness of the antral wall in various sites. The antral wall has smooth contours like the orbital floor; however, harvesting this site can lead to dysesthesia of the infraorbital nerve, and the graft is essentially only cortical bone.14 Although an iliac graft is rich in cortical and medullary bone, this harvest can result in dysesthesia of peripheral sensory nerves and unsightly scarring.17 Calvarial donor sites are associated with possible intracranial injuries and a temporary noncosmetic state.18 The complications of rib donor sites include unsightly chest scars and possible pneumothorax.19 The mandibular site complications include devitalization of teeth, anesthesia of the inferior alveolar and mental nerves, and possible compromise of facial contour. The coronoid process is a membranous bone and has a thick cortical portion. It was introduced first in 1969 for the repair of small discontinuity defects of the mandible.20 Coronoid process bone graft offers advantages over other sources of autogenous bone for orbital reconstruction, for the following reasons: (1) the coronoid process is an autogenous graft; (2) the coronoid process can be harvested by means of intraoral incision causing no facial scarring; (3) no devitalization of the dentition; (4) a good medullary bone source is present between the cortices; (5) the amount of bone harvested is adequate for orbital floor defects up to 27 mm; (6) the coronoid process is a membranous bone, which shows low resorption rate; (7) the similarity of the morphology of the lateral cortex of the coronoid process to the orbital floor; (8) ease of access; (9) its hardness is adequate for drilling holes, which provides rigid fixation by using microscrews and prevents the movement of

* 2014 Mutaz B. Habal, MD

579

Copyright 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Sabhlok et al

The Journal of Craniofacial Surgery

& Volume 25, Number 2, March 2014

the graft; and (10) compared with other autogenous bone grafts, harvesting time is short, and the operative technique is very simple.1,3 Surgical management of excision of the ankylosed joint alone is usually insufficient to provide a satisfactory improvement in mouth opening; because longstanding ankylosis predisposes to fibrosis of the masticatory muscles, additional coronoidectomy is necessary in most patients. In addition, a complete resection of the mandibular coronoid process is advised to avoid a possible reankylosis.21 If the coronoid process is not involved, then it is a wellsuited donor area, because of its easy accessibility, the good shape and thickness of the graft, and its corticocancellous nature. Because the tip of the coronoid process is round and pointed, the outer surface of the coronoid process fits well within the glenoid fossa, more or less resembling TMJ, which may result in favorable postoperative joint movements. In the present clinical cases, elongation of the coronoid process occurred in both the patients because of long-term mandibular hypomobility. The elongated coronoid process thus is well suited to restore the height of the mandible ramus. The coronoid process can be resected safely and easily, without any complications associated with the donor site.1,11,20 In unilateral TMJ ankylosis, the jaw deformity is along all the 3 spatial axes, namely, anteroposterior, transverse, and superiorinferior. This leads to the deviation of the chin to the affected side, retrusion, and microgenia. Gadre et al25 advocated the use of horizontal flip pedicled genioplasty, which has a mathematical basis of turning a scalene triangle to an isosceles triangle and thereby achieving symmetry. The genial segment is fixed in an overriding position, which not only adds to the length of mandible but also overcomes the obstructive sleep apnea many times associated with TMJ ankylosis. A novel addition to this procedure in our series was the use of coronoid graft for additional augmentation of the chin after horizontal flip genioplasty. This gave more prominence to the chin and hence a better aesthetic result. The merits of using the coronoid process are as follows: (1) it can be harvested more safely and easily, and the secondary surgical site and donor complication are avoided; (2) the size, shape, and thickness are suitable for reconstruction of the condyle, and it can provide enough length for restoring the height of the ramus as well as sufficient strength for TMJ loading force; (3) less bone resorption occurs, owing to its membranous origin; and (4) compared with the costochondral graft, the coronoid process is much stiffer, which facilitates the use of rigid internal fixation and allows the jaw movement immediately after surgical procedure. The limitation in using coronoid process is: If the ankylosed segment also involves the coronoid process, then it cannot be used as a substitute for condylar reconstruction.22Y24 In such cases, the contralateral coronoid is considered, or alternate donors are utilized. Our experience has shown that the mandibular coronoid process is an excellent source of bone for reconstruction of moderate-size defects. It can be harvested with relative ease and low morbidity, and the quality and contour of the bone graft are very adaptable for the reconstruction of various regions of the maxillofacial skeleton. Hence, we believe that the use of coronoid process grafts has a wide variety of applications in maxillofacial reconstructive surgery.

