Bone Graft Reconstruction Research Articles

Clinical Evaluation of Endosseous Implants in Nonvascularized Fibula Bone Grafts for Reconstruction of the Severely Atrophied Mandibular Bone

The purpose of the present study was to assess changes in graft height after augmentation of the severely atrophied mandibula with the use of avascular fibula bone grafts, as well as evaluation of the clinical success of endosseous implants placed in the grafted mandibula. This retrospective study included 10 patients with a mean observation period of 31 months (range, 3 to 76 months). A total of 40 implants were placed. Clinical criteria included implant success, graft success, and crestal bone resorption. The grafting procedure was successfully performed in all patients. All implants were integrated, 2 implants could not be used for prosthetic rehabilitation. One implant was lost 2 years after abutment connection. The maximum bone resorption of 7.21% (+/- 2.7%) was seen within the first year; no significant resorption was seen thereafter. In this clinical and radiographic evaluation, it was found that nonvascular fibula graft is a reliable material for augmentation procedures. The resorption takes place within the first year after augmentation. The possibility of improving the clinical results in bone grafting situations with avascular fibula grafts will be further evaluated in a prospective follow-up study providing long-term assessment of this procedure.

Recombinant Human BMP-2 and Allograft Compared with Autogenous Bone Graft for Reconstruction of Diaphyseal Tibial Fractures with Cortical Defects

Currently, the treatment of diaphyseal tibial fractures associated with substantial bone loss often involves autogenous bone-grafting as part of a staged reconstruction. Although this technique results in high healing rates, the donor-site morbidity and potentially limited supply of suitable autogenous bone in some patients are commonly recognized drawbacks. The purpose of the present study was to investigate the benefit and safety of the osteoinductive protein recombinant human bone morphogenetic protein-2 (rhBMP-2) when implanted on an absorbable collagen sponge in combination with freeze-dried cancellous allograft. Adult patients with a tibial diaphyseal fracture and a residual cortical defect were randomly assigned to receive either autogenous bone graft or allograft (cancellous bone chips) for staged reconstruction of the tibial defect. Patients in the allograft group also received an onlay application of rhBMP-2 on an absorbable collagen sponge. The clinical evaluation of fracture-healing included an assessment of pain with full weight-bearing and fracture-site tenderness. The Short Musculoskeletal Function Assessment (SMFA) was administered before and after treatment. Radiographs were used to document union, the presence of extracortical bridging callus, and incorporation of the bone-graft material. Fifteen patients were enrolled in each group. The mean length of the defect was 4 cm (range, 1 to 7 cm). Ten patients in the autograft group and thirteen patients in the rhBMP-2/allograft group had healing without further intervention. The mean estimated blood loss was significantly less in the rhBMP-2/allograft group. Improvement in the SMFA scores was comparable between the groups. No patient in the rhBMP-2/allograft group had development of antibodies to BMP-2; one patient had development of transient antibodies to bovine type-I collagen. The present study suggests that rhBMP-2/allograft is safe and as effective as traditional autogenous bone-grafting for the treatment of tibial fractures associated with extensive traumatic diaphyseal bone loss. Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Efficacy of small reconstruction plates in vascularized bone graft mandibular reconstruction

Utilization of vascularized bone grafts rigidly fixated with titanium reconstruction plates is the method of choice for reconstruction of segmental mandibular defects. We hypothesized that the use of the newer 2.0-mm locking reconstruction plate (LRP) is not associated with higher rates of complications when compared with larger, previously used plating systems. A retrospective case series of 184 patients undergoing 185 vascularized bone graft reconstruction procedures of the mandible was conducted. There were 37 plate complications. There was no significant difference in complication rates for the 2 most used plate types (14.5% with the 2.0-mm LRP and 22.2% with the 2.4-mm LRP). Use of the smaller 2.0-mm LRP was not associated with an increase in the complications of plate fracture, exposure, infection, or nonunion. Because of its lower profile and ease of application, the 2.0-mm LRP is our plate of choice for mandibular reconstruction.

