Periodontology 2000 - 2023 - K mmerer

Received: 26 March 2023 | Revised: 21 May 2023 | Accepted: 26 May 2023
DOI: 10.1111/prd.12499
REVIEW ARTICLE
Bone reconstruction of extensive maxillomandibular defects in

adults
Peer W. Kämmerer | Bilal Al-Nawas

Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Mainz, Germany
Correspondence
Peer W. Kämmerer, Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, Mainz 55131, Germany.
Email: peer.kaemmerer@unimedizin-mainz.de
1 | I NTRO D U C TI O N A N D H I S TO R I C A L free bone grafting of mandibular defects,6 when the recipient bed
D E V E LO PM E NT was categorized as “strong”, “weak”, and “incapable”. This constitutes
a systematic approach that is still used today to describe the indica-
Extensive maxillomandibular defects have been integral to recon- tion for microvascular grafts to reconstruct “incapable” osseous defi-
structive oral and maxillofacial surgery for more than 100 years. ciencies. Another significant contribution of his work was explaining
Dentists often performed primary care during World War I for acute the need for immobilization. Gerry used an acrylic stent and wires to
battlefield injuries. It became evident that modern warfare has in- shape and fixate the graft material.7 Freeman described the first func-
creased facial injuries, including to the jaws.1 Complex facial traumata tional, stable bridging plate in its modern form in 1948.8 These ideas
were treated with dental techniques like splinting and occlusal fixa- of immobilization and primary bone healing led to the development of
tion.2 Apart from warfare, another driving force was the development large compression plates for fracture healing at the mandible.9 In the
of tumor surgery starting in the mid-19th century. Jaw resections 1970s, mini plates and screws allowed safe fixation of osseous grafts
became more common where there was no possibility of reconstruc- using intra-oral approaches.10,11 A comprehensive overview of bony
tion. It was in 1850 when the French dentist Préterre tried to form an maxillary and mandibular reconstructions followed in the first half of
alloplastic reconstruction of a jaw defect using a prosthesis. This led the 20th century, published by Hjørting-Hansen.12 In 1950, Converse
3
to discussions about functional and esthetic outcomes. A wide field in the USA13 and Clementschitsch in Austria14 started to successfully
of dental resection prostheses was developed in the second half of transplant nonvascularized autologous grafts from the iliac crest onto
the 19th century, as described in a well-written narrative review by the maxillofacial area. The availability of antibiotic prophylaxis led to
Sigron.4 Modern obturators or alloplastic reconstruction can be seen further development in this field.15 However general anesthesia is
as developments in this field. Ollier was the first to publish landmark mainly needed for extensive bone reconstructions.
5
biological aspects of grafting in 1891, describing the differences Many of those historical bone grafting principles are generally
between autologous, homologous, and heterologous grafts. With a accepted. After considering the indications for extensive craniomax-
focus on graft properties, it was postulated that only viable, autol- illofacial osseous reconstruction, the respective recipient site prin-
ogous bone could be successfully transplanted and that the perios- ciples, local/systemic factors of influence, techniques for stabilizing
teum plays a crucial role in graft survival. Histological studies from the grafts, and using different bone grafts must be considered. Also,
Barth227 from the same time showed that, after grafting, the perios- other alternatives to “biological” augmentations, such as alloplastic
teum and bone marrow become nonvital. Starting from the recipient materials, need to be discussed.
bed, and depending on its vitality, new blood vessels revascularize
the graft. Barth drew attention to the viability of the recipient bed
and the vascularization. Modern ideas regarding the viability of the 2 | I N D I C ATI O N S
recipient site, the bony envelope, and graft vascularization with re-
sorption and revitalization, are related to this work. After some case A clear definition of “small” and “large” craniomaxillofacial bone de-
descriptions, in 1911 Lexer published the first systematic analysis of fects is missing in the literature. A systematic review stated that a
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provided the original work is properly cited.
© 2023 The Authors. Periodontology 2000 published by John Wiley & Sons Ltd.
