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INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
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GRAFT is defined as—a portion of tissue removed from one site & placed at another,either in the same or in another individual, in order to repair a defect caused by operation,accident or disease.” CRITCHLEY I978
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GRAFT SOFT TISSUE GRAFT
BONE GRAFT
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COMPOSITE GRAFT
SOFT TISSUE GRAFT Split thickness skin graft Full thickness skin graft Composite full thickness skin & cartilage graft Pinch graft. Dermal and fat graft. Fascial graft Chondromucosal graft www.indiandentalacademy.com
Split thickness graft Thin Medium thick
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Life span---3wks at 4 degree celcius, when wraped in gauze & moistened in saline
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Technique
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electric dermatomes--expensive
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Process of take
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Condition of successful take Vascularization—bed capable of capillary outgrowth to vascularize the graft e.g., face, pericondrium,periostium No bare bone No previous radiotherapy No infection---S. pyogens,P. aerugenosa produce fibrolysis Thin grafts---easier to take Close contact No haematoma Immobile contact www.indiandentalacademy.com
Donor sites Arm Thigh Abdomen
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METHODS OF ADAPTING A GRAFT ď Ž Exposed grafting---graft is laid on the defect,without dressing of any kind & allowed to attach by fibrin adhesion only Primary grafting--*control of bleeding points *trapped air is pressed out Delayed exposed grafting Late exposed grafting —wound allowed to granulate
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Quilt grafting disadv—quilt sutures produce occasional bleeding from the bed
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PRESSURE METHODS Immobility Haemostasis Bolus grafting—concave area Polyurethane foam is most suitable
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DENTAL APPLIANCE METHOD --This method is used where treatment of tumor involves resecting a part of hard palate & upper alveolus IMPRESSION of defect is taken with the help of tray or denture by STENT COMPOUND OR GUTTAPERCHA
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APPLICATION OF GRAFT--Two ways— 1. MASTISOL glue 2. Direct suturing to the margins of the defect.Dental splint with its bolus is then inserted & fixed in position www.indiandentalacademy.com
FIXATION OF APPLIANCE— INTRAORAL FIXATION --direct wiring to upper alvolus --wire suspension from zygomatic arch
EXTRA ORAL FIXATION
--metal plate inset in the midline --supraorbital pin fixation www.indiandentalacademy.com
BONE GRAFT
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Bone is the basic unit of the human skeletal system. provides the framework for and bears the weight of the body, protects the vital organs, supports mechanical movement, hosts hematopoietic cells, maintains iron homeostasis.
Graft may be defined as a transferable material that contains living cells and can be used for reconstruction.
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Classification of bone Bones can be classified based on their position, shape, size, and structure Based on location Axial skeleton - Bones of the skull, vertebral column, sternum, and ribs Appendicular skeleton - Bones of the pectoral, pelvis girdles, and limbs Acral bone - Part of the appendicular skeleton, including bones of the hands and feet
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Based on shape Flat bone - Bones of the skull, sternum, pelvis, and ribs Tubular bone - Long tubular bone, including bones of the limbs; short tubular bone, including bones of the hands and feet, such as phalanges, metacarpals, and metatarsals Irregular bone - Bones of the face and vertebral column Sesamoid bone - Bones developing in specific tendons, the largest example of which is the patella Accessory bone or supernumerary bone - Extra bones developing in additional ossification centers or bones that failed to fuse with the main parts during development (Accessory bones are common in the foot and may be mistaken for bone chips or fractures.) www.indiandentalacademy.com
Based on size
ď ąLong bone - Tubular in shape with a hollow shaft and two ends, including bones of the limbs ď ąShort bone - Cuboidal in shape, located only in the foot (tarsal bones) and wrist (carpal bones)
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Types of bone tissue Based on texture of cross sections ď ąCompact bone (dense bone, cortical bone): Compact bone is ivorylike and is dense in texture without cavities. It is the shell of many bones, surrounding the trabecular bone in the center. It consists mainly of Haversian systems or secondary osteons. ď ąSponge bone (trabecular bone, cancellous bone): Sponge bone is spongelike with numerous cavities and is located within the medullary cavity. It consists of extensively connected bony trabeculae, oriented along the lines of stress.
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Compact bone morphology
Lacuna
Haversian canal
Central canal for blood vessels, etc
Canaliculi
osteocyte home
Osteocyte processes
Lamellae
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Concentric circles representing appositional bone deposition
Compact
cancellous
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In contrast to compact bone, complete osteons usually are absent due to the thinness of the trabeculae. Sponge bone also is more metabolically active than compact bone due to its much larger surface area for remodeling.
