Application of cranial bone grafts for reconstruction of maxillofacial deformities

Reza Movahed, DMD, Lecio P. Pinto, DDS, PhD, Carlos Morales-Ryan, DDS, MSD, Will R. Allen, DDS, and Larry M. Wolford, DMD

This retrospective study evaluated outcomes with the use of calvarial bone grafts (CBGs) in maxillofacial reconstruction as well as donor and recipient site complications. The records of 50 consecutive patients from a private practice were reviewed; there were 34 women and 16 men, with an average age of 32.4 years (range 16 to 66 years). Among the 50 patients, CBGs were placed in 63 sites: the ramus (10), nasal dorsum (14), maxilla/alveolar ridge (12), glenoid fossa/temporal bone (14), mandibular body/symphysis (3), and orbitozygomatic complex (10). The longest follow-up averaged 22.4 months (range 12 to 48 months). An outer-table CBG harvest technique was utilized. All subjects were evaluated for infection, dehiscence, loss of graft, and any other complications. Three complications occurred (5%) at the recipient sites. Two grafts became infected requiring removal, and one nasal dorsal graft was mobile but remained in position. At 50 donor sites, 2 complications (4%) occurred, resulting in dural tears in two patients that were immediately repaired with no untoward consequence. In conclusion, CBGs are an effective bone source for maxillofacial reconstruction with low donor and recipient site complications.

utogenous bone grafts are the gold standard for reconstruction of maxillofacial defects. Autogenous bone becomes osseointegrated and vascularized at its site of implantation, which decreases the chances of infection, displacement, and foreign body reaction compared with alloplastic implants. The drawbacks are the harvest time, donor site morbidity, graft resorption, modeling changes, and harvest volume limitations (1). The clinician has to choose the site of bone harvest wisely, taking into account the nature of the reconstruction and volume requirements. Autogenous bone can be harvested from multiple sites, including the calvarium, tibia, anterior ileum, posterior ileum, rib, sternoclavicle, zygoma, mandible, and so forth. The use of calvarial bone grafts (CBGs) was rst reported in 1670, when Van Meekren reconstructed a Russian soldiers calvarial defect utilizing a CBG from a dog (2). Other early contributors were Konig (3) and Muller (4) in 1890, reporting on human CBGs for the correction of posttraumatic craniomaxillofacial defects. In the 1980s, Tessier popularized the technique as an aid in the correction of craniofacial deformities (5). Pensler and McCarthy (6) published a study on the
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thickness and specic anatomy of the calvarium for safe and predictable harvesting. CBGs have been utilized in reconstruction of the mandible (7), maxilla (8, 9), orbital oor (10, 11), orbital roof (12), malar region (13), and as a strut for nasal reconstruction (14). In craniofacial surgery, the CBG can be used to reconstruct advancement gaps resulting from Lefort I, II, and III procedures. Outer-table CBGs can be taken from the parietal region of the skull, posterior to the coronal suture, where the skull is the thickest. CBGs can usually be harvested with minimal morbidity at the donor site, with a scar hidden in the hair-bearing region. The geometry and convexity of the CBG makes it suitable for most maxillofacial reconstructions. Due to its cortical nature, the CBG can be rigidly xated, providing a stable platform for revascularization and osseointegration. In maxillofacial reconstruction, the proximity of the CBG donor site to the surgical site avoids the need for a second distant surgical eld, but may preclude simultaneous bone graft harvest and recipient site preparation. Postoperative complications are few, and recovery is relatively painless. The donor site defect of the outer table can be reconstructed with a bone cement that solidies with endothermic reaction. The graft should not be harvested in the midline because of the risk of injuring the sagittal sinus. METHODS This retrospective study consisted of 50 consecutive patients (34 women and 16 men), treated from 1996 to 2010 by a single private practice, in whom only cranial bone grafts were used to reconstruct maxillofacial defects (Figures 12). This study was exempt from institutional review board approval. Records were reviewed, including operative reports, discharge summaries, progress notes, radiographs, and photographs. Subjects were excluded from the study if they had less than 12 months of follow up or inadequate records. All subjects underwent bone harvesting and grafting by the same surgeon (Wolford). The outer-table CBG harvest technique
From the Department of Oral and Maxillofacial Surgery, Baylor College of Dentistry, Texas A&M University System Health Science Center, and Baylor University Medical Center at Dallas. Corresponding author: Larry Wolford, DMD, 3409 Worth Street, Suite 400, Dallas, TX 75246 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2013;26(3):252255

