Facial Bone Reconstruction Research Articles

The Cortical Shield for Facial Bone Reconstruction of Severely Damaged Sockets with Simultaneous Implant Placement: A Feasibility Clinical Trial.

To evaluate a novel proof-of-principle technique of simultaneous bone regeneration and implant placement in severely damaged sockets. This study consisted of patients who required a single implant and presented with severe facial bone loss. Individuals were randomly assigned to either the immediate or delayed implant placement protocol. Socket reconstruction and simultaneous implant placement were performed through periosteal-guided bone regeneration. Implants were encased in a customized shield of autogenous cortical bone harvested from an adjacent site. Re-entry surgery was performed at 12 to 18 weeks. Peri-implant tissues and pink esthetics were assessed following established success criteria. Of the 34 patients treated, 28 patients-consisting of 15 women and 13 men with an average age of 50.8 ± 4.5 years-continued to the final follow-up. All individuals showed new facial cortical bone regeneration at second-stage implant surgery after an average healing time of 14.9 ± 2.2 weeks (range: 12 to 18 weeks). Implants remained stable after loading. Success rates were 100% at 12 months. Mean pink esthetic score (PES) was 7.8 ± 1.2 (range: 6 to 9 on a scale of 0 to 10). Linear regression analysis showed that provisionalization and attachment loss are independent risk factors affecting pink esthetics (P < .01). Mild and moderate/severe attachment loss decrease pink esthetic scores by 0.9 and 1.7 points, respectively (95% CI: 0.2-1.5; P < .01). The use of provisional restorations improves pink esthetic scores by 1.6 points (95% CI: 0.8-2.4; P < .001). A PES > 7 was four and five times more likely to be expected for delay and immediate implants, respectively, if the implant had a provisional restoration delivered post-second-stage (RR = 4 to 5; 95% CI: 1-31; P = .07; P = .02). Cramér's V test showed a strong association between lack of implant provisionals and low pink esthetic scores (≤ 7, value = 0.7; P = .02). Facial implant transparency at follow-up was absent, and all implants had a band of keratinized tissue > 2 mm. Facial bone regeneration and simultaneous implant placement is feasible in severely damaged sockets through periosteal-guided bone regeneration after a short healing period following immediate or delayed protocols. The assisted regenerated intrasocket bone allows for functional implant stability. Adjacent tooth attachment loss and lack of implant provisionalization negatively impacts pink esthetics. The proposed approach decreases costs, morbidity, and treatment duration and eliminates the need for multi-stage approaches.

Bitemporal Blindness in Traumatic Head Injury

We report a case of isolated bitemporal hemianopia in traumatic chiasmal syndrome. A 20-year-old male motorcyclist was brought unconscious into the emergency department after an alleged accident involving a horse-drawn vehicle. He was intubated for three days. Computed topography of the brain revealed bifrontal and facial bone fractures, associated with subarachnoid haemorrhage. He underwent frontal bone and facial bone reconstruction. Three weeks later, patient complained of left eye blurred vision. On examination, the visual acuity was 6/7.5 in the right eye and 6/12 in the left eye, with a left relative afferent pupillary defect. Visual field charting showed complete bitemporal hemianopia. Over the next six months, the visual acuity of the left eye worsened to 6/45, while the field defect remained static. Bitemporal hemianopia in traumatic chiasmal syndrome is a rare complication of severe head injury. A history of trauma should always be elucidated in patients with visual field defects.

A Clinical Trial to Evaluate the Efficacy and Safety of 3D Printed Bioceramic Implants for the Reconstruction of Zygomatic Bone Defects.