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Based on matrix arrangement
ď ąLamellar bone (secondary bone tissue): It is mature bone Collagen fibers arranged in lamellae. In sponge bone, lamellae are arranged parallel to each other, whereas in compact bone, they are concentrically organized around a vascular canal, termed a Haversian canal.
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ď ąWoven bone (primary bone tissue): Woven bone is immature bone Collagen fibers arranged in irregular random arrays, Contain smaller amounts of mineral substance and a higher proportion of osteocytes than lamellar bone. Woven bone is temporary and eventually is converted to lamellar bone. Woven bone is pathologic tissue in adults, except in a few places, such as areas near sutures of the flat bones of the skull, tooth sockets , and the insertion site of some tendons
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Based on maturity ď ąImmature bone (primary bone tissue): Immature bone is woven bone. ď ąMature bone (secondary bone tissue): Mature bone characteristically is lamellar bone. Almost all bones in adults are lamellar bones
Histology of bone. mature bone viewed under polarized microscope; lamellae are shown as alternating dark and bright layers due to perpendicular orientation of collagen fibers in the neighboring lamellae www.indiandentalacademy.com
Based on developmental / embryogenic origin ď ąIntramembranous bone (mesenchymal bone): Intramembranous bone develops from direct transformation of condensed mesenchyme cells following this cellular deposition of collagen follows finally there is calcium salts deposition in intercellular spaces direct bone formation occurs without intermediate process . Flat bones are formed in this way. ď ąIntracartilaginous bone (cartilage bone, endochondral bone): in this a primitive cartilage is required before bone formation occurs . Majority of the bones in the axial skeleton are proceeded by a primitive hyaline cartilage .these types of bones are referred to as cortical and cancellous. Most of the Long bones are formed in this way. www.indiandentalacademy.com
Bone matrix
Bone matrix consists of organic and inorganic components. The association of organic and inorganic substances gives bone its hardness and resistance. The organic component is composed of collagen fibers with predominately type I collagen (95%) and amorphous material, including glycosaminoglycans associated with proteins. Osteoid is uncalcified organic matrix. Inorganic matter composed calcium and phosphorus, smaller amounts of bicarbonate, citrate, magnesium, potassium, and sodium. www.indiandentalacademy.com
Osteoinduction Osteoinduction describes a process whereby new bone is produced in an area where there was no bone before, where one tissue or its derivative causes another undifferentiated tissue to differentiate into bone matrix was shown to induce bone formation within muscle pouches of many species of animals.
Osteoconduction Osteoconduction describes bone formation by the process of in growth of capillaries and osteoprogenitor cells from the recipient bed into, around and through a graft or bioimplant.
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BONE GRAFT are used— Management of non union & delayed union Treatment of pseudarthrosis Filling of osseous defects Arthrodesis Stablization of spinal segments Osteochondral grafts used for diseased articulation Augmentation of skeletal deficiency www.indiandentalacademy.com
CLASSIFICATION OF BONE GRAFTS BASED ON --1.ORIGIN -autograft -allograft -xenograft -bone substitute material www.indiandentalacademy.com
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2. STRUCTURE -cortical graft -cancellous graft -corticocancellous 3.GRAFTING TECHNIQUE -onlay -inlay -dowel bone graft -strut graft -muscle pedicle graft www.indiandentalacademy.com
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4. BLOOD SUPPLY -non-vascularized graft -vascularized graft
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AUTOGRAFTdefined as tissue transplanted from one site to another within the same individual ADVANTAGES
-considered as gold standard -has optimal ability to become incorporated -no immunologic sequelae www.indiandentalacademy.com
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DISADVANTAGES
-has to be harvested from a secondary site--means more morbidity -insufficient amount -inability to mold jn desired shape
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CELLULALAR EVENTS IN AUTOGRAFT Haematoma Ingrowth of granulation tissue along with mesenchymal components Osteoclastic activity Osteoconduction by mesenchymal cells Regulated by BMP
Osteogenesis with repair & incoorporation of graft www.indiandentalacademy.com
CORTICAL BONE GRAFT They are used in areas of with greater mechanical stress