Periodontology 2000. 2023;00:1–18. wileyonlinelibrary.com/journal/prd | 1

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2 KÄMMERER and AL-NAWAS
mean horizontal and vertical bone gain of 3.7 mm is possible using 3 | R EC I PI E NT S ITE PR I N C I PLE S
particulated materials. Bone blocks or other techniques are needed
for more significant deficits.16 Others state that a vertical augmen- 3.1 | Local and systemic factors
tation above a threshold of 2.55 mm poses a substantial risk for
complications.17 Even so, the type of reconstruction is also based on The vitality of the bone bed is critical for graft healing. Local fac-
other properties, such as location, local and systemic factors, as well tors like the cleft area, knife-edged cortical ridges in the mandible,
as patients' characteristics.17–20 or anatomic variations, can be challenging. Also, a history of inflam-
matory diseases such as periodontitis might increase the risk of
complications.35 Whereas some report that older age increases the
2.1 | Alveolar reconstruction complication rates,35 also as a result of impaired angiogenesis,36 oth-
ers could not find a significant difference.37 Nevertheless, medical
Alveolar bone reconstruction of the maxilla and/or the mandible fol- conditions also have to be taken into account. Unfortunately, little
lowing atrophy was a significant challenge before dental implants is known about medically compromised patients and more exten-
were available. A landmark work from Tallgren in 1975 demonstrated sive bone grafting. For example, sildenafil has been shown to impede
the effect of denture wearing on the long-term atrophy of the man- early bone healing, but only in animals.36 Other drugs, such as sero-
21
dible. Recently, it was shown that using two implants for fixation tonin reuptake and proton pump inhibitors, have negatively influ-
of dental protheses can slow down bone resorption in the edentu- enced bone remodeling, although these data mainly refer to dental
22
lous jaws. Despite shorter and narrower implants, especially in the implant healing.38–41 Earlier, in 1996, it was shown that osteoporosis
esthetic zone, a predictable bony and soft tissue reconstruction re- might affect graft healing.42 Vitamin D deficiency might also be a risk
23–25
mains the clinical and scientific focus. In conclusion, a sizeable factor for graft complications.43 However, substituting with vitamin
alveolar reconstruction that relies on parameters such as local and D did not lead to a better histological outcome in sinus floor eleva-
systemic factors, the surgical incision and grafting technique, and tion.44 Very few data on diabetes and more extensive augmentation
the grafting material, is still needed in many cases. procedures are documented. Animal data showed slower graft in-
corporation compared with a healthy control group.45 Some authors
have even commented that large block grafts should be avoided.46
2.2 | Continuity defects of the mandible In brief, uncontrolled diabetes in particular has been recognized as a
risk factor in craniofacial bone regeneration.47 For smokers, less new
For reconstruction of continuity defects of the mandible, free iliac bone formation and osteogenic marker expression was reported,
crest grafts were the historical standard, requiring an extraoral ap- leading to a higher complication rate after bone augmentation pro-
26–28
proach without a predictable option for primary reconstruction. cedures.35,48 After radiotherapy, bone grafts are known to be less
A staged approach with resection, then later a nonvascular iliac predictable, and often, large grafts are also avoided.49 In patients
crest graft for reconstruction, followed by the insertion of dental with low-dose bisphosphonate therapy (e.g., for osteoporosis treat-
implants, led to predictable results. 29 Nowadays, these defects, with ment), the successful healing of autologous grafts is described in a
poor regenerative capacity of the recipient bed, difficult immobili- case series.50 Nevertheless, bisphosphonate treatment is related to
zation, and low vascularization properties, have become a domain negatively affecting osteogenesis, preventing osteointegration and
of microvascular anastomosed grafts. Those transplants allow the the remodeling of bone grafts.51 According to some authors, bone
primary reconstruction of soft and hard tissues and avoid resorp- grafting should be avoided under high-dose antiresorptive ther-
tion. Besides, the principle of rigid fixation using bicortical screws apy.52 In conclusion, more evidence-based knowledge is needed on
30
and ridged bridging plates applies. the impact of local and systemic risk factors regarding the recon-
struction of significant maxillomandibular bone defects.
