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Bony Reconstruction of the Jaws

The goals of reconstruction
1-to provide morphology and position of the bone in relation to its opposing jaw. 2- provide adequate height and width of bone, restore continuity of the mandible and maxilla. 3- provide facial contour and support for soft tissue structures.

Defects of the Mandible

Defects of the mandible can involve single subsets of the mandible, several segments, or the entire mandible. Marginal defects involve loss of the mandibular bone with the inferior and posterior portions left intact. In marginal defects the continuity of the mandible is intact, and reconstructive efforts are focused on maintaining bulk and contour. Segmental defects involve loss of mandibular bone and either the posterior or inferior border and confer a continuity defect of the mandible.

Defects of the Maxilla
Defects of the maxilla can be divided into those that disrupt partitioning of cavities and those that represent inadequate bulk or position of bone in one of the subsets. Partitioning disruptions need to be evaluated in terms of both size and location. Small defects in the bone interfering with partitioning can be managed by soft tissue procedures only and may not necessarily need to undergo bony reconstruction. Larger defects in bone interfering with partitioning can be successfully obturated by maxillofacial prostheses and, similarly, may not need bony reconstruction. Many reconstructive options exist for these types of defects. The demands of occlusal restoration or stability of the upper jaw represent the majority of needs for bony reconstruction. Positioning of the upper jaw segments can be managed through orthognathic surgery

Limitation of Bony Reconstruction
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Bony reconstruction of the jaws depends largely on the amount of soft tissue available. Soft tissue coverage and recipient bed nourishment need to be addressed prior to any bony reconstruction. The soft tissue evaluation and management should precede any efforts at bony reconstruction. The limitations of bony reconstruction lie largely in the imagination and skills of the practitioner. Host limitations relate to the existing soft tissue envelope in terms of both bulk and blood supply and systemic factors in the patient.

Bone Biology
The hallmark of reconstruction of the jaws is the grafting of bone into sites of loss or need. Bone reconstruction on a physiologic level is accomplished by combinations of three processes: osteogenesis, osteoconduction, and osteoinduction. Osteogenesis is the formation of new bone from osteocompetent cells. Osteoconduction is the formation of new bone along a scaffold from the host’s osteocompetent cells. Osteoinduction is the formation of new bone from the differentiation and stimulation of mesenchymal cells by the bone-inductive proteins