The Treatment of Osteoradionecrosis of the Mandible: The Case for Hyperbaric Oxygen and Bone Graft Reconstruction

c o h c s t r alignancies of the head and neck represent approxmately 4% to 5% of all newly diagnosed cases of ancer in the United States, over 50,000 on an annual asis. The vast majority of these cancers (85%) are quamous cell carcinomas in origin and the remaining 5% are distributed among salivary gland, lymphoid, nd sarcomatous tumors. During the course of the isease, more than 50% of these cases at one point ill receive radiation therapy alone or in combination ith surgery and/or chemotherapy. Of these, aproximately half will become long-term survivors, lacing this group of patients at risk for developing omplications from the above therapies. Despite the any advances in treatment of head and neck cancer, mprovement in the survivability of the patient with dvanced stage disease (stage III and IV) continues to e a challenge. Surgical management is unlikely to esult in significant gains in locoregional control in pite of continuous advances in microsurgical recontruction that permits more aggressive resections and upports reconstruction of large areas of soft and hard issues allowing for restoration of form and function. ore recent protocols, including combinations of diferent modalities of radiation therapy concurrent with hemotherapy, have shown promise in their efficacy or controlling advanced disease. The advantages of hese protocols appear obvious not only from their otential for curing these cases but also from organ

A case of metacarpal chondrosarcoma of the thumb

Enchondroma is the most common primary benign bone tumor of the hand. Chondrosarcomas in this location, however, are extremely rare. It often is difficult to make a histological distinction between benign cartilaginous tumors and low-grade chondrosarcomas, because enchondromas at this site often show histological features suggestive of malignancy. However, distinguishing the two conditions is clinically relevant because chondrosarcomas of the hand require prompt and more radical treatments such as ray amputations. On the other hand, Mankin has recently given attention to a less aggressive behavior of chondrosarcomas of the phalanges compared with those of other locations. And also, ray amputation does not cause much functional deficit in the finger but does for the thumb. This is a case report of chondrosarcoma affecting the metacarcal bone of the thumb, treated by en block resection and preserving the function of the thumb by bone graft reconstruction, with reference to the literature.

Evaluation of bone volume following bone grafting in patients with unilateral clefts of lip, alveolus and palate using a CT-guided three-dimensional navigation system

In cleft patients the eruption of the permanent canine depends very much on the amount of bone available following bone grafting. The purpose of this study was to evaluate the initial defect in alveolar clefts and the volume of bone bridging found in unilateral clefts which had undergone bone grafting. To determine the fate of the bone graft in cleft palate patients a three-dimensional CT-based Navigation System (Zeiss, Aalen, Germany) was used. CT scans of 16 patients with unilateral clefts were taken immediately preoperatively and 1 year postoperatively. The patients underwent surgery between the age of 9 and 14 years using iliac crest bone grafts. The data was transferred to the work station of the navigation system. Using the STN software, the defect at the alveolar clefts and volume of the bone grafts were determined in each case. Three-dimensional models were created showing the amount of bone immediately preoperatively and 1 year postoperatively. The size of the cleft defect did not correlate with the success rate of the alveolar bone grafting. The form of the transplant remained almost constant when the permanent canine erupted spontaneously into the graft. In cases of absence of the permanent tooth or when the permanent canine required orthodontic treatment, significant bone loss could be observed in the buccopalatal direction. Three-dimensional reconstruction of bone grafts using a navigation system enables a valuable objective assessment of graft volume. Bone formation can be assessed in all three dimensions showing a high grade of resorption in patients lacking physiological load.