2.3 | Midface/orbital reconstruction

3.2 | Surgical incision designs for large grafts
Midfacial reconstruction is often indicated following trauma or
tumor resections.31,32 Also, syndromes may lead to malformations The earliest standardized alveolar grafts were bone grafts in cleft lip
33
of the zygoma and midface. The main issue in such cases is to allow and palate patients. Trauner described the typical buccal incision, 53
a precise, unique reconstruction in the planned position. This is done which became the standard.54 The intention was to localize the in-
34
using various autologous grafts, but alloplastic grafts can be used cision far away from the graft so that minor dehiscence would not
if sufficient soft tissue coverage is available. In conclusion, recon- lead to direct contact with the graft. This technique, often called
struction of the midface and/or the orbit—which is not the focus of “poncho” incision, is still used in particular indications in maxillofa-
the present review—is challenging, and is primarily based on indi- cial surgery for large grafts (Figure 1).55 The tunnel approach in the
vidual requirements. mandible was described in 1965, mainly for mechanical transplant
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KÄMMERER and AL-NAWAS 3
fixation,56 then came back in the 1980s to stabilize hydroxyapatite report stable implant success over 5 years.73,82 Recently, long-term
onlay grafts,57 and is now used primarily for predictable beneficial implant success in large iliac crest grafts has been discussed more
wound-healing properties.58 Originating from the marginal access critically.72,83 Wiltfang et al.84 covered the onlay grafts from the iliac
59,60
in periodontal surgery with guided bone regeneration, larger crest with a thin layer of deproteinized bone matrix. Because this
incision designs were developed using the crestal approach. Klein- material does not show any resorption, it led to a significant reduc-
61
heinz et al. systematically analyzed the angiosomes of the oral tion of graft resorption over a follow-up of 2 years.85 An impressive
62
cavity underlying the theoretical background for crestal incisions. long-term follow-up of 10 years after iliac crest grafting has recently
Buccal periosteal releasing incisions are needed to close the flap. A been published with a promising rate of 95% implant survival.86 Sim-
63 64
periosteal flap can allow a double-layer closure. Urban et al. illus- ilar data have been presented for calvarial grafts, a technique only
trated the additional blunt lingual preparation a few years ago, allow- used by a few groups.87,88
ing tension-free flap closure in the lateral mandible. In comparative
studies, this coronally advanced lingual flap showed less dehiscence
than other techniques (Figure 1A–C).65 3.4 | Inlay grafts
The transplanted bone is positioned interpositionally into the re-

3.3 | Onlay grafts sidual bone for inlay grafts. Historically, problems with graft fixation
and healing led Härle to split the anterior mandible longitudinally,
In cases of onlay grafts, the transplanted bone is placed on the re- keeping the lingual soft tissue attached and reattaching the bone
cipient's bed. Onlay grafts to augment the atrophic mandible came with wires. This “visor” or “sandwich” osteotomy technique increases
to attention after the introduction of small osteosynthesis screws in the height of the mandible without the need for a graft (Figure 3).89
the 1980s. Up until then, fixation was a significant issue, but one that Other groups adopted this method.90–92 It showed predictable
was now finally solved. A widely discussed method in the atrophic outcomes with an implant survival rate of 94% after a mean follow-up
mandible was the rib graft used by Davis et al.,66,67 which was also of 3.7 years, but a high rate (41%) of (temporary) nerve disturbances.93
68
described by others for the maxilla. The authors also documented One of the modifications still in use is the interposition graft.94–96 The
80% graft resorption within the first 3 years. Accordingly, the iliac high rate of neurosensory disturbances (61% in one study) was also
crest became the standard for large onlay grafts (Figure 2A,B), with documented for the modifications of the interposition graft.97 The
69
long-term graft resorption data available in 1980. method still has its place in the lateral mandible and anterior zone.98,99
Currently, monocortical grafts from the inner table of the iliac In 1976, Farrell et al. published the first report of a Le Fort I oste-
crest are still used.70 Interestingly, the harvesting morbidity was dis- otomy, with interposition of iliac crest bone (Figure 4A,B).100 Other
cussed relatively late.71–73 Comparative (retrospective) data show a groups rapidly adopted this technique.101 Long-term follow-up stud-
higher rate of donor site morbidity from the extraoral iliac crest and ies showed high implant survival rates over 10 years.102 Early on,
74
calvaria grafts compared with mandibular ramus grafts. In the early Sailer and Teuscher103 pointed out that this technique also corrected
1990s, grafts were combined with immediate implants to overcome the intermaxillary relationship; Sailer was the first to publish a report
75–77 78
the resorption. As graft healing was not always predictable, on single-stage Le Fort I osteotomy and implant insertion.104 The im-
later on, implants were inserted after the graft had been given time mediate implant insertion led to more implant failures and was only
to heal.79 However, graft resorption80 and critical implant long-term adopted by a few clinicians.105 The availability of piezosurgery and
81
survival have both been the focus of research, even if many studies a better understanding of the anatomy has led to the combination
F I G U R E 1 (A) “Nike” modification of the classical buccal “poncho” incision with thick, soft tissue for better vascularization; (B) Tunnel
incision; and (C) Crestal incision with periosteal releasing incision and blunt lingual preparation.
