Bone grafts for

maxillofacial reconstruction
Dr. Ravi Veeraraghavan M D S D N B M N A M S
Pro fesso r a n d He a d , OM FS ,
A m r i ta S c h ool o f De nt i st r y,
A m r i ta I n st it ute o f M e d ical S c i e nces, Ko c h i .
 Maxillofacial bone defects
Surgical ablation of pathology
Gross Trauma
Developmental defects
Cosmetic
 Goals of jaw reconstruction
 to restore continuity of the jaw

 to provide facial aesthetic contour

 to provide support for soft tissue structures

 to provide morphology and position of the bone as

related to the opposing jaw and

 to provide adequate height and width of alveolus

Reconstruction options
 Bone graft biology
Process of graft ‘take’
 Osteogenesis
 Osteoconduction
 Osteoinduction
Osteogenesis
• Osteoblasts from graft lays new bone
• Significant role only in free flaps and distractions
Osteoconduction
 Main method of healing of bone grafts
 Hematoma  Granulation Tissue Callus  Mineralisation
 Angiogenesis brings in osteoblasts
 Graft is a passive framework
Osteoinduction
 the active molecules (‘factors’) released by the graft stimulate the
stem cells from the host to differentiate and deposit bone.
 Bone morphogenic proteins (TGF β family)
 BMP 2, 4, 7

 Also aid in chemotaxis

Sources of bone

 Autogenous
 Allogenic
 Xenografts
 Alloplastic
 Autogenous bone graft source
 Large quantity of cancellous and/or cortical bone
 Minimal risk of morbidity
 Prominent sites
 Accessibility
 Minimal dissection
 Bone graft sources
 Iliac crest
 Anterior
 Posterior

 Rib
 Calvarium
 Tibia
 Oral sites
The pelvis
Ilium
Iliac crest
Anterior superior iliac spine
(ASIS)
ASIS attachments
 Anterior iliac crest bone graft

Harvesting technique
 Position supine
 Palpate ASIS
Anterior iliac crest
Incision
 Iliac crest harvesting - incision
Press on the abdomen so that the incision line slides medially to align with the
iliac crest
 Dissection across skin, subcutaneous tissue, Scarpa’s fascia
 Reach periosteum of the crest medial to the tensor fascia lata and lateral to the
external oblique muscle
Anterior iliac crest - Dissection
Incise periosteum and continue
subperiosteal into the medial surface
Anterior iliac crest
Bone harvesting
Grillon GL, Gunther SF, Connole PW: A new technique for obtaining iliac bone
grafts, J Oral Maxillofac Surg 42:172, 1984.
Calm shell approach Trap door approach Tschopp approach Tessier approach
 Anterior iliac crest graft

Complications
• ASIS avulsion fracture
• Numbness to lateral thigh (damage to lateral femoral
cutaneous nerve )
• Pain
• Gait disturbances
• Adynamic ileus, hernia (too much retraction of medial
muscle)
 Posterior iliac crest
 Dingman (1950)
 High volume of
cancellous and cortical
bone
Posterior superior iliac crest
(PSIS)
Posterior iliac crest
Anatomy
Posterior iliac crest
Prone jackknife position with the table
flexed at 210 degrees
Adequate padding
Posterior iliac crest
 PSIS palpation
PIC graft harvesting
PIC graft harvesting
PIC graft complications
 Seroma
 Hematoma
 Fracture
 Gait distrubances
Rib graft
 Harold Gillies – 1920s
 Prominent location
 Natural curvature similar to
contralateral mandible
 Cortical bone
 Can be split to increase width
 Can be scored to make it flexible
 if cartilage is included, may have
growth potential
 Rib graft - indications
1. Ramus-condyle unit reconstruction in growing
children

