Clinical Reference Strategy for the Selection of Treatment Materials for Maxillofacial Bone Transplantation: A Systematic Review and Network Meta-Analysis.

Bone graft materials have mixed effects of bone repair in the field of oral maxillofacial surgery. The qualitative analyses performed by previous studies imply that autogenous odontogenic materials and autogenous bone have similar effects on bone repair in clinical jaw bone transplantation. This retrospective systematic assessment and network meta-analysis aimed to analyze the best effect of clinical application of autogenous odontogenic materials and autogenous, allogeneic, and xenogeneic bone grafts in bone defect repair. A systematic review was performed by searching the PubMed, Cochrane Library, and other journal databases using selected keywords and Medical Subject Headings search terms. 10 Papers (n = 466) that met the inclusion criteria were selected. The assessment of heterogeneity did not reveal any overall statistical difference or heterogeneity (P = 0.051 > 0.05), whereas the comparison between autogenous and allogeneic bone grafts revealed local heterogeneity (P = 0.071 < 0.1). Risk of bias revealed nine unclear studies and one high-risk study. The overall consistency was good (P = 0.065 > 0.05), and the local inconsistency test did not reveal any inconsistency. The publication bias was good. The confidence regarding the ranking of bone graft materials after GRADE classification was moderate. The effects on bone repair in the descending order were as follows: autogenous odontogenic materials, xenogeneic bone, autogenous bone, and allogeneic bone. This result indicates that the autogenous odontogenic materials displayed stronger effects on bone repair compared to other bone graft materials. Autogenous odontogenic materials have broad development prospects in oral maxillofacial surgery.

Validation of a simulator for cranial graft lift training: Face, content, and construct validity.

PURPOSE: Surgical skills can be improved through practical exercise. The use of specimens, human as well as animal, or live animals for surgical training is limited due to ethical concerns. Drawbacks of simulators are costs, fidelity and creditibility. Thus, simulators must be evaluated objectively to determine their validity before they can be used as teaching modalities. The aim of this study was to verify the face content and construct validity of a novel model-based simulator for lifting tabula externa transplants from the parietal skull. MATERIALS AND METHODS: Participants were invited to perform a tabula externa graft lift during a training session on the simulator. Task performance was analyzed with a standardized assessment tool evaluating realism and appropriateness. Specialist ratings were used to evaluate the performance of the participants. This was an exploratory study using a questionnaire, at Kepler University Hospital, Linz, Austria, a university hospital. According to their expertise in craniomaxillofacial surgery, 17 participants were subdivided into 3 groups: 8 novices, 7 experts and 2 raters. RESULTS: The face validity (realism) obtained an average score of 4.2 of a maximum of 5 points. Likewise, the content validity (appropriateness as a teaching modality) obtained an average score of 4.8 of maximum 5 points. No differences were found between experts and novices concerning the recorded surgery completion times (p = 0.418) or the sizes of the lifted grafts (p = 0.110). During the evaluation of task performance, the expert surgeons (46.9 ± 3.7) were graded significantly better than the novices (36.4 ± 8.5), which proved the construct validity of the simulator (p = 0.001). CONCLUSION: All investigated validities were confirmed and approved the simulator as a valid training tool for parietal graft lift.

Total Face, Eyelids, Ears, Scalp, and Skeletal Subunit Transplant Cadaver Simulation: The Culmination of Aesthetic, Craniofacial, and Microsurgery Principles.

BACKGROUND: The application of aesthetic, craniofacial, and microsurgical principles in the execution of face transplantation may improve outcomes. Optimal soft-tissue face transplantation can be achieved by incorporating subunit facial skeletal replacement and subsequent tissue resuspension. The purpose of this study was to establish a reconstructive solution for a full face and scalp burn and to evaluate outcome precision and consistency. METHODS: Seven mock face transplants (14 cadavers) were completed in the span of 1 year. Components of the vascularized composite allograft included the eyelids, nose, lips, facial muscles, oral mucosa, total scalp, and ears; and skeletal subunits of the zygoma, nasal bone, and genial segment. Virtual surgical planning was used for osteotomy selection, and to evaluate postoperative precision of hard- and soft-tissue elements. RESULTS: Each transplant experience decreased each subsequent transplant surgical time. Prefabricated cutting guides facilitated a faster dissection of both donor and recipient tissue, requiring minimal alteration to the allograft for proper fixation of bony segments during inset. Regardless of donor-to-recipient size discrepancy, ample soft tissue was available to achieve tension-free allograft inset. Differences between virtual transplant simulation and posttransplant measurements were minimal or insignificant, supporting replicable and precise outcomes. CONCLUSIONS: This facial transplant model was designed to optimize reconstruction of extensive soft-tissue defects of the craniofacial region representative of electrical, thermal, and chemical burns, by incorporating skeletal subunits within the allograft. The implementation of aesthetic, craniofacial, and microsurgical principles and computer-assisted technology improves surgical precision, decreases operative time, and may optimize function.