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F I G U R E 2 (A) Atrophic maxilla with iliac crest onlay graft and sinus floor elevation; and (B) The final result after dental restoration.
F I G U R E 3 Interposition technique: the

principle of the inlay/interposition graft
with high regenerative potential.
F I G U R E 4 (A) Intraoperative situation of Le Fort I and sinus floor elevation; (B) With six implants inserted.
of sinus floor elevation and Le Fort I osteotomy.106 Recently, a large 4 | S TA B I LIZ ATI O N O F PA RTI CU L ATE D
cohort study with combined Le Fort I osteotomy and Sinus floor el- GR AFTS
evation was published after 5 years of follow-up, showing that sinus
membrane perforation was relatively common. Also, fistula and In a broader sense, particulated graft materials can be subsumed as
wound dehiscence were noted. However, the long-term result re- deriving from the patient (autologous), from other people (alloge-
garding implant survival was promising.107 In conclusion, onlay and neic), of animal origin (xenogenic), or artificially created (alloplastic),
inlay techniques are frequently used and must be considered appro- and each has a different regenerative potency.16,108 In bone regen-
priate for major bone augmentations individually. eration, graft materials, at least in their function as scaffolds, are
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essential for the attachment and differentiation of regenerative polytetrafluoroethylene,134 and hydroxyapatite/poly-lactide135
cells from the environment.109,110 The graft materials mentioned are were described.130 Using polytetrafluoroethylene meshes, a mean
primarily used in guided bone regeneration. The principles of these vertical gain of 5.5 mm with no exposure rate (0/10) was seen.134
techniques date back to experimental studies on the regenerative In conclusion, customized meshes are suitable for various bone
potential of periodontal tissues in the 1970s and 1980s. In theory, defects, including complex and larger ones. A high exposure rate
a separate space should be created by an occlusive barrier with the (Figure 6) and the need for secondary removal should be considered.
help of a membrane, which should only be recolonized by cells from In the case of such an adverse event, the site must be kept as clean
the periodontal ligament or the alveolar bone while excluding other as possible. Early mesh removal is not recommended if there are no
cells.111 Much more important, however, seems to be the stability signs of infection, because dental implant placement is often possi-
provided by the barrier membrane, which contributes significantly ble later on.121
to the success of regeneration. It prevents soft tissue from collapsing Data on comparing meshes with other techniques in advanced
into the defect and leads to the accumulation of growth factors.60,112 defect situations are still needed. In addition, clinical data on nonti-
Larger maxillomandibular defects might be regenerated using mem- tanium meshes have yet to be reported.
branes with increased mechanical stability and space-maintaining
capacity.
4.2 | Shell techniques
4.1 | Titanium meshes Another way to stabilize the particulate graft materials to recon-
struct significant bone defects is the shell technique, which can be
Nonresorbable titanium meshes that rigidly maintain the osteo- performed using autogenous or allogeneic cortical plates in different
genic space – originating from classical osteosynthesis – may offer alveolar ridge defects.136–141 In brief, a thin cortical block (“shell”) is
an attractive alternative to other major bone reconstruction tech- used to create a three-dimensional, secluded, stable space filled with
niques.16,113,114 No differences in the outcome using collagen mem- autologous bone and/or a bone substitute material, enabling osse-
branes versus titanium meshes were seen for more minor defects ous regeneration (Figure 7).138,142,143
115–117
(< 3–4 mm). The disadvantages reported for titanium meshes Also, three-dimensional printed templates and rigid resorbable
are a long time for surgery and a need for additional manual skills barrier systems were reported as being applied as shells.142,144–147
because of intraoperative bending. The potential sharp edges and Like meshes, the shells are stable over the long term, and even
the problem in achieving tension-free suturing might result in soft complex defects can be reconstructed precisely using two or more
tissue trauma and later exposure.118–120 Modern techniques such as bone shells.148 The main complication constitutes dehiscences,