Figure 1. Loss of left maxillary alveolar ridge secondary to trauma, reconstructed with layered calvarial bone grafts.

Figure 3. Surgical approach for harvesting of calvarial bone grafts.

The evaluation consisted of the clinical description of any complication at the donor or recipient site during the procedure, immediately after surgery, and at longest followup. The healing and integration of grafts were evaluated clinically and radiographically. RESULTS Fifty patients with 63 grafted areas were evaluated. The distribution of grafted areas is shown in the Table. The six grafted areas Figure 2. Reconstruction of right ramus and temporomandibular joint with calvarial bone grafts and TMJ included mandibular body/symphysis, ramus, Concepts prosthesis (previously Techmedica Inc, Camarillo, CA), following removal of Vitek total joint nasal dorsum, maxilla/alveolar ridge, glenoid prosthesis (Vitek Inc, Houston, TX), containing Proplast/Teflon that destroyed the ramus. One calvarial fossa, and orbitozygomatic complex. Patients bone graft was attached to the prosthesis to replace the lateral cortical bone, and the second piece was average age was 32.4 years (range 16 to placed on the medial side of the ramus to replace the medial cortex. 66 years), and the longest follow-up averaged 22.4 months (range 12 to 48 months). was utilized in all patients, and the volume of the bone was harThe percentage of complications associated with the revested according to the recipient site defect. The harvest of the cipient sites was calculated from the total number of grafted CBG was performed following completion of the recipient site anatomical locations, while the percentage of complications preparation. The initial incision was made 2 cm posterior to the associated with the donor site was calculated using the total hair line and 2 cm lateral to the midline. The incision was made in number of patients, since there was a single donor site per paa curvilinear fashion, superior to the temporalis muscle attachment tient. At the recipient sites, three complications were noted (Figure 3). Using a #10 scalpel, the incision was carried down to the (4.8%). In one case of a maxillary ridge augmentation with cranium. Raney clips were placed at the edges of the incision. Minisimultaneous osseointegrated dental implants, the graft was lost mal use of Bovie cautery and minimized harvest time decreased secondary to infection. The second patient had facial congenital damage to the hair follicles. The bone to be harvested was outlined inltrating lipomatosis and received a unilateral orbitozygousing a 701 burr, to correlate to the amount of bone necessary for matic reconstruction with a CBG, following extensive resection the recipient site. The site of harvest was usually 2 cm lateral to the of the tumor, which involved the orbit, zygoma, and associated sagittal and squamoparietal sutures. The unicortical osteotomies soft tissue. There was partial loss of the graft secondary to inof outer cortex bone to be harvested were connected. The inferior fection, related to the poorly vascularized recipient bed. In the or superior edge of the donor site was beveled using a pineapple third case a nasal dorsal reconstruction graft became mobile, burr in order to access the diplo, deep to the outer cortex. Using a failing to integrate and fuse to the nasal bony structure, but it combination of slightly curved and straight osteotomies, the bone remained in place 3 years after surgery. The rest of the grafts grafts were dislodged from the diplo. The bone was kept in saline healed uneventfully and at the radiographic evaluation appeared and placed on ice for preservation. Hemostasis was achieved. The to demonstrate adequate integration between the graft and the Raney clips were removed, and the incision was closed in a single host bone at long-term follow-up. layer using a 2.0 or 3.0 Prolene suture. A compression dressing At the donor sites, two complications were identied (4.0%). was placed for prevention of hematoma. Sutures were removed A dural tear occurred on a 16-year-old patient who had only 7 to 10 days after surgery. one cortical plate of the parietal bone. The tear was primarily
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Table. Distribution of grafts and outcome

