Bone Grafts In Maxillofacial Surgery

Maj Ajay P Desai Resident 2nd Yr Oral &Maxillofacial Surgery

Col N K Sahoo Senior Specialist Oral &Maxillofacial Surgery

A successful bone graft is one which after application, heals, becomes incorporated, revascularises and eventually assumes the form desired.

Review of literature

Van Meekeren

1668.

successful transplantation of xenogenic bone from dog to a man in restoring cranial defect Von Nussbaum reported the first free transplant in a 5 cm long defect in the ulna after an infected comminuted fracture

In 1875

The discovery of anaesthesia and nitrous oxide in 1844 by Horace Wells, and ether by William Morton in 1846 opened up new surgical possibilities, which had never existed before The discovery of anaesthesia and the introduction of antisepsis by Lister in 1864 made bone grafting a possible clinical procedure

In 1895 Barth nearly came to the opposite conclusion, that all parts of grafted bone will die, and the major importance of a bone graft is to be osteoconductive

In 1909 Georg Axhausen

A living periosteal-covered graft shows marked cellular proliferation under the periosteum,which produces and establishes a vascular connection between the graft and its bed. The compact bone of a graft always exhibits empty cell spaces into the greater part of its content.

A graft containing marrow shows new bone formation from the marrow tissue, wherever this is in contact with living vascular tissue. The viability and proliferation of allografts are more uncertain than those of autografts. Xenografts become in capsulated or absorbed and show neither vitality nor proliferate capacity.

Bardenheuer 1892 used a pedicled flap from the mandible itself to rebuild a mandibular defect

W. Sykoff in1900 reported on, as he called, the autoplastic transplantation of bone

Ludwig von Rydygier reported that in 1892 he already used a pedicled bone graft from the clavicle to replace a defect in the mandible.The bone graft was surrounded by the skin, left in place for 8 12 days and then transplanted with a long skin flap to the mandible

1917 McWilliams reported on grafting of mandibular defects after trauma and especially in cases of osteomyelitis

emphasized that during the healing period after removal of necrotic bone the segments of the mandible have to be kept in right anatomical position by intermaxillary fixation. stressed the importance of an intact oral mucous membrane before grafting

Mandibular augmentation 1954 Schmid demonstrated a number of cases with reconstruction of alveolar defects and continuity defects where iliac bone grafts were used via an intraoral approach, under antibiotic coverage but claimed, that he also had been performing this before antibiotics were available. The reconstructions included both jaws.

Rehrmann was probably one of the first to design a surgical method for ridge augmentation with iliac crest bone followed by his design of a vestibular lingual sulcoplasty, described in his publications from the early fifties

The tunneling approach was introduced by Celesnik in 1965, who restored atrophic mandibles via this approach

Davis et al in 1970 reported 6 cases, where transoral autogenous rib grafts were used to restore the atrophic mandible. In details they described how the operations were carried out, that the ribs were placed vertical and that the triangular space between the mucosa and the rib was filled with chips in order to avoid dead space.

Maxillary augmentation

Farrell et al [30] were the first one to apply the Le Fort I osteotomy for treatment of the atrophic maxilla in their report from 1976, where an iliac bone graft was interpositioned and a simultaneous submucous vestibuloplasty was made to utilize the increased height of maxilla

Distraction osteogenesis Tissue engineering

The bone induction principle originally discovered by Marshall Urist The first clinical study was conducted in 1988 by Johnson and associates, who studied purified human BMP

BMP

Bone grafting is dynamic phenomenon . A bone graft is used clinically mainly to provide a bridge of connective tissue

Habal MD, Reddy: bone grafts and bone substitutes WB saunders company, Philadelphia, 1993

common theme in the development of bone from primitive mesenchymal tissues to a well-structured, well-organized histological structure that one associates with mature bone

Bone formation
Intramembranous Endochondral

Principles for enhancing bone healing and bone formation

Bone induction is new bone formation from determined osteogenic precursor cells Bone conduction is enhanced bone formation due to a favourable structural environment where bone is formed Bone genesis is stimulated by modulations of natural biochemical processes that initiate and maintain bone formation during a healing response

Bone induction

cell-mediated and growth factor-mediated

bone precursor cells can be harvested from bone marrow and placed in, for example, bone defects requiring bone induction to heal sufficiently bone morphogenetic proteins (BMP) have the unique property of stimulating mesenchymal stem cells to differentiate towards chondroand osteoblastic lineage.

