Principles of reconstructive surgery of

defects of the jaws

‫اعداد الدكتور سجاد الخالدي‬

‫الدورة االكترونية الخاصة‬

 Oral surgery

Defects of the jaw bones have a variety of causes, such as:

1 Eradication of pathologic conditions ‫القضاء على الحاالت المرضية‬
2 Trauma
3 Infections
3 Congenital deformities
The goals of reconstruction
1 recreate normal oral function
2 provide a satisfactory cosmetic result
3 permit prompt and careful follow-up

Bone reconstruction
Bone reconstruction
1 The tissue most commonly used to replace lost osseous tissue is bone
2 A graft is defined as a tissue that is transplanted and expected to become a part of the host
to which it is transplanted
3 The healing of bone and bone grafts is by new bone formation that arises from tissue
regeneration rather than from simple tissue repair with scar formation

The three basic mechanisms of bone generation are:

1. Osteogenesis which is the formation of new bone from living cells transplanted within the
graft.
2. Osteoinduction which involves new bone formation through the recruitment and
stimulation of recipient site osteoprogenitor cells using bone growth factors transplanted within
the grafted material.
3. Osteoconduction is the physical process in which the graft acts as a 3D scaffold on which the
cells are able to form new bone

Two-phase theory of osteogenesis

1 autotransplantation. When bone is transplanted from one area of the body to another

A The first phase (phase I) of bone regeneration arises from transplanted cells in the graft that
proliferate and form new osteoid. The amount of bone regeneration during this phase depends on the
number of transplanted bone cells that survive the grafting procedure.
 The second phase (phase II)
1 bone regeneration begins approximately in the second week
2 angiogenesis and fibroblastic proliferation from the graft bed begin after grafting, and osteogenesis
from host connective tissues begins
3 second phase is also responsible for
A the orderly incorporation of the graft into the host bed with continued resorption
B replacement
C remodeling

Types of grafts

1 Autogenous grafts
A are composed of tissues from the same individual
B It is the only type of bone graft that can supply living, immunocompatible bone cells essential
to phase I osteogenesis
C is the type used most frequently in oral-maxillofacial surgery.

Block grafts.they are solid pieces of cortical bone with or without underlying cancellous bone
(Corticocancellous). The iliac crest and the ribs are often used as a source for this type of graft.

Particulate marrow and cancellous bone grafts; they are obtained by harvesting the medullary
bone and the associated endosteum and hematopoietic marrow.

Note The ideal bone graft should have the structural characteristics of a block graft with the
e osteogenic potential of particulate marrow and cancellous bone grafts

Common sites for the procurement of this type of graft

Intraoral sites; these are limited by size, quality, and amount of cancellous bone.
1 Ramus of mandible: It provides cortical bone of about 1 cm × 3 cm, the possible
complications are inferior alveolar nerve injury and mandible fracture.
2 Symphysis: It can provide cortical and corticocancellous blocks of about 1.5 cm × 4 cm with a
thickness of 1 cm, the possible complications are mental nerve injury and chin ptosis.
 Anterior iliac crest Cranium The rib Tibia:
1 It can provide It provides cortical bone raft with or It can provide about 40
corticocancellous blocks up with limited amounts of without a cc of cancellous bone
to 5 cm × 5 cm block and cancellous bone of cartilaginous cap
cancellous bone graft of 1 cm × 4 cm increments
about 50 cc

Complications of the Complications may include Complications complications are

procedure include gait hemorrhage of superior may include wound dehiscence, gait
disturbance, fracture of the sagittal sinus, dural tear, pneumothorax, disturbanceand
anterior iliac spine, meningitis, and hair loss cosmetic fracture of tibial
postoperativeileus, deformity, and plateau
hematoma, seroma, and intercostal
postoperative paresthesias paresthesia

Composite grafts
1 are transplanted autogenous bone grafts while maintaining their blood supply
2 are known as composite grafts because they contain soft tissue and osseous elements
3 Composite grafts can be accomplished by two methods:
1. Pedicled flaps; the bone graft is pedicled to a muscular (or muscular and skin) pedicle
preserving some blood supply to the bone graft.
2. Vascularized free tissue transfer; the autogenous bone can be transplanted without losing
blood supply is by the use of microsurgical techniques

Advantages of autogenous grafts

1 They provide osteogenic cells for phase I bone formation
‫أنها توفر خاليا عظمية المنشأ لتكوين العظام في المرحلة األولى‬
2 No immunologic response occurs.‫ال تحدث استجابة مناعية‬
Disadvantages of autogenous grafts
Necessitate another site of operation for procurement of the graft (donor site morbidity).