Good mechanical filling Presence of ease of penetration Withstand great mechanical pressures They require a fixation system to work well but if fixed well graft can survive without getting viable for a long time Used in long bones , in facial skeleton it is used for discontinuity repairs , to improve existing contours or to expand the boundary to give a normal facial balance www.indiandentalacademy.com
Imp drawback --reduced rate of revascularization because the architecture of the cortical graft acts as a dense barier Bone resorption follow the haversian canals,with a preference for the periphery—followed by laying down of new bone approx 12wks after transplantation CREEPING SUBSTITUTION-new bone surrounds cores of necrotic osteoid that are gradually resorbed www.indiandentalacademy.com
Cancellous bone graft
Ease of application for achieving fusion Can also be used in contaminated wounds Revascularization takes place well Can be used in open wounds in the oral cavity Supply site is mostly the iliac region and the tibia Do not have mechanical strength for application in large defects www.indiandentalacademy.com
Good frame work for new bone formation Creeping substitution—new bone surrounds cores of necrotic osteoid that are gradually resorbed Becomes strengthened faster than cortical bone
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Corticocancellous
Enables good vascularization and also mechanical support Rigid fixation can be used to give desired contour Can be obtained in large blocks which can be reshaped before application
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BONE SLURRY
Bone slurry is a mixture of small particulate of bone usually ground form and mixed with blood or other microfibular collagen Can be obtained in large blocks which can be reshaped before application Particulate size is small enough to cause revascularization Used to allow quick revascularization and treatment of non stress bearing area Supported by metallic or non- metallic mesh www.indiandentalacademy.com
BONE PASTE( BONE PATE) -gelatinous past of bone & blood -quick revascularization -require 18 to 24 months for remodelling,solidification & incoorporation
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COMPLICATION OF AUTOGRAFT Non-union Pseudarthrosis Infection Tumor recurrence Fracture
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Types of bone grafts
Autograft or autogenous bone graft Allograft or allogenic bone graft Xenograft or xenogenic bone graft Alloplast or alloplastic bone graft
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The Autograft is considered the Gold Standard. It is defined as tissue transplanted from one site to another within the same individual. The only disadvantage of the autograft is that it has to be harvested from a secondary site in your body, which usually means more morbidity There are essentially two forms of nonvascularized free autogenous bone grafts: cortical and cancellous
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The Allograft is defined as a tissue graft between individuals of the same species (i.e., humans) but of non-identical genetic composition. The source is usually cadaver bone, which is available in large amounts There are three forms of allogeneic bone: Fresh frozen, Freeze-dried and Demineralized bone matrix (DBM).
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The Xenograft is defined as a tissue graft between two different species (i.e. bone of bovine origin). They are deproteinate bone particles ,this processing reduces the antigenicity making these implants more tolerable to host tissues.
The Alloplast usually includes any synthetically derived graft material not (coming) from animal or human origin. Hydroxypatite
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Types of bone grafts Non vasularized
Vascularized
Cortical Cancellous Corticocancellous Others forms are bone pasts. particulate bone and bone slurry www.indiandentalacademy.com
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Cortical bone Good mechanical filling Presence of ease of penetration Withstand great mechanical pressures They require a fixation system to work well but if fixed well graft can survive without getting viable for a long time Used in long bones , in facial skeleton it is used for discontinuity repairs , to improve existing contours or to expand the boundary to give a normal facial balance
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Cancellous Ease of application for achieving fusion Can also be used in contaminated wounds Revascularization takes place well Can be used in open wounds in the oral cavity Supply site is mostly the iliac region and the tibia Done not have mechanical strength for application in large defects If allografts are used in highly vascularized area revascularization takes place early leading to an immunological reaction causing rejection phenomenon www.indiandentalacademy.com
Corticocancellous Bone slurry is a mixture of small particulate of bone usually ground form and mixed with blood or other microfibular collagen