In bone conduction, normal bone formation is helped to extend due to a favorable structural environment in which the bone conductive material serves as a scaffold for new bone formation Bone matrix is storage medium for growth factors that participate in activation and maintenance of cellular processes during bone formation and healing

Clinical uses and functions of bone grafts

the delayed and non-union of fractures the arthrorisis of joints the filling of cavities in bone replacement of bone and joint loss the augmentation of skeletal deficiency in the forehead, nose, maxilla and mandible the fusion of growth plate cartilages

Osseous implants may be divided in three different classes depending upon[48]

their origin type of bone used graft placement technique

Classification of grafts

Autograft represents the transplanted material which is taken from the same individual Allograft represents those grafts which are taken from the unrelated donor but of the same species Xenografts represents those grafts which are taken from another species Implants represents those grafts that involve the utilisation of chemical themselves eg calcium sulphate or chemically treated grafts eg freeze dried or lyophilized bone.

Depending on the structure

cortical contains pure cortex of dense bone and only space for revascularisation is that of the nutrient vessel cancellous provides more open spaces for revascularisation cortico-cancellous has both above characters composite grafts is an auto graft but has added organic an inorganic components to enhance its biologic activity

Depending on the grafting technique used and their functions

onlay grafts inlay grafts muscle pedicle grafts vascularised grafts

Bone grafts

Cancellous Corticocancellous bone grafts

cortical

Allografts

Autografts Source Ilium, rib, cranium, tibia, mandible

Xengrafts

Limited

Clincal applications
Varied Clinical outcome

Not very useful

Satisfactory

FORMS OF GRAFTS Bone grafts can be obtained in different forms as outlined below: Bone blocks

Bone blocks consist of large pieces of bone which can be reshaped before application Cortical bone ideally can be used in this form.

Bone chips:

particulate bone which can be applied in those areas where no mechanical strength is required the defect is also bridged with a mechanical device, internal or external and the defect filled with particulate bone Different sizes and shapes of chips can be used.

Bone slurry

It is mixture of small particles of bone, usually of the size of 100/250 microns ground from cortical and other components such as microfibrillar collagen Quick revascularization can be obtained by this method but it should beused in non stress bearing areas protected healing, either an external or external holding device needs to be used.

Bone paste

It is usually similar to slurry in that the components are in the mixture that appears gelatinous and does not have structure its biologic nature allows quick revascularization of the graft so that quick healing, remodeling, solidification, and incorporation can take place require a total time of 18-24 months

AUTOGENIC BONE GRAFTS

Autogenous bone is the gold standard for bone regenerative grafting materials for several reasons including capability to support osteogenesis, osteoinductive and osteoconductive properties Requires donor site Three forms of free bone grafts include cortical, cancellous, and corticocancellous.

Mandible

Symphyseal region Coronoid process Ramus Lingual cortex Frozen autogenous mandible

Calvarial Iliac crest Tibial

Ilium
The iliac crest cortical, cancellous, and cortico-cancellous graft. limitations

disturbance of the growth center of the ilium morbidity associated with the surgery

The Ilium consists of a lower extremity or body that contributes mainly to the formation of the acetabulum and the upper extremity, or ala, which expands superiorly to form the iliac crest. The tubercle and the anterior superior spine are the basic orientation landmarks when harvesting bone.

Anterior approach

Posterior approach

Iliac Crest Harvest Complications Arterial injury Ureteral injury Herniation Chronic pain Nerve injury Infection Fracture Pelvic instability Cosmetic defects Hematoma

Rib
two fold purpose in the jaw reconstruction ready source of bone and has a chondral component as well constructing the condylar portion of the In cases of children and young adults that are younger than 16 yrs of age, the chondral part has been shown to exhibit growth via a growth plate like phenomenon at the bone cartilage junction

Indications Split rib in buccolingual orientation are used in hemimandibular continuity defects that have a proximal segment that includes the ramus and the angle. Mainly useful in reconstructing the body and the symphysis regions of the mandible .

Rib costochondral graft is indicated in hemimandibular defects that do not have proximal condylar segments. In children this graft serves as growth centre

Complications

The most common postoperative complication is pleural lacerations which are associated with multiple rib harvesting and require chest tube drainage. Pneumothorax Post operative pain, which lasts for an average of 2 weeks was described by Simon et al in 1984. The late morbidity may be related to the contour defect of bone. Scar marks of average 7.5 cms in length and 0.3 cm in width along with pain, which lasts for more than two years have been reported.