Allogeneic grafts

1 allogeneic grafts are grafts taken from another individual of the same species
2 The type of response the immune system mounts against the foreign grafts is primarily a cell-mediated
response by T-lymphocytes
3 Several methods of treating grafts have been used, including
boiling, deproteinization, freezing, freeze-drying, irradiation, and dry heating.

4 the most commonly used allogeneic bone is freeze dried

5 All of these treatments destroy any remaining osteogenic cells in the graft, and therefore allogeneic
bone grafts cannot participate in phase I osteogenesis, they offer a hard tissue matrix for phase II
induction.

Advantages of allogeneic grafts

1 They do not require another site of operation in the host
2 A bone of similar shape to that being replaced can be obtained
Disadvantages of allogeneic grafts
1 The allogeneic graft does not provide viable cells for phase I osteogenesis.
2 Rigorous screening of donors is required to reduce the risk of disease transmission associated with
osseous allografts.

Xenogeneic grafts
1 xenogeneic grafts are taken from one species and grafted to another
2 The antigenic dissimilarity of these grafts is greater than with allogeneic bone
3 the graft must be treated more vigorously to prevent rapid rejection of the graft
Advantages of Xenogeneic grafts
1 They do not require another site of operation in the host.
2 Large quantity of bone can be obtained.
Disadvantages of Xenogeneic grafts
1 They do not provide viable cells for phase I osteogenesis.
2 Must be rigorously treated to reduce antigenicity.

Alloplasts
1 The most routinely used alloplastic materials are hydroxyapatite, tricalcium phosphates, and
bioactive glasses.

Advantages of Alloplasts
1 They do not require another site of operation in the host.
2 Large quantity of bone can be obtained.
Disadvantages of Alloplasts
1 They do not provide viable cells for phase I osteogenesis.
2 They are osteoconductive without any osteoinductive or osteogenic potential on their own.

Adjuvants

1 used to enhance bone repair

2 These range from blood components, gene therapy, and recombinant proteins
 Bone morphogenetic
proteins
1 are a group of osteoinductive proteins that belong to the transforming growth factor-beta (TGF- 𝛽)
family
2 they are capable of stimulating mesenchymal cells within the body to become osteoblastic and to
form bone
3 More than 20 members were identified, BMP2 and BMP7 are the most widely studied subtypes.
The advantages are
1 do not require another site of operation in the host
The disadvantages are
1 do not provide viable cells for phase I osteogenesis.
2 is a liquid
3 collagen sponge is used for this purpose

Platelet concentrates

1 provide a high concentration of growth factors such as platelet-derived growth factor (PDGF), TGF- 𝛽,
insulin-like growth factor (IGF), epidermal growth factor (EGF) and vascular endothelial growth factor
(VEGF).

2 enhance wound healing and have a potential bone regenerative effect

Generation of platelet concentrates

1 Platelet-rich plasma
A the first generation of platelet concentrate ‫الجيل األول من تركيز الصفائح الدموية‬
B t is prepared by two-step centrifugation of collected blood with anticoagulant
C The function of PRP promotes the release of growth factors for a short period (24 hours).
2 Platelet rich fibrin
A is the second generation of platelet concentrates
B It is prepared by a constant speed single-step centrifugation of collected blood without anticoagulant
C advantage of PRF over PRP is the formation of a three- dimensional flexible and dense fibrin clot
with a strong network to support cellular migration
D the PRF contributes to sustained and prolonged release of growth factors for more than seven days

3 Concentrated growth factor

1 is the third generation of platelet concentrates.
2 The protocol to prepare CGF consists of a single step of centrifugation with alternate speed
3 CGF induces a constant and sustained release of growth factors longer than PRP and PRF, which may
last up to 14 days.
Combinations of grafts
1 A combination of bone grafts can be used such as the combination of allogenic grafts as a scaffold that
can provide the desired bulk and shape supplemented
2 The disadvantage is that this procedure necessitates a second site of operation in the host to obtain
autogenous particulate marrow and cancellous bone graft.