low. The outer-table CBG harvest technique is a time-consuming procedure compared with use of alloplastic and tissue-engineered materials. In comparison to bone grafts obtained from other anatomical sites, CBGs benet the operator with one eld of surgical access, eliminating the preparation of a distant second site. The reported complication rates are low. This bone grafting procedure is an eective technique for reconstruction of maxillofacial defects.
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repaired. In the second patient the dura tear was also closed primarily. Both patients healed uneventfully. DISCUSSION CBGs are used for a multitude of maxillofacial reconstructions, with low complication rates (15). The literature has reported clinical observation of minimal to no resorption of the CBG at short-term follow-up (16, 17). The reconstruction, although technique sensitive in its adaptation to the recipient site, is safer and more cost-eective than alloplastic grafting (1820). CBGs can be considered the material of choice for maxillofacial reconstruction due to their histocompatibility, anatomofunction, and mechanical properties (21). Additionally, CBGs are fresh live tissue that will revascularize and osseointegrate to adjacent bone, having a low rate of infection (22). Although CBGs require time for harvest, unlike alloplastic graft materials, the disadvantages associated with CBGs are few. When large bone grafts are harvested, the donor defect can be reconstructed with synthetic substitutes, which have been reported to result in infections and inammatory reactions (23). The chance of dural tear exists with outer-table CBG harvesting if the inner table is penetrated (24). In harvesting outer CBGs, the possible complications are intracerebral hematoma, subarachnoid hemorrhage, and cerebrospinal uid leaks (25), none of which were encountered in this study. Additionally, the volume of graft to be harvested could be a limiting factor for large defects requiring reconstruction (24). Removal of the outer table where the residual defect is inadequately lled can result in a cosmetic defect in the skull. Although no controlled human studies have measured the exact rate of resorption and retained volume of CBGs, the clinical studies support stable outcomes (2628). DeLuca et al reported an animal study, where the CBGs had a volume retention rate of 85.1%, and recommended CBGs as the gold standard for craniofacial reconstruction (29). In our retrospective study, the complication rates at the donor site (4.0%) and the recipient site (4.8%) were relatively
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Rogers GF, Greene AK. Autogenous bone graft: basic science and clinical implications. J Craniofac Surg 2012;23(1):323327. 2. Papel ID, ed. Facial Plastic and Reconstructive Sur2/50 subjects (4.0%) gery, 3rd ed. New York: Thieme, 2009. 3. Konig F. Der knocherne Ersatz grosser Schadeldefekte. Zentralbl Chir 1890;17:65. 4. Muller W. Zur Frage der temporaren Schadelresektion an Stelle der Trepanation. Zentralbl Chir 1890;17:65. 5. Tessier P. Autogenous bone grafts taken from the calvarium for facial and cranial applications. Clin Plast Surg 1982;9(4):531538. 6. Pensler J, McCarthy JG. The calvarial donor site: an anatomic study in cadavers. Plast Reconstr Surg 1985;75(5):648651. 7. Tet S, Vinci R, Zara S, Zizzari V, Cataldi A, Mastrangelo F, Mortellaro C, Gherlone E. Atrophic jaw reconstruction by means of calvarial bone graft: long-term results. J Craniofac Surg 2010;21(4): 11471152. 8. Pereira CC, Gealh WC, Martins MM, Homsi N, Garcia IR Jr. Utilization of surgical trepan for the obtainment of calvarial autogenous bone graft in maxillary reconstructions. J Oral Implantol 2011;37(3):347351. 9. Ferri J, Lauwers L, Jeblaoui Y, Genay A, Raoul G. Le Fort I osteotomy and calvarial bone grafting for dental implants. Rev Stomatol Chir Maxillofac 2010;111(2):6367. 10. Ilankovan V, Jackson IT. Experience in the use of calvarian bone grafts in orbital oor reconstruction. Br J Oral Maxillofac Surg 1992;30(2):92 96. 11. Zunz E, Blanc O, Leibovitch I. Traumatic orbital oor fractures: repair with autogenous bone grafts in a tertiary trauma center. J Oral Maxillofac Surg 2012;70(3):584592. 12. Penfold CN, Lang D, Evans BT. The management of orbital roof fractures. Br J Oral Maxillofac Surg 1992;30(2):97103. 13. Tatum SA, Kellman RM. Cranial bone grafting in maxillofacial trauma and reconstruction. Facial Plast Surg 1998;14(1):117129. 14. Cheney ML, Gliklich RE. The use of calvarial bone in nasal reconstruction. Arch Otolaryngol Head Neck Surg 1995;121(6):643648. 15. Smolka W, Eggensperger N, Kollar A, Iizuka T. Midfacial reconstruction using calvarial split bone grafts. Arch Otolaryngol Head Neck Surg 2005;131(2):131136. 16. Gruss JS, Mackinnon SE, Kassel EE, Cooper PW. The role of primary bone grafting in complex craniomaxillofacial trauma. Plast Reconstr Surg 1985;75(1):1724. 17. Powell NB, Riley RW. Facial contouring with outer-table calvarial bone. A 4-year experience. Arch Otolaryngol Head Neck Surg 1989;115(12):1454 1458. 18. Agrawal A, Dulani R, Mahadevan A, Vagaha SJ, Vagha J, Shankar SK. Primary Ewings sarcoma of the frontal bone with intracranial extension. J Cancer Res Ther 2009;5(3):208209. 19. Agrawal A, Rao KS, Krishnamoorthy B, Shetty RB, Anand M, Jain H. Single stage craniofacial reconstruction for fronto-nasal encephalocele and hypertelorism in an adult. Singapore Med J 2007;48(8):e215e219. 20. Hayward RD. Cranioplasty: dont forget the patients own bone is cheaper than titanium. Br J Neurosurg 1999;13(5):490491.