Calvarium

Calvarial bone grafts have become increasingly popular as grafting materials in maxillofacial surgery for the past decades.

Smith and Aleremson (1974)

Tessier (1983) who finally initiated the use of calvarial bone for facial reconstruction. The calvarium follow the rapid growth pattern of the brain and reaches 80% of its potential size by age four and 100% by age of 8. The cranium continues to attain the thickness but not the size and complete bony regeneration is there following craniectomy

The speed of regeneration however is dependent on the age of the patient i.e. younger the patient faster is the regeneration. The frontal, occipital and parietal bone are potential sources of graft materials. The areas of the sutures, especially the sagittal area are avoided to avoid bleeding from the underlying sagittal sinus. The region of the temporal line is not suitable due to thin bone

Indications Inner table calvarial grafts are employed in craniofacial surgery where craniotomy has been done and has the advantage of not leaving the depression in the skull

Outer table grafting is most commonly used in cases of facial reconstructive surgery and craniotomy has not been performed. Outer table consist of drilling through the outer table into the diploic layer of the skull cutting through the diploic layer leaving the inner table intact

Complications [49] Donor site morbidity should be considered and weighed against the need for bone graft and whether better sites are available. Accidental visualization of the Dura matter remains to be of major concern The disadvantage of the technique includes the limited amount of bone available. Difficulty in shaping the bone Lack of patient cooperation. Unpredictable eventual hairline.

Tibial bone grafts The tibial plateau [57] (provisional head of tibia) is another excellent reservoir of cancellous bone. It can be assessed for 25 to 40 cc of bone without affecting the structural support of tibia.

Indications In the neonatal treatment of palatal alveolar clefts in open cleft lip and palate patients. In cases of nonunion Osteotomy separations Sinus lift procedures. In addition it acts as a useful adjunct to increase the quantity of bone graft when performing a graft procedure in a patient who already has three or four areas of the ilium harvested but the bone graft material is insufficient.

Complications 1. Mild disability in the immediate post grafting period 2. Wakening of the mechanical strength of tibia.

Mandibular bone grafts

Success of mandibular bone as a graft in the maxillofacial region is partly explained by the ectomesenchymal origin of the bone. Membranous bone is more likely to retain its volume and undergo less resorption than bone of endochondral origin (Zinn and whitaker, 1979).

The use of mandibular symphyseal bone as a donor site for bone grafting in the maxillofacial region was started in 1959 by Kole et al. In the Kole procedure, bone from the inferior border of anterior mandible is used with an anterior sub apical segmental osteotomy mainly to correct cases of anterior open bite. Aslasian et al 1971 employed cortico cancellous symphyseal bone to correct malunion of maxillary fractures.

Recently, mandibular symphyseal bone has been used with considerable success in reconstruction of secondary alveolar clefts. (Sindet, Peterson,et al 1990). Kole et al 1989 also demonstrated better incorporation and less resorption of mandibular (membranous) bone than iliac crest (endochondral) bone in repair of alveolar clefts. The harvesting of bone can be done either by manual retrieval method in which high speed hand pieces, burs, osteotomies and mallets are used or trephine retrieval can be done in which surgical trephine driven by latch tight contra angle or straight hand piece is used.

However, whenever a large quantity of bone is required iliac crest and rib are the preferred sites. Thus, there is limited amount of mandibular symphyseal bone and this restricts its use, especially prior to eruption of permanent lower canine teeth (Selaire et al 1983).

Coronoid process [59] The Coronoid process can be easily harvested by an intraoral approach and has been used for Para nasal augmentation in the correction of midfacial deformities (Pill Hoon- Choung2001).

This process has following technical advantages: 1. Operation field is closed to the midface and the whole operation is possible in one operation field 2. It may be approached by means of an intraoral incision, which does not produce a visible scar 3. Being a membranous bone it has thick cortical expansion and hence shows less resorption. 4. Its other advantages include its biocompatibility, availability and definitely reduced operation time. It was first used in the repair of small discontinuity defect of the mandible (Youmans R D et al, 1969). Recently, it has also been used for orbital floor reconstruction (Mintz et al, 1998).

This process has the following limitations: 1. The amount of bone available and its thickness pose a limiting factor to its use.

Frozen autogenous mandible

The advantages of the use of this procedure are:

Good esthetic result as the shape of the graft coincides with the surgical defect Avoidance of bone grafts from other body parts, thus reducing morbidity.