Assessment of patient in need of reconstruction

1 Patients who have defects of the jaws can usually be treated surgically to replace the lost portion

2 Analysis of the patient’s problem must take into consideration the hard tissue defect, any soft tissue
defects, and any associated problems that will affect treatment

3 The patient’s age, health, psychological state, and the patient’s desires must be assessed

Hard tissue defect

1 Osseous defects of the jaws must be thoroughly assessed to formulate a viable treatment plan
2 requires adequate clinical and radiographic evaluation to assess the full extent of the bone defect
3 Important points to consider:
1 The size of the defect
A defects of certain sites of the mandible are more difficult to reconstruct
B a residual portion of the ramus with the condyle still attached makes osseous reconstruction easier
because the temporomandibular articulation is difficult to restore
C The position of the residual fragments; in continuity defects of the mandible the muscles of
mastication no longer work in harmony and may severely displace residual mandibular fragments into
unnatural positions.

Soft tissue defect

1 assessment of the quantity and quality of surrounding soft tissue is necessary before undertaking bone
graft procedures
2 The availability of an adequately vascularized soft tissue bed is an essential factor for the success of
any bone-grafting procedure
3 treatment of malignancies may require composite resection of hard and soft tissues

Reconstruction of mandibular defects

1 Acquired defects of the mandible result from trauma, infection, osteoradionecrosis, and, most
commonly, ablative surgery of the oral cavity and lower face.

2 Goals of mandibular reconstruction IMPROTANT

1 Restoration of continuity and contour; it is the highest priority when reconstructing mandibular
defects to achieve better functional movements of the mandible and tongue and improved facial
esthetics by realigning any deviated mandibular segments.
‫استعادة االستمرارية والكفاف؛ إنها األولوية القصوى عند إعادة بناء عيوب الفك السفلي لتحقيق حركات وظيفية أفضل للفك السفلي‬
‫واللسان وتحسين جماليات الوجه عن طريق إعادة تنظيم أي أجزاء الفك السفلي المنحرفة‬
2 Restoration of alveolar bone height; an adequate alveolar process must be provided during the
reconstructive surgery to provide a foundation for dental rehabilitation.
‫ يجب توفير عملية سنخية كافية أثناء الجراحة الترميمية لتوفير األساس إلعادة تأهيل األسنان‬.‫استعادة ارتفاع العظام السنخية‬
3 Restoration of osseous bulk; any bone-grafting procedure must provide enough osseous tissue to
withstand normal function.
‫استعادة الجزء األكبر من العظم؛ يجب أن يوفر أي إجراء لتطعيم العظام ما يكفي من األنسجة العظمية لتحمل الوظيفة الطبيعية‬

classifications for mandibular defects have been suggested by Jewer et al (1989):

1 The (C) represents central defects involving both canines.

2 The (L) represents lateral defects excluding the condyle.
3 The (H) represents the hemimandibular defects including the condyle.

Reconstructiveoptions
Reconstructive options

1 Gap bridging with reconstruction plates

1 Reconstruction plates are rigid plates USED FOR
A bridging mandibular continuity defects ‫سد عيوب استمرارية الفك السفلي‬
B stabilizing remaining segments ‫استقرار القطاعات المتبقية‬
C maintaining occlusion and facial contour ‫الحفاظ على االنسداد ومحيط الوجه‬
D fix non_vascularized bone blocks or vascularized bone grafts to the remaining mandible
‫تثبيت الكتل العظمية غير الوعائية أو الطعوم العظمية الوعائية في الفك السفلي المتبقي‬
Note. is considered to be relatively fast and simple and with no donor site morbidity.