Bone Grafting Biology

The repair of bone is divided into two phases. The first phase consists of cellular proliferation and production of osteoid in a disorganized fashion. The second phase is characterized by resorption of the osteoid and replacement by more organized lamellar bone. During the first phase of bone regeneration the transplanted cells within the graft proliferate and form new osteoid over the course of a few weeks. The amount of bone regeneration is dependent on the amount of bone cells that survive the transplantation procedure. These cells’ survival is integrally related to the nourishment from the recipient bed. For the first 3 to 5 days diffusion by plasmatic circulation is the source of nutrients; by day 5, capillary ingrowth from the surrounding soft tissue and bone edges penetrate the graft. Free grafts of bone can be either cancellous, cortical, or corticocancellous
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blocks.Within a graft, cancellous bone revascularizes sooner than corticocancellous or cortical block grafts. A second phase of bone growth follows the initial consolidation and begins at about 2 weeks. Fibroblasts and other mesenchymal cells differentiate into osteoclasts and begin a resorption of the osteoid. This differentiation of cells is accomplished by BMPs found in the transplanted bone. New bone is laid down in a more orderly fashion. The two-phase theoryof bone healing applies to all types of autogenous grafts. In summary: (1) cancellous grafts are revascularized more rapidly than cortical grafts. (2) cancellous bone incorporates by an appositional phase followed by a resorptive phase but cortical grafts incorporate by a resorptive phase followed by an appositional phase. (3) cancellous grafts tend to repair completely whereas cortical grafts remain a mixture of necrotic and viable bone. Bone grafts improve in their mechanical properties over time. Cancellous bone grafts tend to be strengthened over time with the addition of new bone. As the necrotic cores are replaced, the strength of the bone returns to normal. Cortical grafts have a different time course and actually undergo a weakening of the bone during the osteoclastic phase. Cortical grafts have been shown to be 40 to 50% weaker than normal bone from 6 weeks to 6 months following transplantation, a period in which the porosity of the graft increases approximately 15%.21 After 1 to 2 years the mechanical strength becomes equal to normal bone. Other sources of bone are available for grafting, but none has surpassed autogenous grafts. Grafts can be either homologous grafts (allografts) or heterografts (xenografts). The ability to obtain grafted bone without donor site morbidity to the patient has been a longtime goal of reconstructive surgeons. Autogenous bone grafts have been shown to be superior to allogeneic bone, xenogeneic bone, bone substitutes, and alloplasts in terms of the function, form, and adaptability. The superiority is due to the transfer of a greater number and density of osteocompetent cells. Homologous grafts, also known as allografts or allogeneic grafts come from another person. Allogeneic grafts are genetically dissimilar and to avoid tissue rejection phenomena must be rendered nonantigenic.
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Allograft materials have been used in several jaw reconstructive procedures, but their volume and lack of osteocompetent cells make their use limited. Alloplastic graft materials include hydroxylapatite crystals, bioactive glasses, calcium sulfate, beta tricalcium phosphate, and biphasic calcium phosphate. Hydroxylapatites are the most commonly used alloplasts. Porous nonresorbable hydroxylapatite found in coral has been used but with only limited success. New bone can grow into the pores, but the nonresorbable coral matrix shields the new bone from stress and prevents it from maturing as well as might be desired.
Table 39-2

Bone Morphogenetic Proteins

BMPs are an attractive restorative material. Although technically a graft, this material derives its ultimate effect by bone formation in the host. Be Grafts With a goal to increase the available bone for placement of endosseous implants in the maxilla, BMPs have been placed into the maxillary sinus with collagen sponges as a carrier to induce new bone formation Autogenous Bone Grafting Sites Intraoral Bone Grafts Grafts that can be obtained from a local or regional site are attractive in that they are easily obtained, often in the same surgical field. They are, however, usually limited in size, quality, or cancellous bone content. Intraoral donor sites include the symphysis (chin), ramus, mandibular inferior border, mandibular body, coronoid process, and zygoma. Limited amount of bone is available from these sites, and the amount of cancellous bone is sparse. For harvesting of grafts from the chin: either an intrasulcular or vestibular incision can be made. The periosteum and mentalis muscle are stripped from the chin region, and osteotomies are performed on the buccal surface beginning below the apices of the teeth. Alternatively a trephine can be used to obtain the graft. The midline is usually left intact, and grafts can be harvested from the right and left sides simultaneously if necessary; graft volumes of 1 to 3 cc have been reported.
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A mild pressure dressing is applied to the chin region for 5 days. Temporary paresthesia of the chin has been reported in at least 43% of cases. For harvesting of ramal grafts, several incisions can be used. In the edentulous patient a crestal incision is used extending posteriorly to the ascending ramus at the level of the occlusal plane. With healthy natural teeth, an intrasulcular incision is used, extending it posteriorly to the ascending ramus. When prosthetic crowns are present, consideration should be given to a submarginal incision along the mucogingival line, again extending to the ascending ramus. Following any of these incisions, a full thickness mucoperiosteal flap is developed along the lateral aspect of the mandible, exposing the lateral ramus of the mandible. A rectangular block of cortical bone up to 4 mm in thickness, up to 3.5 cm in anteroposterior dimension, and up to 1 cm superoinferiorly can be harvested. The medialmost osteotomy cut is lateral to the teeth and 4 to 6 mm medial to the external oblique line. The osteotomies can be cut with burs, saws, or a small diamond wheel (especially useful for the inferiormost cut). Using osteotomes and chisels the block can be removed. Alternatively, trephines can be used to obtain bone. Morbidity from this procedure includes fracture of the mandible, lingual or inferior nerve neurosensory disturbance, bleeding, and incision dehiscence

