Sharma S et al. Reconstruction of continuity defects of the mandible with non-vascularized bone grafts.

Journal of Advanced Medical and Dental Sciences Research

@Society of Scientific Research and Studies NLM ID: 101716117

Journal home page: www.jamdsr.com doi: 10.21276/jamdsr Index Copernicus value = 85.10

(e) ISSN Online: 2321-9599; (p) ISSN Print: 2348-6805

Original Research
Reconstruction of continuity defects of the mandible with non-vascularized
bone grafts- Original study
Dr. Shreshth Sharma1, Dr. Sachin S. Hotkar2, Dr. Ashish B. Matne3, Dr. Krishna vallabhaneni SS4, Dr. Achyuth
Ravipati5, Dr. Ankita Khandelwal6

1. Consultant Oral and Maxillofacial Surgeon, Bhopal, Madhya Pradesh

2. PG student Dept of Oral & Maxillofacial Surgery, YMT Dental College Kharghar, Navi Mumbai
3. PG student Dept of Oral & Maxillofacial Surgery, YMT Dental College Kharghar, Navi Mumbai
4. Reader, Department of Pediatrics and Preventive Dentistry, Sibar Institute of Dental Sciences,
Takellapadu, Guntur, Andhra Pradesh
5. Consultant Oral and Maxillofacial Surgeon, Guntur, Andhra Pradesh, India
6. Senior Lecturer, Department of Conservative Dentistry and Endodontics, Index Institute of Dental
Sciences, Indore, Madhya Pradesh

ABSTRACT:
Aim: The purpose of the study was to assess the success of using non- vascularized bone grafts in mandibular continuity
defects. Methodology: The inclusion criteria were patients who had received NVBGs, such as anterior or posterior iliac
crest and costochondral grafts, to reconstruct segmental defects of the mandible. Patients with a history of irradiation of the
head and neck and patients with inadequate follow-up were excluded from this study. Success was judged by radiographic
and clinical evidence of bone continuity and stability at a minimum of 4months postoperatively. Failures were considered
loss of all or part of the graft, resulting in a residual continuity defect requiring further bone grafting. Results: We identified
21 potential cases, of which 16 met the inclusion and exclusion criteria. The mean age of the patients at the time of grafting
was 42 years (range, 17 to 81 years), with a mean follow-up length of 18 months. The length of defects ranged from 2 to 22
cm. The grafts were 6 cm or less in length in 7 defects and greater than 6 cm in length in 22 defects. All cases were grafted at
a minimum of 6 months after resection, and bone morphogenetic protein was used in 5 cases (86%). Failure occurred in 1
patient in the group with grafts of 6 cm or less and 2 patients in the group with grafts greater than 6 cm, corresponding to
success rates of 86% and 91%, respectively. Conclusion: The results of our study show that NVBGs are a viable, safe, and
effective treatment option for segmental mandibular defects over 6 cm in length in non-irradiated patients.
Keywords non-vascularized bone grafts, bone morphogenic protein, mandibular reconstruction.

Received: 23/09/2020 Modified: 18/10/2020 Accepted: 20/10/2020

Corresponding Author: Dr. Shreshth Sharma, B.D.S, M.D.S, Consultant Oral and Maxillofacial Surgeon, Bhopal, Madhya
Pradesh

This article may be cited as: Sharma S, Hotkar SS, Matne AB, SSV Krishna, Ravipati A, Khandelwal A. Reconstruction
of continuity defects of the mandible with non-vascularized bone grafts- Original study. J Adv Med Dent Scie Res
2020;8(11):23-26.

INTRODUCTION function becomes more and more difficult as the

Surgical management of several pathological tissues resected become larger and complex in
conditions occurring in head and neck region require nature.1 Mandibular continuity defect is defined as
the resection of the pathology along with good loss of a portion of the bone resulting in a gap of more
margin. After resection the patient would be left with than 2cm or more in the lower jaw. The etiology is
considerable hard and soft tissue deficit which mainly acquired and rarely congenital. 2 Causes
mandates reconstruction not only to replace the include cysts, benign and malignant tumors, trauma,
missing structural component, but also to restore the and chronic osteomyelitis.3 Resection of benign
associated function. This restoration of form and the invasive odontogenic tumors and avulsion due to

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Sharma S et al. Reconstruction of continuity defects of the mandible with non-vascularized bone grafts.