Micro vascular free bone grafts

In 1963, the arterialized forehead flap was introduced by Mc Gregor for reconstruction of intraoral defects

Indications for microvascular surgical tissue transfer:

Free composite tissue transfer is indicated when covering of a wound or other defect and no satisfactory local tissue is available. In a poorly vascularised recipient bed due to preoperative radiotherapy or infection, the amount of bone loss in free autologous grafts may reach up to 40 %(Reidiger 1988).

Advantages of micro vascular tissue transfer: Only one operative procedure is required, as no feeding pedicle has to be preserved. The possibility of reconstructing the mandible in the same surgical procedure is also a benefit. Repeated anesthesia is avoided and the time of hospitalization can be reduced.

Immobilization of the part of the body involved, such as in the case of pedicle transplants or circular pedicle flaps is no longer necessary. The loss of tissue at that point of removal is noticeably smaller, as no large sections of the skin are needed for the feeding vessel pedicle..

Micro vascular flaps can be taken from the inconspicuous areas such as groin, the axilla, or the dorsum of the thorax. These donor sites are easily concealed by even brief conventional clothing and are usually cosmetically more acceptable to the patient than the multiple scars associated with distant flaps or even some local flaps. In most areas, donor defect can be closed by approximation of the tissues.

The ability to perform one stage transfers of skin flaps from a variety of distant donor sites greatly increases the options available for reconstructive surgeon. The size, texture, and color of the flap may be varied to a degree not previously possible.

Even the earliest published series of free flaps demonstrate that these procedures are as reliable as most pedicled flap transfers

Handling of bone grafts

Tonicity of storage medium. Temperature of storage medium Sterility of bone cell handling Trauma of bone handling

Assessment of bone graft healing

Radiograph An arteriogram Technetium99 CT scan Biopsies and histological evaluation Tetracycline labelled fluorescent lighting

Five Stages of Graft Healing

1. Hemmorrhage 2. Inflammation (days)

Chemotaxis stimulated by necrotic debris Osteoblast differentiation from precursors

Five Stages of Graft Healing

3. Revascularization

Osteoblast and osteoclast function Marked by vascular invasion and resorption of graft Osteoconduction (months) New bone forming over scaffold
(years)

4. Creeping Substitution

5. Remodeling

Five Stages of Graft Healing

Independent of all other factors, successful graft incorporation and union primarily depends on:

stability of the construct apposition of graft substance to host

Fate of grafts
Bone graft incorporation Functional adaptation of bone grafts

The fate of bone graft will depend upon the recipient bed. The requirements of a good recipient are as follows

Infection Free Well Vascularised Properly Immobilised

Functional adaptation is the ability of the newly formed bone graft to transfer its elements to the biologic predetermined constituents needed for its survival and withstand mechanical stress and shear pressure to resist fatigue under external physical forces This functional adaptation may take 12 to 24 months to be completed

Bone bank
A bone bank consist of of collected bone which is stored in a sterile frozen condition for later use After the experiments of Campbell[101] et al in 1953, bone banks were established In the US and the concept of allografts as an orthopedic replacement for traumatically lost, tumour-ridden and diseased bone was done

Type of bone banks In general two types of bone bank are recognized Surgical: it involves collecting surgical discarded bone, processing, storing, distributing this bone. Regional: Are usually expensive and involve a labour intensive proposition of supplying bone.

Procedures involved in Bone banking

Donor selection Bone recovery Culture Wrapping and labeling Bone storage Secondary sterilization Bone distribution

The fate of any graft depends on the nature of the recipient bed which includes the factors like vascularity of the region, immobilization of the site and sterility of the graft. Other factors which influence healing are bone metabolism, internal hormonal changes and external traces exerted during the functional adaptation of the graft. Patients physical health and nutrition is equally important in the success of the graft

Bone grafting has revolutionized the treatment of craniofacial trauma as severely comminuted bones may be replaced either by autogenous bone or various implant materials available. The anatomically positioned grafts restore the facial skeletal architecture and prevent the overlaying the soft tissue shrinkage thus restoring the original esthetic and function

BMPs, which are extracts from bovine or human allogenic bone carry the bone induction principle along with them and hence can induce bone formation without the placement of a graft. Grafting of the antral floor, reconstruction of large hemimandibulectomy defects and clefts by human recombinant BMP-2 has been done successfully in monkeys. Though clinical trials are been conducted in animals, their use in human being is not a far cry