The purpose of this study was to evaluate the clinical efficacy and safety of patient-specific additive-manufactured CaOSiO2-P2O5-B2O3 glass-ceramic (BGS-7) implants for reconstructing zygomatic bone defects at a 6-month follow-up. A prospective, single-arm, single-center, clinical trial was performed on patients with obvious zygoma defects who needed and wanted reconstruction. The primary outcome variable was a bone fusion between the implant and the bone evaluated by computed tomography (CT) at 6 months post surgery. Secondary outcomes, including implant immobilization, satisfaction assessment, osteolysis, subsidence of the BGS-7 implant, and safety, were assessed. A total of eight patients were enrolled in the study. Two patients underwent simultaneous reconstruction of the left and right malar defects using a BGS-7 3D printed implant. Cone beam CT analysis showed that bone fusion at 6 months after surgery was 100%. We observed that the average fusion rate was 76.97%. Osteolysis around 3D printed BGS-7 implants was not observed. The mean distance displacement of all 10 implants was 0.4149 mm. Our study showed no adverse event in any of the cases. The visual analog scale score for satisfaction was 9. All patients who enrolled in this trial were aesthetically and functionally satisfied with the surgical results. In conclusion, this study demonstrates the safety and promising value of patient-specific 3D printed BGS-7 implants as a novel facial bone reconstruction method.

Orbital wall reconstruction in rabbits using 3D printed polycaprolactone-β-tricalcium phosphate thin membrane

Orbital fractures are recognized as one of the most common types of facial bone fractures. Although surgical reconstruction techniques exist as a remedy for such fractures, prolonged complications, such as diplopia and gaze restriction, may still occur. This article proposes a simple technique for facial bone reconstruction though use of a thin-membrane patch made of the polycaprolactone-β-tricalcium phosphate composite material.The application of the proposed technique is described by means of a surgical operation performed on an orbital fracture model of a rabbit taken as a subject. The thin-membrane patch was directly attached onto the fractured bone, and subsequently, microcomputed tomography was employed to assess the progress of fracture healing. Two such assessments were performed, respectively, 8 and 16 weeks after the surgical operation.Results of these assessments reveal a reduction in fracture volume and prevention of undesirable soft-tissue filling in the membrane-patched groups. This indicates that the proposed thin membrane patch is able to secure space for the bones, thereby preventing the occurrence of an inflammatory response.The damaged area, however, was diagnosed to have been slightly filled up and blocked by the presence of unsuitable cells, such as immune cells. In a future study, the authors intend to synthesize thin membranes using alternate biological materials, such as stem cells, to improve the therapeutic result of the proposed technique for orbital fracture treatment.

Facial Bone Reconstruction Using both Marine or Non-Marine Bone Substitutes: Evaluation of Current Outcomes in a Systematic Literature Review.

The aim of the present investigation was to systematically analyse the literature on the facial bone reconstruction defect using marine collagen or not and to evaluate a predictable treatment for their clinical management. The revision has been performed by searched MEDLINE and EMBASE databases from 2007 to 2017. Clinical trials and animal in vitro studies that had reported the application of bone substitutes or not for bone reconstruction defect and using marine collagen or other bone substitute material were recorded following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The first selection involved 1201 citations. After screening and evaluation of suitability, 39 articles were added at the revision process. Numerous discrepancies among the papers about bone defects morphology, surgical protocols, and selection of biomaterials were found. All selected manuscripts considered the final clinical success after the facial bone reconstruction applying bone substitutes. However, the scientific evidence regarding the vantage of the appliance of a biomaterial versus autologous bone still remains debated. Marine collagen seems to favor the dimensional stability of the graft and it could be an excellent carrier for growth factors.

Facial bone reconstruction with prefabricated vascularized calvarium flaps in children and young adults: Advantages and long-term results