Enables good vascularization and also mechanical support Rigid fixation can be used to give desired contour Can be obtained in large blocks which can be reshaped before application Particulate size is small enough to cause revascularization Used to allow quick revascularization and treatment of non stress bearing area
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Bone sustitutes
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ALLOGRAFT -Defined as a tissue graft between individuals of same species(i.e.,humans) but of non-identical genetic composition. Source---usually the cadaver bone
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Three forms of Allograft Allograft
Fresh frozen
Freeze dried bone
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Decalcified freeze dried bone
FRESH FROZEN -Harvested under sterile condition -kept frozen at -80—does not undergo enzymatic destruction
FREEZE DRIED(lyphophylized)bone(FDB) -Mainly used as a composite -bending strength is lowered to 55-90% -retain its antigenicity www.indiandentalacademy.com
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DECALCIFIED FREEZE DRIED BONE(DFDB) -retains its osteoinductiveness
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CELLULAR EVENTS IN ALLOGRAFT Inflammatory response Slower vascular ingrowth Vessels are occluded with inflammatory cells Necrosis ( Ist stage) Osteogenesis (2nd stage) www.indiandentalacademy.com
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XENOGRAFT----defined as a tissue graft between two different species TYPES— -Kiel bone -Frozen calf bone -Freeze dried calf bone -Decalcified Ox bone -Ospurum -Anorganic bone -Boplant www.indiandentalacademy.com
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KIEL BONE -Deproteinized bone(extracted with hydrogen peroxide) -weakly antigenic -lacks osteoinductive capability -acts as a mechanical spacer to prevent soft tissue ingrowth -slowly resorbed,which allows new bone to mature www.indiandentalacademy.com
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Case reportsGoran & Murthy showed osseous fusion without resorption in 10 patients of anterior cervical spinal fracture Salama used autologous marrow impregnated Kiel bone with 87% success rate
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ANORGANIC BONE-Prepared by boiling the calf bone in ethylenediamine for several days -Can be stored indefinitely without refrigeration -Brittle----trimmed with scalpel BOPLANT-Kiel bone treated with propiolactone & organic solvants -Freeze dried for storage www.indiandentalacademy.com
ALLOPLASTIC GRAFT 1.
CORAL-This is the porous calcium carbonate structure resulting from the removal of organic material from sea corals -architectural similarities to bone tissue -porous(150milli micron) -conducive to invasion of the cell components -organisation of blood supply www.indiandentalacademy.com
2. CORALLINE HYDROXYAPATITE Replamineform technique Hydrothermal exchange
Coral
Hydroxyapatite
(calcium carbonate)
(porous material)
-resorbs slowly -osteoconductive -architecture similar to scaffolding of natural spongy bone www.indiandentalacademy.com
TYPES— 1.Interpore 200 2.Interpore 500 3.Osprovit 4.Ortho Matrix HA SYSTEM
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3. TRICALCIUM PHOSPHATE(TCP) -Synthetic porous bone graft -Resorb too rapidly Two commercially available forms are1.Ceros 82 2.Calciresorb
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4. COMBINATION OF HYDROXYAPATITE & TCP-Provide best environment Commercially available forms— -Triosite—60%ha &40%tcp -Ostilit------20%ha & 80% tcp
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5. BIOACTIVE GLASS CERAMICS -BGC made of CaO,N2O,SiO2,P2O5 in same proportion as bone & teeth -Regenerate bone -Formation of biologically active HYDRATED CALCIUM PHOSPHATE(HCP) layer at the surface of bioactive glass---BONE-IMPLANT BOND
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Neurosurg Focus 14 (2):Article 8, 2003, GREGORY J. ZIPFEL, M.D., BERNARD H. GUIOT, M.D., AND RICHARD G. FESSLER, M.D., PH.D. www.indiandentalacademy.com
Areas for obtaining bone grafts Head & neck Cranium Mandible Thorax Ribs Scapula Forearm Lower limb Hip (Iliac crest) Tibia Fibula 2nd metatarsal
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Iliac crest Common site is the ant wing Rapid revascularization Graft can also be obtained form post region Both cortical and canecllous grafts can be obtained Can be obtained as large blocks for weight bearing and mechanical support Cancellous bone as bone chips / particulate bone can be used Used extensively in secondary alveolar bone grafting However corticocancellous is not able to bear weight until it solidifies www.indiandentalacademy.com
BONE FROM ANTERIOR ILIUM— Cancellous bone here is limited to the crestal 2cm between tubercle of ilium & ant iliac spine Maximum amount of cancellous bone available without morbidity is 50cc.