The Use of Immediate Bone Grafting in Reconstruction of Clinically Infected Mandibular Fractures: Bone Grafts in the Presence of Pus

Current approaches to the treatment of infected mandibular fractures include antibiotics, drainage, immobilization of the segments, and debridement followed by secondary bone grafting of residual defects once the infection is resolved and the wound healed. Over the past 30 years, the time from debridement to grafting has diminished from several months to a few weeks. We present our experience with a treatment model managing clinically infected fractures of the mandible with antibiotics, debridement, rigid internal fixation, and immediate autogenous bone grafting. In this retrospective study, we present a series of 43 patients who demonstrated clinical/laboratory findings consistent with infection in one or more mandibular fractures (50 infected fractures). These patients underwent a combination of incision and drainage, fracture debridement, rigid internal fixation, and immediate bone grafting of the resulting defect in a single stage. Both transoral and transfacial approaches were used. Of the 50 fractures, 43 showed both resolution of infection and bony union of fractures with long-term follow-up of 2 months to 4 years. Four fractures developed recurrent infection but proved to have bony union and were successfully treated by hardware removal only. Three other patients were deemed failures with persistent infection, loss of graft, nonunion, and need for retreatment. Each of these patients was afflicted with underlying immunocompromise. Although careful patient selection is a must, immediate bone grafting of infected mandibular fractures, when used in conjunction with rigid internal fixation and appropriate intraoperative debridement, is an effective treatment modality which allows a single surgical procedure and dramatically shortens the course of treatment.

Use of osteochondral bone graft in coronoid fractures

Results of the treatment of the deficient coronoid and chronic elbow instability have not been reported. The purpose of this study was to analyze the results of structural bone graft for reconstruction of the coronoid process. Structural bone graft was used to reconstruct the coronoid process of 6 patients. All injuries were of the terrible triad: fracture of the coronoid, radial head fracture, and collateral ligament disruption. All cases had persistent posterior subluxation averaging 6 months (range, 1-13 months before reconstruction. Patient charts, surgical records, and radiographs were reviewed. All patients were contacted at a mean of 64 months after treatment to answer a specific set of questions to determine the Mayo Elbow Performance score. In 1 patient, radiographs showed complete resorption of the graft and severe osteoarthritis of the elbow at 54 months after surgery (case 4). The Mayo Elbow Performance score showed 1 excellent, 2 good, 1 fair, and 2 poor results. Structural bone graft may be a useful option for a deficient coronoid process and an unstable elbow, but the outcome is unpredictable.

Arthroplasty of the Elbow Joint Using Vascularized Iliac Bone Graft for Reconstruction of Massive Bone Defect of the Distal Humerus

The authors present a case of a 39-year-old man with an enormous bone defect of the distal humerus secondary to an infected nonunion, who was successfully reconstructed using a vascularized iliac bone graft. The use of a vascularized iliac bone graft may be an option for reconstructing such massive defects of the metaphyseal area of the humerus.

Bone Grafting Procedures for Osseous Defects Associated with Dental Implants

The purpose of this study was to clinically and radiographically evaluate the use of bone grafting therapy for treatment of osseous defects before implant surgery. After bone graft reconstruction, implants may be placed in previous areas of osseous defect with the expectation of long-term positive results.

Extended bilaminar forehead flap with cantilevered bone grafts for reconstruction of full-thickness nasal defects

Extended bilaminar forehead flap with cantilevered bone grafts for reconstruction of full-thickness nasal defects

Multidirectional flexibility analysis of cervical artificial disc reconstruction: in vitro human cadaveric spine model