Reconstruction of facial bone defects in children is challenging. The use of well-vascularized bone is mandatory to obtain stable lasting results. This study reports our experience of facial bone reconstruction using prefabricated vascularized calvarium flaps. Retrospective case series of 50 patients who underwent 52 maxillary, malar, and mandibular reconstructions between 1988 and 2014 using prefabricated vascularized calvarium flaps. Forty-nine patients suffered from noma sequels; one patient had craniofacial cleft Tessier 3-11. Surgery consisted of a two-step procedure beginning with flap delay and prelamination with skin grafting on the galea. Flap harvest followed at least 2 weeks later (range, 2-16 weeks), including a full-thickness calvarium fragment, which was set into the facial defect. Early complications concerned wound healing and infections requiring surgical revision in six patients at the recipient and six at the donor site. There was one flap loss. Clinical long-term assessment at 15-year median follow-up (range, 1-27 years) showed good results, assuring facial height and contour. Radiological long-term results demonstrated excellent integration of the flap to the adjacent facial skeleton of the growing child. Prefabricated vascularized calvarium flaps are an effective, safe and lasting method for reconstruction of facial bone defects in children.

Use of 3D Printing Model for the Management of Fibrous Dysplasia: Preliminary Case Study

Fibrous dysplasia is a relatively rare disease but the management would be quite challenging. Because this is not a malignant tumor, the preservation of the facial contour and the various functions seems to be important in treatment planning. Until now the facial bone reconstruction with autogenous bone would be the standard. Although the autogenous bone would be the ideal one for facial bone reconstruction, donor site morbidity would be the inevitable problem in many cases. Meanwhile, various types of allogenic and alloplastic materials have been also used. However, facial bone reconstruction with many alloplastic material have produced no less complications including infection, exposure, and delayed wound healing. Because the 3D printing technique evolved so fast that 3D printed titanium implant were possible recently. The aim of this trial is to try to restore the original maxillary anatomy as possible using the 3D printing model, based on the mirrored three dimensional CT images based on the computer simulation. Preoperative computed tomography (CT) data were processed for the patient and a rapid prototyping (RP) model was produced. At the same time, the uninjured side was mirrored and superimposed onto the traumatized side, to create a mirror-image of the RP model. And we molded Titanium mesh to reconstruct three-dimensional maxillary structure during the operation. This prefabricated Titanium-mesh implant was then inserted onto the defected maxilla and fixed. Three dimensional printing technique of titanium material based on the computer simulation turned out to be successful in this patient. Individualized approach for each patient could be an ideal way to restore the facial bone.

Tissue-engineered autologous grafts for facial bone reconstruction.

Facial deformities require precise reconstruction of the appearance and function of the original tissue. The current standard of care-the use of bone harvested from another region in the body-has major limitations, including pain and comorbidities associated with surgery. We have engineered one of the most geometrically complex facial bones by using autologous stromal/stem cells, native bovine bone matrix, and a perfusion bioreactor for the growth and transport of living grafts, without bone morphogenetic proteins. The ramus-condyle unit, the most eminent load-bearing bone in the skull, was reconstructed using an image-guided personalized approach in skeletally mature Yucatán minipigs (human-scale preclinical model). We used clinically approved decellularized bovine trabecular bone as a scaffolding material and crafted it into an anatomically correct shape using image-guided micromilling to fit the defect. Autologous adipose-derived stromal/stem cells were seeded into the scaffold and cultured in perfusion for 3 weeks in a specialized bioreactor to form immature bone tissue. Six months after implantation, the engineered grafts maintained their anatomical structure, integrated with native tissues, and generated greater volume of new bone and greater vascular infiltration than either nonseeded anatomical scaffolds or untreated defects. This translational study demonstrates feasibility of facial bone reconstruction using autologous, anatomically shaped, living grafts formed in vitro, and presents a platform for personalized bone tissue engineering.

Skeletal Approach to Mandible Reconstruction Represented as an Image

ABSTRACTMandible or facial bone reconstruction is a serious challenge in craniomaxillofacial surgery. Considering the complex shape and structure of the mandible, careful presurgical planning or availability of objective methods to analyse the patient mandible is necessary to achieve predictable outcomes. It has become evident that methods that can retrieve back the exact shape and structure of the mandibular defect across any anatomical location of the mandible are required. Skeletons, a dimensionally reduced version of the shape, are an important descriptor capable of capturing the most relevant features. In this paper, a technique to retrieve the shape of the mandible from its skeleton properties, by comparing it to the skeleton of a mandible with no defects, also called template mandible has been addressed. It is also employed to correct the mandibular structure for the type of discontinuity in it, to obtain a reconstructed mandible. This will enable to look at how the defect or the discontinuity in t...