trauma frequently cause the defects in sub-Saharan mandibular defects 2 cm or larger with NVBGs.
Africa and Asia, while malignancies, Patients with a history of irradiation of the head and
osteoradionecrosis and bisphosphonate related neck, incomplete notes, and lack of follow-up
osteonecrosis are mostly responsible for the defects in panoramic radiographs at least 4 months
Europe, America and parts of Asia.4 Prevalence rates postoperatively were excluded from the study. All
of the defects are not available in literature probably cases followed a similar surgical protocol. All patients
because of diverse and multiple etiologies. underwent secondary mandibular reconstruction with
Reconstruction of mandibular continuity defects is a autogenous NVBGs at a minimum of 6 months after
great challenge to surgeons because of the form and the initial resection of the defect, and all defects were
biomechanical functions of the bone. 5 Currently, the reconstructed via an extraoral approach.
state-of-the-art technique to reconstruct this type of Corticocancellous blocks were used to span the
defects is vascularized bone grafting (VBG) because it defect, and the blocks were rigidly fixated to a
is able to provide immediate blood supply to the bone mandibular reconstruction plate. Autologous
graft and a soft tissue paddle for external cover and corticocancellous chips and cancellous marrow were
intraoral lining. This results in faster wound healing then crushed and mixed with a bone morphogenetic
11
and better resistance to infection and radiation protein (BMP)–impregnated collagen carrier (if used)
effects.6 However this is a complicated technique that and packed around the secured blocks. The remainder
requires high skills, technology, infrastructure and of the BMP-impregnated carrier (if used) was then
materials. In addition, it has the disadvantages of overlaid on the grafted blocks. Success was defined
longer operating time, increased blood loss and lower by radiographic evidence of bony continuity and
cost.7 An alternative for reconstruction of mandibular stability at a minimum of 3 months postoperatively, as
defects is the use of non-vascularized bone grafts well as complete closure of intraoral and extraoral
(NVBG), which involves harvesting only bone grafts wounds. The success rates of grafts greater than 6 cm
from sites like the ilium, rib, fibula, calvarium or parts versus 6 cm or less were compared.
of the mandible itself.8 This technique has the
advantages of shorter operating time, lesser amount of RESULTS
blood loss and more affordable to patients. This is Of the patients who had received NVBGs 2016 to
particularly important in centers which lack sufficient 2019, 16 were included in the study based on the
expertise or the infrastructure and economic resources inclusion and exclusion criteria. Overall, there were
to perform microvascular anastomosis, required for 10 male and 6 female patients with a mean age of 42
the VBG. Failure to reconstruct mandibular defects years (range, 17 to 81 years). The mean follow-up
causes collapse of the portion of the face leading to length was 12 months. The most common etiologies
aesthetic, functional and psychosocial challenges for of mandibular defects were benign conditions,
the patients.9 These challenges have socioeconomic including ameloblastoma, odontogenic keratocyst,
impact on the patients and to improve their quality of myxoma, fibrous dysplasia, and ossifying fibroma
life, reconstruction of the defects takes utmost priority The success rate of short grafts, measuring 6 cm or
in the patients’ management. Defects up to 6cm long less, was 86% (5 of 6 patients), whereas the success
(such as those extending from the first premolar to the rate of long grafts, measuring greater than 6 cm, was
third molar), are regarded as short defects, while 91% (8 of 10 patients). This corresponded to 3 total
defects longer than 6cm, are considered long defects. failures, with 1 short graft failure. (Table 1) Minor
Several articles described the use of NVBG for complications included infection at the donor or
reconstruction of the mandibular defects ranging from recipient site, seroma, necessity for hardware removal,
3 to 14cm and achieved success rates of 38% to wound dehiscence, and fracture at the donor site, all
100%. Most articles reported their outcomes for a of which were treated without further sequelae.
period of 6-12 months, evaluation of long-term
outcomes (>1year) is useful to assess the survival of DISCUSSION
NVBG for the treatment of mandibular bone defects. With considerable advances in the field of
10 maxillofacial reconstruction, surgeons face an
increasing number of decisions in reconstructing
AIM OF THE STUDY segmental mandibular defects. NVBGs have been
The purpose of the study was to assess the success of used successfully since the turn of the 19th century11
using non- vascularized bone grafts in mandibular and have been used in mandibular reconstruction
continuity defects for proper reconstruction as well as since the first documented case by Skyoff in 1900. 12
to analyse any post-operative complications However, since the first major publication of the use
encountered post-operatively. of a fibula free flap for mandibular reconstruction by
Hidalgo,13 nonvascularized grafts have been falling
METHODOLOGY out of favor in mandibular reconstruction.
This was a retrospective study carried out at the Vascularized grafts have repeatedly been shown to be
Department of Oral and Maxillofacial Surgery in our superior in irradiated areas, in sites with composite
institution. The inclusion criteria were patients who defects, and in cases of immediate reconstruction
had undergone reconstruction of segmental compared with nonvascularized grafts.3

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Sharma S et al. Reconstruction of continuity defects of the mandible with non-vascularized bone grafts.