Total Face, Eyelids, Ears, Scalp, and Skeletal Subunit Transplant Research Procurement: A Translational Simulation Model.

BACKGROUND: Cadaveric face transplant models are routinely used for technical allograft design, perfusion assessment, and transplant simulation but are associated with substantial limitations. The purpose of this study was to describe the experience of implementing a translational donor research facial procurement and solid organ allograft recovery model. METHODS: Institutional review board approval was obtained, and a 49-year-old, brain-dead donor was identified for facial vascularized composite allograft research procurement. The family generously consented to donation of solid organs and the total face, eyelids, ears, scalp, and skeletal subunit allograft. RESULTS: The successful sequence of computed tomographic scanning, fabrication and postprocessing of patient-specific cutting guides, tracheostomy placement, preoperative fluorescent angiography, silicone mask facial impression, donor facial allograft recovery, postprocurement fluorescent angiography, and successful recovery of kidneys and liver occurred without any donor instability. Preservation of the bilateral external carotid arteries, facial arteries, occipital arteries, and bilateral thyrolinguofacial and internal jugular veins provided reliable and robust perfusion to the entirety of the allograft. Total time of facial procurement was 10 hours 57 minutes. CONCLUSIONS: Essential to clinical face transplant outcomes is the preparedness of the institution, multidisciplinary face transplant team, organ procurement organization, and solid organ transplant colleagues. A translational facial research procurement and solid organ recovery model serves as an educational experience to modify processes and address procedural, anatomical, and logistical concerns for institutions developing a clinical face transplantation program. This methodical approach best simulates the stressors and challenges that can be expected during clinical face transplantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

A rapid, flexible method for incorporating controlled antibiotic release into porous polymethylmethacrylate space maintainers for craniofacial reconstruction.

Severe injuries in the craniofacial complex, resulting from trauma or pathology, present several challenges to functional and aesthetic reconstruction. The anatomy and position of the craniofacial region make it vulnerable to injury and subsequent local infection due to external bacteria as well as those from neighbouring structures like the sinuses, nasal passages, and mouth. Porous polymethylmethacrylate (PMMA) "space maintainers" have proven useful in staged craniofacial reconstruction by promoting healing of overlying soft tissue prior to reconstruction of craniofacial bones. We describe herein a method by which the porosity of a prefabricated porous PMMA space maintainer, generated by porogen leaching, can be loaded with a thermogelling copolymer-based drug delivery system. Porogen leaching, space maintainer prewetting, and thermogel loading all significantly affected the loading of a model antibiotic, colistin. Weeks-long release of antibiotic at clinically relevant levels was achieved with several formulations. In vitro assays confirmed that the released colistin maintained its antibiotic activity against several bacterial targets. Our results suggest that this method is a valuable tool in the development of novel therapeutic approaches for the treatment of severe complex, infected craniofacial injuries.

Bone recycling in nasal septal reconstruction.

Septal reconstruction alone or together with rhinoplasty can be a very challenging operation. In situations where septal cartilage is used for grafting or is not enough, bony implants taken from the perpendicular plate of the ethmoid and vomer can be used as a filler material between the mucoperichondrial flaps to avoid from unwanted mucosal atrophy, flapping, and septal perforation. These bony implants can also be used for splinting the dorsal and/or caudal segment of the septal cartilage after reshaping by rongeurs. On rare occasions, they can even be used for subtotal reconstruction of the septum.

Impact of donor site for bone graft harvesting for dental implants on health-related and oral health-related quality of life.

OBJECTIVES: To assess and compare changes in health-related quality of life (HRQoL) and oral health-related quality of life (OHRQoL) after bone graft harvesting for dental implants with respect to the donor site. MATERIAL AND METHODS: Autologous bone grafts were harvested in a consecutive sample of 23 patients (mean age: 46.1 years; 52% female) either from an intra-oral (IO; N = 8; chin, ascending ramus, buttress region) or an extra-oral (EO; N = 15; anterior iliac crest) donor site, followed by implant placements. HRQoL was self-administered by the patients using the Short-Form 36 (SF-36) and OHRQoL was assessed using the Oral Health Impact Profile (OHIP-49) preoperatively, 3 days and 4 weeks after surgery. Impact of donor site on changes in both concepts of QoL was determined in multiple linear regression analyses. RESULTS: Patients with extra-oral donor sites reported a substantial deterioration in the physical component (PC) of HRQoL indicated by an increase in the PC score of the SF-36 (P < 0.001), whereas this score did not significantly change in patients with intra-oral donor sites. The mental health component (MC) of HRQoL (MC score of the SF-36) remained virtually identical in both groups. OHRQoL deteriorated from baseline (67.7 OHIP points) to first follow-up (76.6 OHIP points) in both groups, however, changes were not statistically significant. CONCLUSION: In clinical decision-making regarding donor site for bone graft harvesting, patients and clinicians should be aware of the expected decrease in HRQoL if deciding to use extra-oral donor sites. Whenever possible, intra-oral donor sites should be preferred.