Biomaterials in the Reconstruction of the Oral and Maxillofacial Region.

Reconstruction of maxillofacial bones has proven to be complex due to the aesthetic requirements and functional demands of the jaw. Although autogenous bone grafts and a wide range of biomaterials are routinely used for facial bone reconstruction, these methods are associated with a number of drawbacks, including the limited availability of autogenous grafts and the morbidity associated with bone graft harvesting, whilst biomaterials are also linked with a high failure rate. These limitations have inspired the search for innovative techniques for bone bioengineering and the development of more reliable biomaterials. Tissue engineering approaches yield powerful tools for long-term satisfying results enabling customized reconstruction and the support of natural healing processes. There is no doubt that further advances in tissue engineering are essential to achieve reliable and satisfactory clinical outcomes for patients. This chapter will highlight the clinical application of biomaterials and provide an overview of the current scientific concepts in the field.

Retrobulbar Hematoma in Blow-Out Fracture after Open Reduction

Retrobulbar hemorrhage, especially when associated with visual loss, is a rare but significant complication after facial bone reconstruction. In this article, two cases of retrobulbar hematoma after surgical repair of blow-out fracture are reported. In one patient, permanent loss of vision was involved, but with the other patient, we were able to prevent this by performing immediate decompression after definite diagnosis. We present our clinical experience with regard to the treatment process and method for prevention of retrobulbar hematoma using a scalp vein set tube and a negative pressure drainage system.

Recombinant Human Bone Morphogenetic Protein Type 2 Jaw Reconstruction in Patients Affected by Giant Cell Tumor

Giant cell tumor (GCT) is a relatively common skeletal tumor. Mandibular localization of this tumor is usually treated with resection of the tumor area. Several autogenous bone-grafting techniques are available for the restoration of large continuity defects of the mandible. However, these procedures are associated with limitations involving postoperative morbidity, difficulty in ambulation (hip graft), and pain. The development of a technique of surgical reconstruction not involving autogenous bone would offer new opportunities for facial bone reconstruction, particularly of the mandible. This study aims to underline the effect of recombinant human bone morphogenetic protein type 2 (rhBMP-2) in a collagen carrier with concomitant bone grafting material in the restoration of continuity critical-size defects after GCT resection in the mandible. The rhBMP-2 was used with absorbable collagen sponge. A total dose of 4 to 8 mg of rhBMP-2 was delivered to the surgical site in concentrations of 1.5 mg/mL. The patient was followed up over a period from 6 to 18 months. Occlusal function was initially restored with conventional prosthesis. Bone formation in the surgical area could be palpated at the end of 3 to 4 months and identified radiographically at the end of 5 to 6 months. The results clearly indicated that the use of rhBMP-2 without concomitant bone grafting materials in large critical-size mandibular defects secondary to GCT produced excellent regeneration of the area, establishing the basis for the return of prosthodontic function.

Reconstruction of Mandibular Continuity Defects With Bone Morphogenetic Protein-2 (rhBMP-2)