This in vitro experimental study was conducted to investigate the initial biomechanical effect of artificial intervertebral disc replacement in the cervical spine. The multidirectional flexibility of replaced and adjacent spinal segments were analyzed using a cadaveric cervical spine model. The following three cervical reconstructions were sequentially performed at the C5-6 level after anterior discectomy in seven human cadaveric occipitocervical spines: anterior artificial disc replacement with a bioactive three-dimensional (3D) fabric disc (FD); anterior iliac bone graft; and anterior plate fixation with iliac bone graft. Six unconstrained pure moments were applied with a 6-df spine simulator, and 3D segmental motions at the operative and adjacent segments were measured with an optoelectronic motion measurement system. The 3D FD group demonstrated statistically equivalent ranges of motion (ROMs) when compared with intact values in axial rotation and lateral bending. The 45% increase in flexion-extension ROM was demonstrated in 3D FD group; however, neutral zone analysis did not reach statistical significance between the intact spine and 3D FD. The anterior iliac bone graft and iliac bone graft reconstructions demonstrated statistically lower ROMs when compared with 3D FD in all loading modes (p < 0.05). The adjacent-level ROMs of the 3D FD group demonstrated nearly physiological characteristics at upper and lower adjacent levels. Excellent stability at the interface was maintained during the whole testing without any device displacement and dislodgment. The stand-alone cervical 3D FD demonstrated nearly physiological biomechanical characteristics at both operative and adjacent spinal segments in vitro, indicating an excellent clinical potential for cervical artificial disc replacement.

Cranial Bone Grafting for Orbital Reconstruction: Is it Still the Best?

A variety of etiologies may result in functional and aesthetic deficiencies requiring orbital reconstruction. These are discussed, as are some of the possible repair techniques. In the current study, a randomized, retrospective chart review of one surgeon's experience with orbital reconstruction using cranial bone grafts was performed. The results of the chart reviews are presented, including preoperative diagnosis, clinical signs and symptoms, and postoperative findings. This study allowed a comparison and contrast to be made between exogenous materials and autogenous bone for orbital reconstruction. The differences between cranial and iliac bone as autogenous sources of reconstructive material were examined. The study indicates that cranial bone grafting for reconstruction of the orbit remains the material of choice.

Clinical evaluation of endosseus implants in nonvascularized fibula bone grafts for reconstruction of the severely atrophied mandibular bone

Purpose: The purpose of the present study was to assess changes in graft height after augmentation of the severely atrophied mandibula with the use of avascular fibula bone grafts, as well as evaluation of the clinical success of endosseous implants placed in the grafted mandibula. Patients and Methods: This retrospective study included 10 patients with a mean observation period of 31 months (range, 3 to 76 months). A total of 40 implants were placed. Clinical criteria included implant success, graft success, and crestal bone resorption. Results: The grafting procedure was successfully performed in all patients. All implants were integrated, 2 implants could not be used for prosthetic rehabilitation. One implant was lost 2 years after abutment connection. The maximum bone resorption of 7.21% (2.7%) was seen within the first year; no significant resorption was seen thereafter. Conclusion: In this clinical and radiographic evaluation, it was found that nonvascular fibula graft is a reliable material for augmentation procedures. The resorption takes place within the first year after augmentation. The possibility of improving the clinical results in bone grafting situations with avascular fibula grafts will be further evaluated in a prospective follow-up study providing long-term assessment of this procedure. © 2006 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 64:1427-1432, 2006

The case for bone graft reconstruction including sinus grafting and distraction osteogenesis for the atrophic edentulous maxilla