Complications of calvarial bone harvesting for maxillofacial reconstructions.

BACKGROUND: For almost a century, autologous bone grafts are the criterion standard for facial skeleton rehabilitations. Progressively, because of its various advantages, calvarial bone imposed as one of the most adapted for craniomaxillofacial reconstructions. Also, calvarial harvesting remains a controversial technique because of its potential complications described in the literature. The aim of this study was to report the precocious and late complications encountered in our practice and to compare them with the previous data of the literature. METHODS: We decided to realize a retrospective study over 10 years and 511 cases of calvarial bone harvesting performed in our maxillofacial department. RESULTS: Our results are very clear, reporting some annoying consequences and long-term aesthetic reattempts, but any serious complication. DISCUSSION: According to our experience and previous data of the literature, we described some technical refinements that could improve our technique and reduce its potentials complications. Nevertheless, we think that nowadays calvarial harvesting is the criterion standard for maxillofacial bone grafts, and the complications described in the literature are negligible for experienced operators.

Osteocutaneous face transplantation.

BACKGROUND: Facial transplantation has the potential to become a viable option in the treatment of acquired and congenital facial deformities. Transplantation of the bony maxillofacial skeleton with the soft tissues (osteocutaneous face transplantation) has not been performed clinically nor has it been described experimentally in a human cadaver model. METHODS: A mock osteocutaneous face transplant procedure was carried out on a cadaver model. The face was harvested in the subperiosteal plane and included the Le Fort III osseous segment. The allograft was inset by rigid internal fixation and soft tissue approximation. RESULTS: The face transplant procedure was technically feasible. On the basis of this experiment, review of prior investigations, and our experience in craniofacial surgery, the authors have identified 10 topics that present technical challenges specific to osteocutaneous transplantation of the face: customisation of the bony segment, sensory and motor innervation, extra-ocular movements, dentition, mastication, speech and swallowing, airway, vascular considerations, immunologic considerations, and identity issues. CONCLUSIONS: Once further advances in immunomodulatory therapy are made, face transplantation will likely still be reserved for only the most severe facial defects. Defects of such severity will likely include a substantial bony component in need of reconstruction. In addition to the challenges associated with facial allo-transplantation in general, there are many technical challenges associated specifically with osteocutaneous face transplantation. It is necessary to consider and discuss these challenges in anticipation of future advances that may allow composite face transplantation to become safe and clinically efficacious. This modality of transplantation has the potential to provide substantial benefit compared with autologous reconstruction.

Regeneración osea guiada GBR: revisión de la literatura / Guide bone regeneration GBR: revew of the literature

La regeneración ósea guiada (Guided Bone Regeneration- GBR) actualmente es considerada una terapia de gran importancia en Implantología, para promover la regeneración de hueso en defectos óseos maxilares; la finalidad es crear un lecho adecuado para el posicionamiento de Implantes. La GBR se basa en el uso de membranas reabsorbibles y no reabsorbibles en combinación con biomateriales de relleno como hueso autólogo, homólogo, heterólogo o materiales aloplásticos con funciones de barrera mecánica, tendientes a excluir de la zona de reparación células epiteliales y conjuntivas, permitiendo la invasión de células osteoprogenitoras

Guide Bone Regeneration has been used widely in implantology for enhancing bone healing to optimize implant placements in the maxillary. The GBR is a technique that uses resorbable and non-resorbable membranes in combination with other filling biomaterials as autologous, homologous or heterologous bone graft, or aloplastic materials as mechanic barriers that prohibit the migration of connective and epithelial cells, enabling the osteogenic cells invasion in bone defects

Modified facial translocation technique to prevent necrosis of bone graft.

OBJECTIVE: To assess the efficacy of a modified facial translocation technique in preventing translocated facial bone graft from necrosis, which is the most common complication of facial translocation. STUDY DESIGN: Prospective. METHODS: A lateral nasal flap was preserved and transposed to resurface the inner surface of the translocated facial bone graft in a facial translocation approach to skull base tumors in 35 patients including 24 patients with radiation therapy between July 1998 and December 2000. RESULTS: Only one patient had bone graft necrosis. Thirty-four (97%) of 35 patients had intact mucosa covering the inner surface of the translocated facial bone graft. The outcome was not affected by preoperative or postoperative radiation therapy. CONCLUSIONS: A modified facial translocation technique using a lateral nasal flap to resurface the inner defect of the translocated facial bone graft significantly improved the viability of the translocated facial bone graft, especially in patients who underwent radiation therapy. The use of a lateral nasal flap does not interfere with the detection of early local recurrence.