Several autogenous bone grafting techniques are available for the restoration of large continuity defects of the mandible. However, these procedures are associated with limitations involving postoperative morbidity, difficulty in ambulation, and pain. The development of a technique of surgical reconstruction not involving autogenous bone would offer new opportunities for facial bone reconstruction, particularly of the mandible. This study was instituted to observe the effect of rhBMP-2 in a collagen carrier without concomitant bone grafting material in the restoration of continuity critical-sized defects of the mandible. A case review was made of 14 patients who were selected from a larger group having received BMP-2 in different categories of mandibular defects. The rhBMP-2 in all the cases reported here was used alone with the collagen carrier without concomitant bone materials. The cases involved lesions of the body and angle of the mandible in 2 categories: 1) defects resulting from neoplastic diseases, and 2) defects secondary to osteomyelitis (related to bisphosphonates or irradiation). A total dose of 4 to 8 mg of rhBMP-2 was delivered to the surgical site in concentrations of 1.5 mg per cc (depending on the size of lesion). Cases were followed over a period from 6 to 18 months. Occlusal function was restored with implant-borne or conventional prosthesis. All of the cases reported here had successful osseous restoration of the edentulous area followed by prosthetic treatment. Bone formation in the surgical area could be palpated at the end of 3 to 4 months and identified radiographically at the end of 5 to 6 months. The maintenance of a periosteal envelope was effected by the use of a superiorly placed minibar in the upper portion of the defect, or with the use of titanium mesh superiorly. This metallic tenting up to the mucosa is thought to be necessary to maintain the space for osseous regeneration. This study indicated that the use of rhBMP-2 without concomitant bone grafting materials in large critical sized mandibular defects produced excellent regeneration of the area establishing the basis for the return of prosthodontic function. This study tends to support the use of cytokines, particularly rhBMP-2, in osseous regeneration or repair of facial bones. The technique describes a new alternative to various types of autogenous bone grafting procedures for the treatment of critical sized bony lesions of the mandible.

Comparison of the Effectiveness of Autologous Fibrin Glue and Macroporous Biphasic Calcium Phosphate as Carriers in the Osteogenesis Process With or Without Mesenchymal Stem Cells

Facial bone reconstruction has been a challenge for oral and maxillofacial surgeons for a long time. Recently, some studies have reported the use of stem cells in facial reconstruction to achieve osteogenesis. However, to ensure that stem cells remain in the recipient site, a biocompatible carrier is needed to transfer the stem cells. Fibrin glue has been shown to promote hemostasis in wound management and accelerate soft tissue healing, but the role of fibrin glue in bone regeneration remains debatable. The purpose of this study was to compare the effectiveness of autologous fibrin glue and macroporous biphasic calcium phosphate (MBCP) as carriers in the osteogenesis process with/without mesenchymal stem cells. Fifteen New Zealand white rabbits were used in this study. Mesenchymal stem cells were harvested from the iliac bone, and autologous fibrin glue was made from peripheral blood. Three cranial defects with a diameter of 6 mm were created over the cranial bone in each rabbit. The 15 animals were separated into 2 groups. The first group contained 12 rabbits. The grafted substances placed over the regions of defect were: (1) stem cells plus autologous fibrin glue; (2) stem cells plus MBCP; (3) defect alone as control. In the second group of 3 rabbits, the cranial defects were grafted with: (1) autologous fibrin glue alone; (2) MBCP alone; (3) defect alone as control. Rabbits were sacrificed at 1, 2 and 3 months post operation. Radiography and histology were used to detect bone formation. Stem cells plus autologous fibrin glue induced more bone formation 2 months post operation and more mature bone was found 3 months post operation compared with the other groups. MBCP with or without stem cells showed moderate tissue reaction, including giant cell, histiocyte and eosinophil cell accumulation. Using stem cells plus autologous fibrin glue as the carrier may accelerate new bone regeneration.

Using mesenchymal stem cells in combination with autologous fibrin glue in the rabbit cranial bone reconstruction

Facial bone reconstruction has been a challenge for oral and maxillofacial surgeons for a long time. Many modalities have been developed but some of them have limitations and complications. Recently, some studies have reported the use of stem cells in facial bone reconstruction to achieve osteogenesis. The purpose of this animal study was to detect the effectiveness of reconstructing the rabbit's cranial bone by using stem cells plus autologous fibrin glue versus stem cells plus macroporous biphasic calcium phosphate (MBCP).