REFERENCES
1. Mintz SM, Ettinger A, Schmakel T, et al. Contralateral coronoid process bone grafts for orbital floor reconstruction: an anatomic and clinical study. J Oral Maxillofac Surg 1998;56:1140Y1144 2. Misch C. The harvest of ramus bone in conjunction with third molar removal for onlay grafting before placement of dental implants. J Oral Maxillofac Surg 1999;57:1376Y1379

3. Chuong PH, Kim SG. The coronoid process for paranasal augmentation in the correction of midfacial concavity. Oral Surg Oral Med Oral Pathol 2001;91:28Y33 4. Montazem A, Valauri DV, St-Hillaire H, et al. The mandibular symphysis as a donor site in maxillofacial bone grafting: a quantitative anatomic study. J Oral Maxillofac Surg 2000;58:1368Y1371 5. Mutu T, Kanazawa M. Mandibular reconstruction using the anterior part of ascending ramus: report of two cases. J Oral Maxillofac Surg 1997;55:1152Y1156 6. Matsumo MA, Filho HN, Francischone EC, et al. Microscopic analysis of reconstructed maxillary alveolar ridges using autogenous bone grafts from the chin and iliac crest. Int J Oral Maxillofac Implants 2002;17:507Y516 7. Proussaefs P, Lozada J, Kleinman A, et al. The use of ramus autogenous block grafts for vertical alveolar ridge augmentation and implant placement: a pilot study. Int J Oral Maxillofac Implants 2002;17:238Y248 8. Aziz SR. Oral submucous fibrosis: case report and review of diagnosis and treatment. J Oral Maxillofac Surg 2008;66:2386Y2389 9. Herford AS. Dorsal nasal reconstruction using bone harvested from the mandible. J Oral Maxillofac Surg 2004;62:1082Y1087 10. Axhausen G. Die patologish-anatomischen Grundlagen der Lehre vonfrein knochen-transplantation beim Menschen und beimtier. Med Klin 1907;2:23Y32 11. Amrani S, Anastassov GE, Montazem AH. Mandibular ramus/coronoid process grafts in maxillofacial reconstructive surgery. J Oral Maxillofac Surg 2010;68:641Y646 12. Boyne PJ. Autogenous cancellous bone and marrow transplants. Am J Surg 1975;132:49 13. Kaye BL. Orbital floor repair with antral wall bone grafts. Plast Reconstr Surg 1966;37:62Y65 14. Antonyshyn O, Gruss JS, Galbraith DJ. Complex orbital fractures: a critical analysis of immediate bone graft reconstruction. Ann Plast Surg 1989;22:220Y233 15. Krishnan V, Johnson J. Orbital floor reconstruction with autogenous mandibular symphyseal bone graft. J Oral Maxillofacial Surg 1997;55:327Y330 16. Girdler N, Hosseini M. Orbital floor reconstruction with autogenous bone harvested from the mandibular lingual cortex. Br J Oral Maxillofacial Surg 1992;30:36Y38 17. Kuhn DA, Moreland MS. Complications following iliac crest bone grafting. Clin Orthop 1986;209:224Y226 18. Blankenstein K, Turvey TA. A review of 144 cranial bone grafts. J Oral Maxillofacial Surg. [Suppl 1, Educational Summaries and Outlines, 71st Annual Meeting and Scientific Sessions] 1989;47:98 19. Skouteris CA, Sotereanos GC. Donor site morbidity following harvesting of autogenous rib grafts. J Oral Maxillofacial Surg 1989;47:808Y812 20. Youmans RD, Russell EA. The coronoid process: a new donor source for autogenous bone grafts. Oral Surg Oral Med Oral Pathol 1969;27:422Y428 21. Gu ven O. Treatment of temporomandibular joint ankylosis by a modified fossa prosthesis. J Craniomaxillofac Surg 2004;32:236Y242 22. Liu Y, Li J, Hu J, et al. Autogenous coronoid process pedicled on temporal muscle grafts for reconstruction of the mandible condylar in patients with temporomandibular joint ankylosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:203Y210 23. YongLong H, Xiaoming G, Xinhua F, et al. Modified coronoid process grafts combined with sagittal split osteotomy for treatment of bilateral temporomandibular joint ankylosis. J Oral Maxillofac Surg 2002;60:11Y18 24. Zhu S, Hu J, Li J, et al. Free grafting of autogenous coronoid process for condylar reconstruction in patients with temporomandibular joint ankylosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:662Y667 25. Gadre KS, Halli R, Shah S, et al. Horizontal flip pedicled genioplasty for correction of asymmetric chin in adult unilateral temporomandibular joint ankylosis. J Craniofac Surg 2011;22:233Y237

580

* 2014 Mutaz B. Habal, MD

Copyright 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.