Cranial Bone Grafts
Cranial bone is a time-honored site for obtaining bone for grafting. the technique can yield considerable amounts of cortical bone but limited amounts of cancellous bone. There is an age-dependent relationship of the development of diploic space in the calvarial bones: 80% of children have a diploic space by the age of 3 years, and when present it is
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less than 50% of its adult thickness. The grafts can be harvested from either the inner or outer cortical tables and the procedure is well tolerated by patients. The thickness of the bone should be at least 6.0 mm to consider in situ harvesting. Selection of the side of the head to use should be in the nondominant hemisphere. Grafts from the areas of the parietal bone are the most useful; although harvest from the frontal or occipital regions has been described, the temporal region should be avoided. The incision through the scalp for obtaining the graft can be either coronal (full or partial) or sagittal. The dissection of the scalp flap should proceed in the subgaleal plane, and then the pericranium of the calvaria should be incised sharply. The area of the graft is marked out with a bur staying at least 2 cm from the sagittal suture to avoid overlying the sagittal sinus or arachnoid granulations. The graft donor site should also be chosen to avoid other sutures. For harvest of small areas of bone, a single block can be obtained A bur is used to make initial cuts through the outer cortex of the calvaria. One side is beveled to allow insertion of a curved osteotome in a plane parallel to the outer surface and at the diploic level. For larger block grafts it is advisable to bevel two or more sides to avoid inadvertent perforation of the inner cortex. When larger amounts of graft are needed it may be safer to harvest the bone as several strips, rather than a single block. Once the graft has been harvested the donor bed is checked to assure integrity of the inner cortex, and a piece of gelatin foam is placed over the site. The periosteum is reapproximated and the scalp closed in layers, with the galea being reapproximated. The skin can be closed with either staples or sutures. For grafts from the inner table of the skull (internal table of calvaria), a formal craniotomy is performed and the bone

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flap is handled ex vivo. The graft is obtained from the inner cortex, and the flap is replaced after resuspending the dura then fixated.

Costochondral Grafts
Grafts from the rib are useful in that they contain both bony and cartilaginous tissues. The cartilaginous component is useful for providing an articular surface for the temporomandibular joint and for providing a growth center in growing patients. This source of bone, however, is limited by the size, curvature, and strength of the rib. For reconstructing the temporomandibular joint the contralateral rib usually has the more favorable contours. Ribs from either side can be harvested, but most surgeons prefer to use the right side over the left side Either the fifth or sixth rib can be harvested. because of the position of the heart. An incision is used that corresponds to the submammary crease. This incision is well hidden in women and is a minor concern in men. The incision willusually overlie the sixth rib. A curvilinear incision is used and the skin is incised sharply; sharp dissection is used to enter the plane overlying the ribs from the costochondral junction to the midaxillary line. The sixth rib is usually the inferiormost origin of the pectoralis major muscle, and its use will entail the least amount of stripping of the muscle. A longitudinal incision is made over the bony portion of the rib, and a careful subperiosteal dissection is performed circumferentially around the rib. Care is to be used at the inferior and deep aspect of the rib to avoid the neurovascular bundle. Either saws or rib cutters can be used to divide the rib. The rib can be harvested with a variable amount of cartilage attached to the end. Once the rib is harvested the cut edge of the residual rib remaining in the patient is rounded to avoid sharp edges.
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Sterile saline is placed in the donor site, and the patient’s lungs are inflated to assess for pneumothorax. The wound is closed in layers and a long-acting local anesthetic is administered to the harvest site.