Three-Dimensional Reconstruction and Image Processing in Mandibular Distraction Planning

Mandible or facial bone reconstruction is a serious challenge in craniomaxillofacial surgery. Careful presurgical planning or availability of objective methods to evaluate the three-dimensional (3-D) shape of the patient mandible is necessary to achieve predictable outcomes. The aim of this paper is to apply 3-D techniques of volumetric reconstruction and image processing for planning distraction osteogenesis of the mandible, involving the use of 3-D modeling. To accomplish this task, suitable two-dimensional (2-D)-to-3-D image processing is used in order to obtain a 3-D model of the mandible from standard 2-D computed tomography images. The goal of this paper is to provide the surgeon with a 3-D model of the patient mandible, where it would be possible to find, in the presurgical phase, the exact point of implant with respect to the patient's anatomy and to build a custom-made prosthesis that properly fits the bone surface of the patient for correct control of the vector during the progressive traction of the bone segments

THE FREE FIBULAR FLAP: A USEFUL FLAP FOR RECONSTRUCTION FOLLOWING COMPOSITE HAND INJURIES

The free fibular flap has been used extensively in facial and extremity long bone reconstruction but has not been presented as a tool for reconstruction following composite hand injuries, in particular for reconstruction of the ulnar border of the hand. We present a case of the use of this flap for reconstruction of such a complex composite hand injury.

Principles of Bone Healing and Optimal Methods of Bone Fixation in Head and Neck Reconstruction

This review of contemporary techniques in facial bone reconstruction is written from the perspective of its specific application to defects from benign or malignant tumor resection. These bone defects pose unique reconstructive considerations because of their frequently large size, exposure to the oral cavity and paranasal sinuses, and potentially compromised wound beds due to radiation or loss of soft tissue lining, or both. The role of vascularized bone flaps, allograft bone, metal plating techniques with advances in fixation biomaterial technology, and distraction osteogenesis is discussed for these facial bone defects.

Ostrich eggshell as a bone substitute: a preliminary report of its biological behaviour in animals – a possibility in facial reconstructive surgery

The aim of this study was to assess the biological behaviour of an implant of ostrich eggshell in various animal models of facial bone reconstruction. The implant was first bioassayed in a rat muscle pouch (n =10), and then tested as an interpositional graft in rat (n =10) and rabbit (n =5) cranial defects. It was finally used as an onlay graft on rabbit mandibles (n =5). Animals were killed after two months in the bioassay, three months in the interpositional model, and six months in the onlay model. The specimens were studied by contact radiography and standard histological techniques. All animals showed normal wound-healing. In the bioassay, the implants produced only a minimal inflammatory reaction. In the interpositional model, the implants maintained a good contour, but there was no sign of graft-remodelling. In the onlay model, the grafts were stable and partly osteointegrated. The onlay graft model gave the most promising results. Because ostrich eggshell is inexpensive and has good mechanical properties, it deserves further study. Long-term studies will clarify its possible role in maxillofacial surgery.

Use of Medpor Porous Polyethylene Implants in 140 Patients with Facial Fractures

Use of alloplastic materials in facial bone reconstruction is still controversial. Medpor porous polyethylene is a relatively new implant material that is well suited for this purpose and has a number of advantages over other alloplasts. It is a pure polyethylene with a unique manufacturing process and pore size. Technically, it is easy to work with; it can be carved, contoured, adapted, and fixated to obtain a precise three-dimensional construct. Physically, it is a pure, biocompatible, strong substance that does not resorb or degenerate. It demonstrates long-term stability, high tensile strength, resistance to stress and fatigue, and a virtual lack of surrounding soft-tissue reaction. Rapid tissue ingrowth occurs into the pores. Extensive vascular ingrowth creates the potential to transport cellular products that fight infection deep into the implant. The implant was used in 140 patients from June 1988 to August 1991 to treat acute orbitozygomatic injuries (71), acute Le Fort injuries (24), delayed orbitozygomatic injuries (33), and delayed onlay augmentation (12). In this series, there was 1 instance of implant infection requiring removal, and no implant migration, or exposure.