Table 1- Details of all reconstruction cases included in study arranged by length

Case no. Etiology of Defect Age at Length Success of graft

Grafting (in cm)
1 OKC 23 22 yes
2 Ameloblastoma 28 15 Yes
3 Osteomyelitis 45 18 No
4 Ossifying fibroma 54 20 Yes
5 Pathological fracture 22 16 No
6 Osteomyelitis 62 14 Yes
7 Ameloblastoma 47 4 Yes
8 OKC 18 5 Yes
9 Pathological fracture 22 3 Yes
10 Myxoma 27 11 Yes
11 Pathological fracture 65 18 Yes
12 Ameloblastoma 42 21 Yes
13 Ameloblastoma 41 17 Yes
14 Osteomyelitis 39 9 Yes
15 Ossifying fibroma 59 5 Yes
16 Pathological fracture 21 4 No

However, as the number of surgeons trained in concluding that NVBGs should be used for short bone
microvascular surgery increases and the popularity of defects less than 5 to 6 cm in length.
the vascularized graft continues to gain momentum, it The findings of our study, on the other hand, are in
is important not to overlook classic and considerable stark contrast to those published by Foster et al16 and
advantages of nonvascularized grafts such as Pogrel et al.3 Of our 29 total cases, most (n = 22)
decreased operating time, decreased donor-site received long grafts, measuring greater than 6 cm
morbidity, shorter postoperative hospital stay, and (mean, 11.5 cm; range, 7 to 22 cm), with a success
improved volume and contour of the reconstructed rate of 91%; in comparison, our short grafts (n = 7;
site.14 In this study, we question a recent trend toward mean, 4.1 cm; range, 2 to 6 cm) had a success rate of
using vascularized grafts for reconstruction of large 86%, with no statistically significant difference.
mandibular defects. A pervasive belief in the field that Radiographically, our NVBGs resulted in good bony
NVBGs should not be used to reconstruct large (ie, >6 bulk and contour allowing for future implant
cm) mandibular segmental defects originated in a reconstruction. The differences in the results of the
1983 article by Weiland et al,15 who published their aforementioned landmark studies and our findings
experiencewith 41 VBGs without direct comparison may be attributed to several factors. For instance,
to NVBGs. This idea that 6 cm represents a BMP—which was first used in 2001 for human bony
reconstructive cutoff above which NVBGs should not reconstruction by Moghadam et al17—was not
be used was further bolstered by 2 highly referenced available when Foster et al and Pogrel et al conducted
publications by Pogrel et al3 (1997) and Foster et al16 their studies; in contrast, our study had nearly routine
(1999); they directly compared the success of use of BMP (86% of cases), which may have
mandibular reconstruction with VBGs and NVBGs in considerably impacted our results. In addition,
relation to graft length and claimed that increased patients with a history of radiation to the head and
failure rates of NVBGs were closely correlated to neck were excluded in our study but were included in
increased graft lengths. Pogrel et al reported that 95% the studies by Foster et al (3 of 26 NVBG cases) and
of 39 total VBGs were successful compared with 72% Pogrel et al (3 of 29 NVBG cases). Although this
of 29 total NVBGs; they further noted that short study was limited by the sample size, the results of
NVBGs (<6 cm in length) had a failure rate of 17% our study begin to question the dogma of the need for
compared with a 75% failure rate for long grafts (>12 vascularized grafts over 6 cm in length. We suggest
cm in length), concluding that NVBGs greater than 6 that appropriately selected patients might benefit
cm in length have an increased rate of failure and that greatly from reconstruction of large segmental defects
NVBGs ‘‘should be used with extreme caution in with NVBGs.
defects exceeding 9 cm in length.’’ Foster et al
reported a similar correlation between increased graft CONCLUSION
length and increased graft failure in their study, in The pervasive belief that there is a correlation with the
which they found a 75% success rate for short success of NVBGs based on a 6-cm cutoff mark
NVBGs, measuring less than 6 cm, compared with a should be questioned with further investigation. This
44% success rate for grafts measuring 6 cm or greater, study has shown that one can successfully secondarily
reconstruct large mandibular defects in non-irradiated

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Sharma S et al. Reconstruction of continuity defects of the mandible with non-vascularized bone grafts.

patients without concern for an increased rate of 8. Gadre PK, Ramanojam S, Patankar A, Gadre KS.
failure or complications Nonvascularized bone grafting for mandibular
reconstruction: myth or reality? J Craniofac Surg
2011;22(5):1727–1735.
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