computer-aided design/computer-aided manufacturing aim to fa- which can be an even more frequent problem in extended augmen-
cilitate and increase precision in complex surgeries. Based on the tations141; in cases of autogenous shells taken from the ramus, a
patient's three-dimensional Digital Imaging and Communications in similar complication rate was reported.149 Unfortunately, the shell
Medicine data, a virtual model of the jaw, including the defect, is technique is mostly reported for considerably more minor defects
generated. The necessary bone volume is added using reverse en- (< 3–4 mm), and studies on more extensive reconstructions are
gineering software, and the titanium mesh is generated.121 For im- scarce, even although these are biologically possible.150–154 On
proved surgeons' and patients' reported outcomes, prefabricated the other hand, Khoury and Hanser reported a mean vertical gain
patient-specific meshes were introduced120 and used with promis- using autogenous shells of 6.7 mm after a follow-up of 10 years. 58
ing results, including less exposure (0%–33%) and shorter operation Besides, shell techniques seem to achieve a more significant bone
times (Figure 5).55,114,122–124 gain in combination with less resorption when compared with oral
Nevertheless, a recent systematic review did not find a signifi- bone blocks.154
cant difference in exposure rates between conventional and custom-
ized meshes,125 whereas another review did see this difference.126
For (customized) titanium meshes, most reports analyzed horizon- 5 | AU TO LO G O U S D O N O R S ITE S A N D
tal augmentation of a maximum of 5–7 mm vertically and 4–5 mm G R A F T PR I N C I PLE S
in horizontal height, or did not give exact data on the augmented
volume.121,124,127–131 In one case series, a vertical and horizontal gain For decades, autogenous bone block grafting has been consid-
of up to 9 mm with an exposure rate of 1/10 cases was reported.132 ered the therapeutic gold standard for small and medium-sized
In “large” defects (mean reconstructed bone volume 1004 mm3), craniomaxillofacial defects. Together with the favorable proper-
Lizio et al. 228 summarized a failure rate of 5/19 sites. Chiapasco ties of autogenous bone, they offer the advantage of good stabil-
133
et al. saw a mesh exposure in 11/53 locations, leading to a mean ity and resistance to deformation.155 Autogenous bone blocks can
vertical and horizontal bone gain of 4.8 and 6.4 mm, respectively. be harvested from oral or extraoral sites, each with advantages and
Next to titanium, other materials such as polyetheretherketone,129 disadvantages.
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F I G U R E 5 Mesh-based reconstruction of a mandible defect after resecting an odontogenic tumor. (A) Planning of a CAD/CAM titanium
mesh; (B) CBCT after 6 months, before mesh removal and implant insertion; and (C) Final dental restoration. CAD/CAM, computer-aided
design/computer-aided manufacturing; CBCT, cone beam computed tomography.
difference in achievable vertical and horizontal gain compared with

particulate grafting materials in combination with guided bone
regeneration procedures; in accordance, they are mainly used for
small to medium alveolar defects (< 3–4 mm).16,17,156 In one cur-
rent study, a vertical augmentation above a threshold of 2.55 mm
increased the complication rates 5-fold.17 Nevertheless, block har-
vesting is associated with relevant donor site morbidity.13 Although
intra-oral onlay grafts from the chin were used earlier in 1965,157
later on, at the end of the 20th century, ramus grafts became more
common.158,159 This is because of the more extensive harvesting
morbidity of chin grafts with common sensitivity disturbances,160
F I G U R E 6 Exposed part of a customized titanium mesh after a a problem that seemed to be overestimated according to recent
healing time of 2 months. comparative data.161 Also, permanent nerve disturbance has been
described for ramus grafts.162 Other more extensive studies report
no permanent, but 10% temporary, disturbances.158 For small to
5.1 | Intra-oral bone blocks medium-sized osseous defects, a limited amount of bone can also
be harvested from the zygomatic buttress. Here, specific donor site
Oral autologous bone blocks have been successfully used for aug- morbidity mainly constitutes paresthesia and sinusitis.163 Allogenic
mentation of the jaws for decades, even if there is no significant bone blocks may be an excellent alternative to oral bone blocks,
|
F I G U R E 7 Principle of the block

technique with a lag screw and primary
bone healing, and the shell technique with
a positioning screw.