Iliac Crest Bone Grafts
The ilium is the most preferred donor site for bone grafting. Grafts may be obtained from either the anterior or posterior portions of the bone. It contains the greatest absolute cancellous bone volume and has the highest cancellous-to-cortical bone ratio. Greater amounts of bone can be obtained from the posterior ilium. From a single side, the maximum amount of obtainable bone approaches 50 cc. From the posterior ilium, the maximum obtainable bone approaches 90 cc donor site complications include hematoma, seroma, nerve and arterial injuries, gait disturbances, fractures of the iliac wing, peritoneal perforation, infection, sacroiliac instability, and pain Harvest of the anterior iliac crest bone The skin overlying the iliac crest is gently pulled superiorly and medially to allow the incision to rest in a position inferior and lateral to the prominence of the bone. The incision is made parallel to the crest of the iliac bone and approximately 2 cm posterior to the anterosuperior iliac tubercle. A 3 cm incision is usually adequate to gain access to the iliac bone. The skin is incised sharply down to the subcutaneous fat. Using electrocautery, the subcutaneous tissue is incised down to the fascia overlying the fascia lata and external oblique muscles. An incision is made along the crest of the bone down to and through the periosteum. This incision can usually be made with minimal cutting into the muscle fibers. Once the incision is made through the periosteum, the

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subperiosteal dissection can proceed onto the medial or lateral surfaces of the ilium, depending on the approach used and the need for a multilaminar graft. Once the ilium is exposed by any approach, the bone can be harvested as a corticocancellous block graft, a cortical graft, or a cancellous graft. The size of the graft is outlined, and using saws, osteotomes, or a bur, osteotomies are performed. The cancellous graft can be harvested with curettes, gouges, or trephines. Hemostasis is obtained with the use of gelatin foam or other hemostatic agents if necessary. Use of drains at the donor sites of either posterior or anterior approaches is not indicated; and no difference has been shown in wound healing. Injection of a longacting local anesthetic agent into the overlying soft tissue provides some comfort in the immediate postoperative period. Harvest of the posterior iliac crest is another welldocumented source for bone: The landmarks identified are the spinous processes of the vertebra and the posterosuperior iliac crest and spine. A 5 cm curvilinear incision is made through the skin overlying the iliac crest Using sharp and blunt dissection through the subcutaneous tissues, the posterosuperior crest is identified and the fascia divided between the abdominal and gluteal muscles. Bone can be harvested as a corticocancellous block graft, a cortical graft, or a cancellous graft similar to the approach to the iliac crest. Complication rates for posterior iliac crest bone harvest are, in general, lower than those for anterior harvest.

Tibial Bone Graft
The tibial metaphysis is another important source of autogenous bone. The use of this site is relatively contraindicated in growing patients because of the risk of disturbance to a growth center site, Bone from the tibial site was successfully used
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to graft mandibular nonunions, in orthognathic surgery, as a sinus augmentation, and in mandibular reconstruction. Comparison of tibial grafts against iliac crest grafts in secondary alveolar clefts shows similar bone densities at 6 months. A 3 cm longitudinal and slightly angled incision is made through the skin overlying Gerdy’s tubercle. Gerdy’s tubercle is a prominence of bone on the anterior surface of the proximal end of the tibia located lateral to the tibial tuberosity. It is the distalmost insertion of the iliotibial tract. Sharp dissection is used to obtain a supraperiosteal dissection overlying and inferior to Gerdy’s tubercle. Regardless of the approach (medial vs lateral) used, once the window has been removed or elevated, the cancellous bone can be harvested with curettes. No attempt is made to fill the metaphyseal dead space, and no drains are used. The wound is closed in layers. If smaller amounts of bone are needed (< 15 cc), the procedure can continue through a small stab incision and with use of a trephine or curettes.

Microvascular Free Flaps:
Many microvascular free flaps have been described for reconstruction of the mandible and maxilla, including the fibula, iliac crest, and scapula. Free microvascular flaps have the advantage of having their own blood supply independent of the local tissue bed, and they behave as a microvascular transfer of tissue, except where they interface with the existing recipient bone. In areas of poor vascular supply they have superiority over other bone grafts. Additionally they may be transferred as composite grafts including soft tissue components.

