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

8
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 well-
documented 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

9
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

11
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

12
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

13
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.

14
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

15
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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