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21. Artico M, Ferrante L, Pastore FS, Ramundo EO, Cantarelli D, Scopelliti D, Iannetti G. Bone autografting of the calvaria and craniofacial skeleton: historical background, surgical results in a series of 15 patients, and review of the literature. Surg Neurol 2003;60(1):7179. 22. Aikgz B, Ozcan OE, Erbengi A, Bertan V, Ruacan S, Aikgz HG. Histopathologic and microdensitometric analysis of craniotomy bone aps preserved between abdominal fat and muscle. Surg Neurol 1986;26(6):557561. 23. Simpson D, Robson A. Recurrent subarachnoid bleeding in association with dural substitute. Report of three cases. J Neurosurg 1984;60(2):408409. 24. Earley MJ, Green MF, Milling MA. A critical appraisal of the use of free aps in primary reconstruction of combined scalp and calvarial cancer defects. Br J Plast Surg 1990;43(3):283289.

25. Lin SJ, Hanasono MM, Skoracki RJ. Scalp and calvarial reconstruction. Semin Plast Surg 2008;22(4):281293. 26. Hunter D, Baker S, Sobol SM. Split calvarial grafts in maxillofacial reconstruction. Otolaryngol Head Neck Surg 1990;102(4):345350. 27. Frodel JL. Calvarial bone graft harvest in children. Otolaryngol Head Neck Surg 1999;121(1):7881. 28. Brusati R, Biglioli F, Mortini P, Raaini M, Goisis M. Reconstruction of the orbital walls in surgery of the skull base for benign neoplasms. Int J Oral Maxillofac Surg 2000;29(5):325330. 29. DeLuca L, Raszewski R, Tresser N, Guyuron B. The fate of preserved autogenous bone graft. Plast Reconstr Surg 1997;99(5):13241328.

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