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MUSCLES IN THE AREA— External abdominal oblique Tensor fascia muscle— related to gait disturbance
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NERVES— Iliaco hypogastrc nerve—sensory fibres from L1 & L2. Subcostal neve --courses over the tip of ant spine Lateral femoral nerve—courses medially between psoas major & the medial edge of the iliacus BLOOD SUPPLY- Deep circumflex artery www.indiandentalacademy.com
SURGICAL APPROACH FOR ANT. ILIUM Medial approach is preferred –avoids reflection of tensor fascia muscle Incision is placed 2 finger breadth below the iliac tuberosity on skin crease
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BONY OSTEOTOMY— A. Camshell approach B. Trap door approach C. Tschopp approach D.Tessier approach
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BONE FROM POSTERIOR ILIUM— Muscle—Gluteus maximus Nerves— -Superior clunial nerves(L1,L2 & L3) -Middle clunial nerves(S1& S2) -Sciatic nerves—motor innervation to lower extremity -sciatic notch is 6-8cm inferior to the posterior crest Blood supply—Subgluteal artery www.indiandentalacademy.com
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SURGICAL APPROACH Curvilinear incision– on curvature of the posterior ilium Centre of the incision is placed over the palpable bony prominence of the gluteus maximus insertion Greatest content of cancellous bone Osteotomy allows 5 x 5cm lateral cortical plate removal www.indiandentalacademy.com
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MICROFIBRILAR BOVINE COLLAGEN
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ADVANTAGES-More bone is available(2 to 2.5 times) -less blood loss -less morbidity DISADVANTAGES -patient position -adds about 2hrs to the surgery www.indiandentalacademy.com
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MORBIDITY OF DONOR SITE Early complication -Pain -Tract disturbance -Excessive blood loss -Adynamic ilium -Wound break down -Infection www.indiandentalacademy.com
-Retroperitoneal bleed—vessels at risk -deep circumflex iliac artery -gluteal artery Signs & symptoms -hypotention -hemodynamic instability -decreasing haemocrit -lower abdominal mass www.indiandentalacademy.com
Orthopedic complications -Fracture of acetabulum -Iliac crest sulaxation -Pelvic instability increases with size of graft -Injury to sacroiliac joint -Pelvic fracture www.indiandentalacademy.com
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Late complications -Herniation of abdominal contents through the scar -Gluteus gate-(draging limp) -Neuralgia parastetica(lateral femoral cutaneus nerve of thigh -Hypertrophic scar formation www.indiandentalacademy.com
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Rib graft It is a cortical graft Most the 5th / 6th / 7th rib are used Can be split in the middle Can be contoured to fit the defect Used in mandible have a good weight bearing capacity Correction of saddle nose defect Also can be used as onlay Rapid resorption is seen
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Main indication— - costocondral graft in children under 14yrs -act as growth center & participate in growth plate endochondral ossification
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Surgical approach Small incision is placed in the infra mammary fold Right side is preferred Periosteum incised on the greatest convexity.
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PERIOSTEAL ELEVATION
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Tibial graft Used in alveolar clefts in patients with cleft lip and palate Incision is placed over the tibial plateau Then a small window is removed from the bone Giving access to pure cancellous bone , cortical bone can also be obtained by the approach Mild disability is seen in the post op period Large graft increases the morbidity of the donor site and even cause # of the bone
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Incision 1 cm below and lateral . to the tibial tuberosity
A 6mm trephine inserted into proximal tibia for the first few cores of cancellous bone, followed by von Volkmann’s spoon for further harvest www.indiandentalacademy.com
The proximal tibia donor site in cleft alveolar bone grafting: experience of 75 consecutive cases Journal of Cranio-Maxillofacial Surgery (2002) 30, 12–16 Ceri W. Hughes, Peter J. Revington
Leg wound complications, recorded from patients Questionnaires Problem Number of cases Scar 4 Infection 1 Loss of sensation around scar 1 Aching 1 Swelling and tenderness 1 Lengthy healing time 1 Dip in bone 1 Break in bone 1 No problems 52 No response 12 Total 75 www.indiandentalacademy.com
Calvarial bone graft-The outer table is most useful for obtaining graft It produces least disability and donor site morbidity Cranial grafts can be obtained as cortical bone chips / corticocancellous bone pastes or also as large blocks which can be carved & contoured for specific defects Bone is well vascularized Graft is mostly obtained from temporoparietal region www.indiandentalacademy.com
SURGICAL APPROACH Hemicoronal or bicoronal approach Outer table bur cut outlining Curved osteotome Split or fullthickness graft may be harvested For fullthickness -CNS pressure is reduced by decreasing Paco2 through hyperventillation -IV steriods or mannitol www.indiandentalacademy.com
ADVANTAGES Large quantity of bone available Less resorption Superior aesthetic results Lack of significant post operative pain Easy accessibility to donor site
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COMPLICATIONS Subdural hematoma Dural exposure or tear CSF leak Sagittal sinus perforation CNS infection
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Surgical reconstruction of maxilla and midface: Clinical outcome and factors relating to postoperative complications Journal of Cranio-Maxillofacial Surgery (2005) 33, 1–7
Temporal osteomuscular flaps for maxillary reconstruction. www.indiandentalacademy.com
VASCULARIZED BONE GRAFTS
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Vascularized bone grafts History In 1926 Dax reported that there was delayed healing or non union of # bone in which nutrient artery was injured In 1927 Johnson confirmed Dax’s observation that peripheral vessels contribute little to graft survival . He found that 75% of blood is bone marrow based and 25% came from periphery So in 1970’s it was theorized that if blood supply was so important it would be advantageous to harvest the bone with its blood supply with this advent microsurgery became reality In 1973 McCollough and Fredrickson reported transfer the use of free vascularized graft in animals In 1974 Taylor and associates performed 1st vascularized transfer in humans www.indiandentalacademy.com
Vascularized bone grafts -- Fibular flap DCIA flap Radial fore arm flap Scapula flap Metatarsal flap
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Principles 1.Recipient site preparation 2.Contouring the reconstruction plate----on mandible or maxilla -on CAD-CAM polymer models created from CT.