The 2 basic criteria for restoration of the edentulous maxilla are adequate bone mass and orthoalveolar form. These goals can be achieved by augmentation of the available substrate using prescribed techniques such as vertical and lateral augmentation of the alveolus, sinus floor bone grafting, and jaw bone repositioning. 1-4 When the available substrate is too deficient for implant placement, 1 or more of these options can be used to improve load-bearing capacity for implants. The use of vertical alveolar grafting for augmentation without the placement of dental implants remains suspect as a viable long-term strategy for bone mass maintenance. 5,6 Optimal restoration of the edentulous alveolus suggests the concept of orthoalveolar form. Orthoalveolar form is defined as idealized alveolar bone positioned in Class I relation axially aligned with the opposing arch. When orthoalveolar form is achieved, implant prosthetic horizontal cantilever is minimized and crown/implant ratios are favorable. Restorations are short, “gum set,” and axially placed over implants. 7 Resorption of the atrophic maxilla often results in a disparity of the arches mediolaterally and anterior-posteriorly. The resorbed maxilla decreases in bone mass in all directions. The basal maxilla presents up and back in its cephalometric projection and is often in “cross-bite” in its alveolar position as it relates to the lower arch. This means that despite vertical and lateral grafting, the interarch position of the maxilla, as it relates to a dentate mandible, is still Class III. Therefore, orthoalveolar form is largely unachievable in the resorbed retrodisplaced maxilla with bone graft reconstruction alone. Distraction osteogenesis is required to finalize the jaw into a more favorable position. This subjects the patient to a second surgical procedure, which may not be warranted given the ability for prosthetics to make up for surgical inadequacy. 8,9

Fractures récentes des articulations IPP

Recent PIP fractures are challenging trauma in terms of diagnosis as well as treatment. It must be remembered that the final outcome will have a considerable impact on the global finger and hand function. Immediate mobilization and rehabilitation are mandatory, and may justify a surgical approach and fixation in selected cases. A good understanding of the fracture type is essential and relies in good part on precise, focused and standardized radiographs. Non-displaced fractures are generally treated conservatively. In the proximal phalanx, the orientation of the fracture line dictates the stability of the fracture. Thus non-displaced fractures can occasionally be preventively stabilized, in order to allow early mobilization. Displaced fractures should always be anatomically reduced and surgically fixed. A temporary joint stabilization is optional. In the middle phalanx, one must consider palmar and dorsal fractures differently. Palmar fractures include a distal palmar plate avulsion. The degree of impaction will dictate the stability of the joint towards dorsal subluxation. Dorsal fractures include central slip avulsion of the extensor tendon. An antomical reduction and surgical fixation is mandatory to avoid a progressive boutonniere deformity. Prognosis of all the middle fractures is closely dependent on the degree of impaction. When direct osteosynthesis is not possible, distraction devices, bone graft or palmar plate reconstruction may be useful alternatives. In complex fractures, bone fixation and joint stabilization must be combined in order to prevent secondary displacement and joint instability.

Navigation-aided reconstruction of medial orbital wall and floor contour in cranio-maxillofacial reconstruction

The reconstruction of the anterio-posterior inclination of the medial aspect of the orbital floor, despite a wide 360 degrees exposure, including coronal and conjunctival incisions, is a challenging task in severe injuries of the orbit with massive comminution and complete displacement of the medial orbital wall and orbital floor. Out of a total of 20 patients with orbital fractures, five underwent a surgical intervention of repositioning the medial aspect of the orbital floor and especially the transition area between the orbital floor and medial orbital wall, using navigation-aided procedures. Using the mirroring tool of the Stryker-Leibinger STN-system, post-operative CTs indicated an average difference of the globe position of -4.9% between the operated side and the unaffected side, depending on the position of the medial aspect of the orbital floor. Navigation-aided procedures proved to be an essential precondition for achieving precise and predictable results in orbital reconstruction. In such cases, unlike those with an intact medial orbital wall remnant as a surgical target, bone grafts for reconstruction of the orbital floor cannot be implanted as onlay grafts.