Platelet-Rich Plasma

PRP is a volume of autologous plasma that has a platelet concentration

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higher than normal. In general, PRP contains > 1 ⋅ 106 platelets/μL. PRP is applied to the site of a bone graft to deliver a high concentration of growth factors from platelets. Once the PRP-containing high concentrations of fibrinogen and platelets are mixed with thrombin and calcium, a gel is formed resulting in the release of growth factors from the platelet (〈) granules.Within 10 minutes the platelets secrete 70% of their stored growth factors and close to 100% within the first hour. The platelets then synthesize additional amounts of growth factors for about 8 days until they are depleted and die . The 〈-granules of platelets release at least seven growth factors, including platelet derived growth factor, TGF-®, platelet-derived epidermal growth factor, plateletderived angiogenesis factor, insulin-like growth factor-1, and platelet factor-4. PRP is an autologous preparation; therefore, the risk of disease transmission from its use should theoretically be nil. There has been some concern about the antigenicity of the bovine thrombin used, although this has not been a problem in maxillofacial applications. Hyperbaric Oxygen Therapy After success with treating osteoradionecrosis of the mandible with hyperbaric oxygen therapy, the modality was applied to patients undergoing mandibular reconstruction. Hyperbaric oxygen therapy consists of breathing 100% O2 at 2.4 atm for 90 minutes, commonly referred to as a dive . Protocols for reconstructive procedures differ from those used to treat osteoradionecrosis and consist of 20 dives preoperatively and 10 dives postoperatively. Complications of hyperbaric oxygen therapy include reversible myopia; barotraumas to the middle ear, lungs, teeth, and sinuses from rapid pressure

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changes; seizures (self-limited and causing no permanent damage); claustrophobia; reversible tracheobronchial symptoms (chest tightness, substernal burning sensation, and cough).

Reconstruction of the Mandible
Reconstruction of the mandible can occur immediately at the conclusion of an ablative procedure of the jaw (primary reconstruction); delayed (secondary), after an appropriate time of primary soft tissue healing; or, in the case of developmental or gradually acquired defects, at the time of recognition of the need for reconstruction. The first step in reconstruction is to classify the defect determined by its size, location, and functional or cosmetic impairment. The size of the defect in three dimensions will define the magnitude of the reconstruction. Small defects of the alveolus may require limited bone grafting, while larger defects may require more extensive or staged procedures. Some defects may not necessarily be restored to the original size and bulk of the missing part. Loss of a significant portion of a ramus may be adequately managed by providing continuity from the condyle to the body of the mandible without restoring a coronoid process or several centimeters of anteroposterior width. The bulk of the bone need only be enough to provide for adequate strength to manage the functional loads. Location is important as some defects may not need to be restored, such as the very posterior of the body of the mandible (distal to the first or second molar) where no plan is made for restoration of the dental occlusion of the mandible or opposing dental arch. The functional deficits that exist and those that are to be addressed play a role in the choice of reconstruction. The available soft tissue in terms of quantity and quality is paramount in choosing a reconstructive method. Indeed the soft tissue will determine to a large extent the

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available options. If the soft tissue is adequate in both of these parameters, the options will be many. If, however, the soft tissue is inadequate in size or bulk, efforts will need to be made to provide adequate soft tissue before undergoing bony reconstruction. This can be accomplished by introducing more soft tissue through local flaps, pedicled flaps, or microvascular free flaps. Composite flaps are an option for simultaneous hard and soft tissue reconstruction. Techniques such as distraction osteogenesis can provide increased bone and soft tissue simultaneously like the composite grafts. If the quantity of soft tissue is adequate but the quality of the soft tissue is poor, the reconstruction will be compromised or the options limited. Tissue that has been irradiated or has extensive scarring will provide a poor host bed for any grafting procedures. Adjunctive procedures such as hyperbaric oxygen therapy or soft tissue flaps may be necessary to provide an adequate donor bed. The functional and esthetic requirements will dictate the goal to be accomplished; multiple-stage procedures are the norm rather than the exception. Reconstruction of the Maxilla The same general parameters in approaching the mandibular reconstruction are operative in the maxilla.