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3.Taking the free vascular flap 4.Reconturing, stablization,skin suturing 5.Microvascular anstamosis---9-0 nylon 6. Recipient artery---Facial artery,superior thyroid artery & ECA 7.Recipient veins—common facial vein & EJV
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FIBULA History It was the 1st free vascularized graft used clinically in 1974 (Taylor et al) to reconstruct two tibia defect Hidalgo was the first to describe fibula for reconstruction of mandible ,
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ADVANTAGES it can be used for long bone and even mandibular defects Being cortical it can withstand every day stresses it also remodels under stresses It has a single large artery (peroneal artery ) which can be easily identified in an angiogram Length of the bone upto 20cm can be harvested DISADVANTAGE is that it have a small vascular pedicle at time as short as upto 1cm and there is post operative morbidity leading to difficulty in walking www.indiandentalacademy.com
SURGICAL ANATOMY
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BLOOD SUPPLY ď Ž Peroneal artery
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Harvesting Knee is flexed An incision is made along the ant border , the length of the fibula
Ant dissection is carried out by raising the ant compartment of calf, post dissection proceeds by the identification of hallucis longus muscle www.indiandentalacademy.com
Fibula is freed from the interosseous memb and soleus muscle care is taken not to disrupt the periosteum Section is marked Periosteum incised
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Osteotomies performed with a gigli saw Tibialis posterior is dissected of the pedicle Vascular bundle is ligated and dissected Fibula is taken Skin closure done Cast placed
Vascular bundle
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DEEP CIRCUMFLEX ILIAC ARTERY FLAP History In 1974 , Taylor and Daniel described the use of free vascularized iliac crest for the reconstruction of mandible and certain long bones
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ADVANTAGES The advantage is the curvature and its thickness Can be modified to match the defect perfectly Vascular pedicle can be as long as 8 cm Bone stalk of 8 to 10cm It consist of cancellous bone which allows rapid healing Rapid healing decreases the chances of infection It can be raised as myo osseous , myoosseouscutaneous or osseocutaneous and island skin with or without muscle www.indiandentalacademy.com
DISADVANTAGE •Less bone length can be harvested •Osteocutaneous fat is difficult to handle in obese patients •Removal leads to an undesirable cosmetic/functional defect at the hip •Chances of hernia if closure is not proper
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SURGICAL ANATOMY
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Harvesting •Ant sup iliac spine , the pubic tubercle and the inguinal ligament is palpated •A point 1cm above the inguinal ligament is the origin of circumflex iliac artery •Flap outlined •Sup incision is made 6 to 8cm beyond the ant sup iliac spine carried down 3cm within 3cm of the spine www.indiandentalacademy.com
External oblique & internal oblique muscle incised & retracted
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Deep circumflex iliac artery & vein
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GRAFT RECOUNTERING
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DONOR SITE MANAGEMENT ď Ž
Recontructed by stablising a double thickness of polypropylene mesh
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Scapula Was 1st described by Teof et al. in 1981 because of its vascular property
Swartz and associates reported the use of osteocutaneous scapular flap in the reconstruction of mandible and maxillary defects Advantage of scapula is similar to iliac crest main difference is the vascular supply of the bone and overlying tissue . Aallowing it to be used not only in bony defect but also in soft tissue defects Thin bone Pedicle is 3 to 5 cm long
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If more soft tissue is required a part of the latissmus dorsi muscle can also be mobilized If muscles are not attached to the scapula it can cause donor site morbidity Vigorous rehabilitation is required post operatively to improve shoulder movements Uses Maxillary and mandibular defects floor of the orbit , hard and soft palate defect , malar eminence , also be use to close intra and extra oral defects
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Harvesting Blood supply is the circumflex scapular artery giving several branches to the lat border of scapula superiorly Transverse incision is placed Muscles are dissected and cut Vessels are located superiorly Osteotomies made Pedicle dissected and cut muscles reattached to the remaining scapula Skin closure done