The disadvantage of using reconstruction plates

1 the mandible is that it is associated with long-term complications ‫الفك السفلي هو أنه يرتبط بمضاعفات طويلة المدى‬
2 do not allow dental rehabilitation and fail to address soft-tissue defects
‫ال تسمح بإعادة تأهيل األسنان وتفشل في معالجة عيوب األنسجة الرخوة‬
3 reconstruction plates alone are considered an option for patients who may not tolerate other means of
reconstruction because of medical comorbidities or as a temporary measure before definitive reconstruction
‫خيارا للمرضى الذين قد ال يتحملون وسائل إعادة البناء األخرى بسبب أمراض طبية مصاحبة أو كإجراء مؤقت قبل‬
ً ‫تعتبر لوحات إعادة البناء وحدها‬
‫إعادة البناء النهائي‬

Non-vascularized autogenous bone graft

1 can be useful for small-size defects, especially those resulting from trauma or benign diseases that do
not require radiation.
2 are less technique-sensitive than the vascularized free flaps with shorter operating time
3 require stability of the bone segments and adequate healthy soft tissue bed to provide watertight
closure and prevent oral contamination
4 are considered to be unpredictable and associated with a high failure rate
Pedicled flaps
An example of this type of autogenous graft is a segment of the clavicle transferred to the
mandible, pedicled to the sternocleidomastoid muscle.

Vascularized free tissue transfer

1 This method has revolutionized maxillofacial reconstruction.

2 The vascularized free grafts can resist
1 infection in the face of oral contamination ‫العدوى في الوجه من تلوث الفم‬
2 permit simultaneous hard-tissue and soft-tissue reconstruction
3 allow rapid dental rehabilitation with endosseous implants
Note. the fibula flap supplied by the peroneal artery, and the iliac crest flap supplied by the
deep circumflex iliac artery (DCIA)

Several important principles should be followed during any grafting procedure to reconstruct
mandibular defects:
A Control of residual mandibular segments
B A good soft tissue bed for the bone graft:
C Immobilization of the graft
D Aseptic environment
E Systemic antibiotics

Goals of maxillary reconstruction

1. Restore vertical and horizontal buttresses to provide vertical support to the globe and
associated facial soft tissues.
2. Establish a partition between the sinus and nasal cavities and the oral cavity to allow for
normal speech, swallowing, and velopharyngeal function.
3. Maintain functional lip competence, and masticatory function.
4. Create a stable preprosthetic framework to provide foundation for dental rehabilitation.
Classification of maxillary defects

Vertical defect classification

Class I: Defect of the maxillary alveolus not causing an oroantral communication.
Class II: Maxillary defect causing an oroantral communication but not involving the orbit.
Class III: Maxillary defect causing an oroantral communication involving the inferior orbital rim
and floor.
Class IV: Maxillary defect causing an oroantral communication involving the inferior orbital rim
and floor with exenteration of orbital contents.
Class V: Orbitomaxillary defect.
Class VI: Nasomaxillary defect.
Horizontal defect classification
a. Palatal defect only, not involving the dental alveolus
b. ½ or less of the unilateral palate and alveolus.
c. Anterior maxillary defect.
d. Greater than ½ palatal and alveolar defect.

(Obturation

1 simple nonsurgical method for maxillary reconstruction,

2 allow improved speech and mastication, provide support to the facial tissue
3 allow direct inspection of the residual cavity and assess for recurrent local disease in case of tumor resection
4 obturators carry a negative psychosocial stigma

Local pedicled flaps

1 used to reconstruct localized maxillary defects the posterior maxilla and palate
2 the buccal fat pad flap, palatal flap and temporalis muscle flap
Vascularized free tissue transfer
can be in the form of soft-tissue free flaps such as the radial forearm flap or hard and soft tissue
composite flaps such as the fibula flap or the iliac crest flap supplied by the deep circumflex iliac
artery (DCIA).

Flaps for oral and maxillofacial reconstruction

Classification of flaps

According to blood supply

1 Random pattern flaps receive capillary blood supply in a random pattern and not from a
single nutrient vessel. Buccal advancement flap used in closure of oroantral fistula is an
example of a random flap.
2 Axial pattern flaps are supplied by a single nutrient vessel oriented longitudinally along the
flap axis. Palatal transpositional flap used in closure of oroantral fistula is an example of an
axial flap.
3 Pedicled perforator flaps are supplied by specific musculocutaneous perforators.
4 Vascularized free tissue transfer refers to flaps that are harvested from a remote region and
have the vascular connection reestablished at the recipient site.