2. Ramus-condyle unit reconstruction or other

continuity defects following resections of the
mandible in adults

3. Costal cartilage grafts for reconstruction of

cartilaginous defects in the ear and nose

4. Additional bone graft strut/crib/sandwich to

complement another graft
Rib
Anatomy
Rib
Technique
Rib graft
 5th, 6th or 7th rib
 Incision in the
inframammary crease,
close to the rib
Rib graft - harvesting
 Incision through skin, subcutaneous tissue, fascia and muscle
 Pec major / Rectus abdominis , serratus anterior
 Exposes anterior surface of rib
 Hold the rib
 Incise periosteum
Rib graft - harvesting
 Careful subperiosteal dissection prevents bleeding and
pneumothorax
 Rib doyen
Cut the cartilage first
Rib graft - harvesting
Rib graft - complications
 Pneumothorax
 Pain
 Unaesthetic scar
 Rib graft – check for pneumothorax
Fill effect with normal saline

Exert positive pressure ventilation

Bubbling in the wound

Pleural tear

ICD
Calvarium
 1890, both Mueller and Koenig
 popularized by Tessier 1960s
 included in maxillofacial primary field
 Easy access to scalp
 Curved bone with good surface area
 High cortical content  minimal resorption
Calvarial graft -indications
 Cranial vault reconstruction
 Stabilising maxillofacaial osteotomies
 Onlay bone augmentation
Cleft/cranifacial bone grafting
 Trauma, Pathology defect recon
Calvarium – diploic spaces
Calvarial graft site selection
Parietal bone of non-dominant side
Cranial bone graft harvest
approach
Coronal
Hemicoronal
Any curved incision inside hair
Graft harvesting
Graft harvest
Split thickness graft
Full thickness calvarial graft
Calvarial bone graft alternatives
Tibia
Catone et al (1992)
Good source of cancellous bone
Tibia graft - harvesting
Tibia graft - harvesting
Tibia graft – harvesting and closure
Tibia graft – alternate site
Tibia - complications
 Hematoma
 Weakening/fracture of tibial plateau
 Pain
Intra-oral sites
Symphyseal graft
Ramus graft
Factors in bone graft success
Span of defect
Vascularity of recipient bed
Cancellous vs cortical bone
Inlay vs onlay
Soft tissue coverage
Rigid fixation (immobilization)
Span of defect
 larger the defect (i.e. longer the graft), the
poorer the success rate
 various studies – 4 – 11 cm cut-off
Current consensus - 6 cm
Vascularised bed
Maxillofacial region has good blood supply
Areas of concern
◦ Surgical scars
◦ Irradiation
◦ Poor general health
Cancellous vs cortical bone
Inlay vs onlay
• Inlay grafts – cancellous
• Onlay graft - cortical
Soft tissue coverage
Adequate coverage is essential
Contamination must be avoided
Farina et al (2016) - almost all failures of bone grafting is bcos of lack
of oral seal.
Rigid fixation
Another essential requisite
Rigid fixation improves chances of graft take

 ensures primary healing

 no disturbance to new tender capillaries
Factors in bone graft success
Span of defect
Vascularity of recipient bed
Cancellous vs cortical bone
Inlay vs onlay
Soft tissue coverage
Rigid fixation (immobilization)
Recent advances
Improvements in biomaterials
Porous, biocompatible, BMP
Prefabricated mesh
Recent advances
Combining autologous bone marrow mononuclear cells seeded on
collagen sponge with Nano Hydroxyapatite, and platelet-rich fibrin:
Reporting a novel strategy for alveolar cleft bone regeneration.
Al-Ahmady, H. H., Abd Elazeem, A. F., Bellah Ahmed, N. E., Shawkat, W. M.,
Elmasry, M., Abdelrahman, M. A., & Abderazik, M. A. (2018).
Journal of Cranio-Maxillofacial Surgery. doi:10.1016/j.jcms.2018.05.049
 Cancellous bone in Ti mesh tray

Mandibular Reconstruction With Fibula Bone Graft Followed by Particulate

Cancellous Bone and Marrow Graft With Titanium Mesh Tray.
Ozaki, H., Sakurai, H., Yusa, K., Kitabatake, K., Kobayashi, T., & Iino, M. (2016).
Journal of Oral Implantology, 42(4), 381–384. doi:10.1563/aaid-joi-d-16-00009
 Thank you
Dr. Ravi Veeraraghavan

Bone Grafts in
Maxillofacial Reconstruction