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Rib graft Was described by Straven mostly for the reconstruction of mandible Bone is malleable and can be easily contoured and curved and overlying skin can also be taken vascular pedicle is 12cm long Bone harvested is 10-15 cm Rib can be taken from ant , lateral and post approach , posterior approach can cause spinal cord injury lateral approach presents with too small diameter of artery for successful anastomosis If intercostal arteries are harvested along with the mammary artery is can cause pneumothorax and chest fail www.indiandentalacademy.com
Harvesting Usually 5th rib is used Incision is located over the 4th intercostal space and carried down to the perichondrium An axial incision is made in the 5th intercostal cartilage Section of the cartilage is removed there by allowing the identification of internal mammary artery Then distal extent of flap is established Rib is dissected free Recipient vessel prepared Mammary artery cut Rib is transferred www.indiandentalacademy.com
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RADIAL FOREARM FLAP The vascularity is based on the radial artery passing through the radial intramuscular septum ADVANTAGES Mostly used as fasciocutaneous flap Thin & pliable tissue Skin territories in excess of 20X10 cm can be harvested
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Only 10 to 12 cm of bone can be harvested so useful in small defects There is also a need for skin graft at the donor site if composite graft is harvested As the bone is cortical it is difficult to reshape to fit complex defects www.indiandentalacademy.com
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SURGICAL ANATOMY
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Harvesting Skin marking made Dissection proceeds by identification of the radial artery proximally Brachioradialis muscle is transposed Ant aspect of bone is identified Periosteum preserved
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Bone resected (approx 50% of radius should be left for stability ) Ends are plated together for stability Post operatively if large unit of soft tissues are taken donor site will require skin graft for closure Pt. immobilized in plaster cast for 2 to 3 weeks
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2nd Metatarsal graft Blood supply is based on the dorsalis pedis artery Main use in the reconstruction of ant mandibular defects Advantage include long vascular pedicle and thin facial layer disadvantage include small size which limits its use approx 6 to 7cm of bone Poor donor site healing Donor site morbidity such as difficulity in walking.
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Hatvesting Elevation of flap proceeds by the identification of the dorsalis pedis artery which is traced to its distal margin dorsally to the origin of the 1st metatarsal vessels After identification dissection is continued deep and distal to it Deep transverse metatarsal and digitorium brevis tendon are divided
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Preserve the vascularity of the 1st toe Bone is disarticulated from 2nd toe Dorssal and planter tarsometatarsal ligament are divided Bone are seperated using a sharp osteotome After it is done the dorsalis pedis artery is traced proximally Coverage of donor site is done with skin graft
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Graft healing
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Clinical applications Orbital wall reconstruction with bone grafts from the outer cortex of the mandible Journal of Cranio-Maxillofacial Surgery (2004) 32, 374–380 Out of the 75 patients 13 cases underwent reconstruction using mandibular outer cortex bone from area A, 8 from area B, and 54 from area C. The maximum size available for harvest from area C was7x4 cm; material from this area could also be used for the repair of both medial and inferior orbital wall defects if necessary.
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Conclusion: Bone harvest from the mandible affords several advantages including (1) ease of harvest, (2) ease of trimming, (3) appropriate size and curvature, (4) absence of functional disability, (5) no secondary deformity, (6) no visible scars, (7) post-operative immobilization not necessary, (8) absence of postoperative difficulties with respect to breathing and walking (9) major complications are rare.
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Use of the Fibula Free Flap in Maxillary Reconstruction: A Report of 3 Cases J Oral Maxillofac Surg 60:567-574, 2002
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Recurrence of an ameloblastoma in an autogenous iliac bone graft
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:657-9 www.indiandentalacademy.com
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