Facial translocation approach to the skull base: the viability of translocated facial bone graft.

OBJECTIVES: A retrospective review of 56 patients who were operated through a facial translocation approach was carried out to assess the viability of the translocated facial bone segment. METHODS: Eleven patients had preoperative radiotherapy, and 26 had postoperative radiotherapy. In 14 patients the translocated bone segment was kept attached to the anterior cheek, and in 42 patients the bone segment was detached and then implanted. A vascularized flap was used to obliterate the defect in the paranasal sinuses in 15 patients. RESULTS: Twelve (21.4%) patients had devitalized bone segment and required sequestrectomy. The incidence of devitalized bone segment was higher in the patients who received postoperative radiotherapy (P = 0.04) and lower in the patients in whom the defect in the paranasal sinuses was reconstructed with a vascularized flap (P = 0.006). CONCLUSIONS: The translocated facial bone segment should be kept attached to the cheek soft tissue when possible, or the defect in the paranasal sinuses should be reconstructed with a vascularized flap.

O que devemos saber sobre osso desmineralizado seco-congelado? / What should we know about the use of demineralized Freeze-Dried Bone Allograft (DFDBA)?

O objetivo deste artigo é discutir e esclarecer algumas das controvérsias relacionadas ao uso do osso alógeno seco-congelado (DFDBA - Demineralized Freeze-Dried Bone Allograft) na Odontologia. Indicaçöes e vantagens desse material também säo apresentadas. Apesar de existirem opiniöes contrárias ao seu uso, esse enxerto é considerado seguro para o uso em humanos e vários estudos mostraram-no ser um material eficaz na terapia regenerativa

Three different techniques for mandibular reconstruction after hemimandibulectomy.

Mandibular reconstruction is a condition in which both bone defect and function must be restored. A wide range of approaches--from grafts to distant bone flaps--have been used for correcting bony defects. However, adequate mastication has been restored in only a few cases. In this article the results of three different techniques for mandibular reconstruction after hemimandibulectomy were studied. Sixteen patients underwent a second mandibular reconstruction after hemimandibulectomy and were monitored at least 1 year. Three different techniques were used: (1) full-thickness galeoparietal bone flap (eight patients), (2) free iliac crest graft (three patients), and (3) free fibular grafts (five patients). Occlusion on the nonoperated side and the possibility and function of osseointegrated denture in the vascularized bone transfer were evaluated. The full-thickness galeoparietal flap and free iliac crest bone flap appeared to be good options. However, only acceptable or poor occlusion could be achieved on the normal side. The fibular free flap demonstrated good results and good occlusion. Nonetheless, dental implantation was difficult because a prosthesis for reaching the normal height of the mandible was necessary.

Repositioning of craniofacial tumorous bone after autoclaving.

Thirteen bone tumours that were invading the craniofacial skeleton were operated on by intracranial procedures. The resected tumorous bone was autoclaved and put back. Follow up of no less than one year included 122mTc scanning, computed tomography, radiography, bone biopsy and clinical examination. In every case, when rigidly fixed, most of the autoclaved bone was gradually revitalised by invading new and normal bone. We conclude that autoclaved bone will be replaced by normal bone, and that the present technique is justified for reconstruction of complicated structures or large areas of bone after operations for tumours invading the craniofacial skeleton.

[Craniofacial trauma. Value and methods of early treatment. 70 cases (author's transl)]. / Traumatismes cranio-faciaux. Intérêt et modalités du traitement précoce. A propos de 70 observations.

The two essential problems posed by craniofacial trauma are assessed in the light of 70 collected cases. Firstly, the "time" of treatment. Immediate surgery by two teams, neurosurgical and maxillofacial, may be justified in the presence of craniocerebral lesions. This occurs rarely. The cranial problem is often explored during the first 3 or 4 days and with the exception of certain cases of immediate or delayed coma, maxillofacial treatment may be undertaken early. The treatment of cerebrospinal fluid fistulae remains controversial. Secondly, the surgical technique. Accent is placed upon two points which are still discussed : cutaneous phase and bone phase in open trauma ; reconstruction of the cranial level and the facial mass by fixation using plates or steel wire, bone grafts or inert materials, with in particular surgery for fractures of the floor of the orbit in all cases. A number of clinical cases suggest that suitability of eclectism in this surgical approach to craniofacial trauma.