Advanced approaches to odontogenic cysts and tumors

There is much too much confusion and “controversy” concerning odontogenic keratocysts (OKC) than there ought to be. Although this cyst can and does recur, it is not a tumor and does not invade into soft tissue. Its recurrences are mostly related to surgical imperfection which results from ripping or shredding the cyst to leave part of the lining behind which then redevelops into a recurrent cyst. A smaller percentage of “recurrences” are actually new primary keratocysts from other activated odontogenic rests. Most keratocysts can be cured by a wide access enucleation which removes the cyst in a single unit. Usually this can be accomplished from a transoral approach, but sometimes requires a transcutaneous approach. In no case should Camoy’s solution, cyrotherapy, phenol or bur reduction of the bony wall be necessary. However, a small percentage of OKCs do require a resection for cure. These are essentially those which are the large destructive multilocular ones that an enucleation would eventuate into a fracture or continuity defect or those that have “recurred” on multiple occasions. Many odontogenic tumors are actually hamartomas with limited growth: odontomas, ameloblastic fibrodontomas, ameloblastic fibromas, etc. However, ameloblastomas, odontogeneic myxomas, the calcifying epithelial odontogenic tumor and the ameloblastic fibrosarcoma which will microscopically mimic the harmartomatous ameloblastic fibroma are true invasive neoplasms. These require resections with 1-cm to 1.5-cm margins for cure. Despite such resections required to cure odontogenic true neoplasms, most all can be accomplished without creating a deformity, malocclusion, or significant neurosensory loss. In the mandible these tumors are removed en bloc for a predictable cure with a new nerve pull-back re-anastomosis technique which obviates the need for a nerve graft, returns 90% or more sensation and does not affect the cure. This is possible because of the inability of benign tumors to invade nerve sheaths as they instead merely displace the nerve. Combined with titanium reconstruction plates, this approach achieves a maximum in returning facial form, maintaining the residual occlusion, preparing for a definitive bone graft reconstruction and returning the highest percentage of useful neurosensory function. In addition, the troublesome resections that include the condyle need not result in a jaw deviation, malocclusion, prolonged jaw fixation, external pin fixation or a costochondral graft. With a retained disc, titanium condylar replacements in the adult and allogeneic (tissue bank) condylar replacements in children and teenagers permit long-term stable function without the complications noted in the classic “TMJ Prostheses,” thereby allowing immediate cosmetic and functional results to also be realized in patients who undergo a condylar extirpation.

Self-reinforced bioabsorbable miniplates for skeletal fixation in complex hand injury: three case reports

We report our preliminary experience with 3 cases in which internal fixation with a self-reinforced poly- l/ dl-lactide 70/30 miniplate and 1.5-mm or 2.0-mm screws were used to stabilize an open metacarpal fracture, a metacarpophalangeal arthrodesis in a thumb replantation, and an interposed bone graft for reconstruction of a thumb. Clinical and radiologic follow-up evaluation lasted for 12 to 20 months. Bone healing was uneventful in all 3 cases with no displacement or delayed union. The implants were biocompatible with no clinically manifested foreign body reaction. Because of the self-reinforcing manufacturing technique the plates have metal-like mechanical and handling properties. Complete late resorption makes self-reinforced poly- l/ dl-lactide 70/30 miniplating systems an attractive alternative to metallic implants for skeletal stabilization of small bones of the hand.

Early experience with the Mills sleeve prosthesis for reconstruction of the incus long process

This paper describes the Mills sleeve technique of ossicular reconstruction for defects of the incus long process and reviews the results of 27 procedures. A retrospective review of operations was performed by eight otologists. The results are compared with those from three other reconstruction techniques (cortical bone graft, cortical bone sleeve and incus autograft). Prostheses were supplied to surgeons who expressed an interest. Pre- and post-operative audiological data forms were analysed for each case along with a questionnaire about use of the prosthesis. The mean post-operative air bone gap (ABG) was compared with results from cortical bone sleeve, incus autograft and simple cortical bone graft reconstruction cases previously performed by the senior author. Twenty-seven procedures were performed. Closure of the ABG to within 10 dB was achieved for 44.4 per cent of Mills sleeve cases compared with 44.7 per cent for the cortical bone sleeve, 52.9 per cent for ossicular and 26.9 per cent for cortical bone grafts. The responses to a questionnaire sent to participating surgeons are discussed. For the current follow-up period (three months to three years) the Mills sleeve prosthesis appears to be safe and easy to use with audiological results at least as good as other reconstructive techniques.