Case Example 1: Reconstruction of Large Traumatic Mandibular Defect
The patient is a 17-year-old man who suffered a gunshot wound to the anterior mandible with loss of both hard and soft tissue The maxilla was

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unaffected. The first step in this case is to define the defect in terms of both hard and soft tissue and decide on a strategy for reconstruction. As this is a contaminated wound with ill-defined areas of vital hard and soft tissue, delayed reconstruction is the preferred option. Débridement of free bone fragments and grossly nonperfused soft tissue will enhance the rapidity of primary healing. Once the débridement is complete, the bone components are aligned using available dental landmarks and soft tissue components are reapproximated To aid the ease of reconstruction, anatomic relations are maintained and stabilized with fixation devices to preserve interramal width. At this time a more accurate assessment of soft tissue and bone deficits can be appreciated in three dimensions. There is a segmental mandibular defect with inadequate soft tissues and an opposing dental arch. The functional requirements for reconstruction include: (1) restoration of continuity of the mandible, (2) adequate bone height and width to allow restoration of the occlusion, (3) restoration of mandibular morphology for esthetic and functional requirements. Because of the avulsive nature of the defect, the soft tissue is inadequate in terms of quality and quantity. A period of weeks to months may be required for the soft tissues to mature and heal. Before bony reconstruction can begin, soft tissue must be brought in to provide for an adequate recipient bed for grafting and restoration of contours. In this otherwise healthy individual, autogenous grafting will most effectively supply the adequate bulk and form necessary to achieve the goals. A pedicled myocutaneous graft (pectoralis major) with a skin paddle will provide the blood supply to nourish the graft and to provide adequate bulk of skin in the chin region.

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The residual bilateral condyle-ramal complexes will be stabilized with a titanium reconstruction plate. An appropriately sized skin paddle will restore the missing skin over the chin. The muscle is positioned to restore bulk to the region and to approximate the area of the future bone graft. The soft tissues are then allowed to heal over several weeks prior to definitive bone grafting. Both allografts and autografts will be used, with a cadaveric mandibular crib secured to the reconstruction plate used to maintain the proper morphology of the mandible. A cancellous marrow graft is obtained to provide adequate bulk. Restoration of the contours and functionality of the mandible results at the completion of the reconstruction.

Case Example 2: Delayed Reconstruction of an Ablative Defect of the Mandible
A swelling with associated radiolucency of the mandible is noted (Figure 39-24). Both the medial and lateral cortices have beenndestroyed in the area of the lesion. Because of the location and size of the defect, reconstruction of the defect is indicated to restore bulk and strength of the residual mandible following treatment. After adequate soft tissue healing, an anterior iliac crest cancellous bone graft is obtained and placed in the defect. One year following reconstruction, the bone graft has matured with a normal trabecular pattern. The graft is maintained and the bone is adequate for oral rehabilitation 2 years after grafting

Case Example 3: Reconstruction of the Anterior Maxilla
A 37-year-old man had undergone avulsive trauma to the anterior maxilla during a motor vehicle accident. The residual defect was from the loss of anterior maxillary teeth and a large portion of the alveolus (Figure
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39-25A). Dental models were obtained, and a diagnostic wax-up was prepared to assess the ideal position of the restored teeth. The bony reconstructive effort is therefore guided by the prosthetic plan so that adequate bulk and position of the grafted bone can be assured. The defect in the upper jaw consisted of inadequate bone in terms of height and width and inadequate soft tissues. No oral–nasal cavity partitioning defect existed. A wide pedicled flap is raised to expose the bony defect, and a stent prepared from the diagnostic wax-up is used to assess the bony defect more accurately. Sterile bone wax is used to prepare a template for the graft dimensions . A corticocancellous graft is obtained from the anterior iliac crest, contoured from the template and secured with titanium screws. Using the stent as a guide, endosseous root-form implants are placed in the graft.

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