F I G U R E 8 Dental restoration after a traffic accident with fractures of the mandible and the midface together with considerable bone
loss in a 23-year-old female patient. (A) Panoramic X-ray showing the extent of bone loss in the maxilla; (B) Panoramic X-ray showing the site
after insertion of dental implants; and (C) Clinical picture showing the final restoration.
but they have yet to be systematically investigated for large de- 5.2 | Extraoral bone blocks
fects.17,164,165 Compared with the extraoral bone, intra-oral donor
sites have many advantages, from surgical access and scar forma- Extraoral bone blocks are usually harvested from sites like the rib,
tion to training requirements. Also, histological differences be- fibula, tibia, and calvaria. Because of its bulky cancellous content
tween enchondral iliac crest bone and membranous intra-oral bone with a large volume of bone, and the simple surgical technique re-
have been discussed.166 Bone resorption for intra-oral ramus grafts quired, the anterior part of the iliac crest is often used for augmen-
167
was more common in the mandible, and vertical augmentations tation purposes.170 In a two-team approach, the iliac crest bone can
168
were more critical than horizontal augmentations. In more minor be harvested together with the augmentation procedures. A draw-
defects, long-term data showed no difference between the chin back, however, is the donor site morbidity (mostly pain, sensory
and ramus regarding the resorption rate.169 alterations, and gait problems)37,171; in rare cases, fractures of the
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iliac crest after bone harvesting are reported. Thus, technical adjust- subsequent occlusion (even if there is a discrepancy in height), mas-
ments such as minimizing manipulation of the abductors, avoiding tication, and speech; second, its donor site morbidity is described as
nerve injury, and using hemostatic measures are recommended.172 low (mainly ankle instability, stiffness, and sensory deficits).180
In conclusion, almost 80%–100% of patients reported that they The fibula can be harvested with soft tissue (mainly skin and
would undergo the same treatment again if necessary.173 A recent sys- muscle), facilitating oral or extraoral reconstruction. The poten-
tematic review pointed out that long-term implant survival in sites aug- tial drawbacks are a required three-vessel flow of the leg and a thin
mented with iliac crest bone is consistently lower than augmentations skin paddle.181 The iliac crest also offers enough bone (10–16 cm) for
72
with intra-oral grafts. Also, the survival of implants placed in the iliac complete maxillary and mandibular reconstruction. Still, it is mainly
crest bone has been worse than implants in pristine bone.83 This may advocated for the maxilla allowing restoration of the bone and simul-
also result from the high resorption rates of the iliac crest bone, espe- taneous oronasal separation and intranasal lining.182 However, the
cially during the initial postoperative healing phase, indicating the need donor site morbidity of the iliac crest flap is high (mostly postopera-
for early implant placement after 3 months of healing.86,174 Even so, tive hernias), the flap is bulky, and the skin paddle is unreliable.181 The
iliac crest bone is mainly used in advanced cases needing more bone scapula free flap is also well established for mandibular and maxillary
and, therefore, with potentially higher complications (Figure 8). reconstruction. Its advantages lie in an additional large volume of soft
In summary, intra-oral and extraoral bone grafts have different tissue, the possibility to combine more than one flap using the same
indications and are used for various rehabilitations; therefore, com- vascular system, and its low morbidity (mostly restriction of shoulder
parisons may have a particular bias. In continuity-interrupting defects, motion), which is reported to be the lowest when compared with the
the success rates of nonvascularized bone are less when compared fibula, iliac, and radial forearm flap.183 A significant disadvantage is the
with vascularized transplants, mainly if immediate reconstruction is necessity to reposition the patient for flap harvesting. Accordingly, the
intended. Besides, exposure to the oral site may lead to a significantly operative time is extended, and a two-team approach is challenging.
increased failure rate. Nevertheless, nonvascularized iliac crest bone Traditional free-hand techniques have been replaced by virtual
blocks are still an option for such large defects of the jaws. Here, planning and computer-aided surgery with personalized devices, such
careful patient selection with an emphasis on the lateral mandible is as guide-based osteotomies, for the microvascular reconstruction
recommended.175 The complication rate increases with defect length of bony segments. In brief, this process includes planning, modeling,
(especially > 6 cm), lack of rigid fixation, radiotherapy, and infection.170 surgical, and postoperative evaluation phases.184 For planning and
preoperative manufacturing via computer-aided design and computer-
aided manufacturing, usually a computed tomography scan of the
6 | M I C ROVA S C U L A R R ECO N S TRU C TI O N recipient and the donor site is obtained that is converted into a three-
dimensional standard tessellation language file format. The computer-
For this purpose, autologous vascularized tissue reconstructs extensive aided design/computer-aided manufacturing workflow for modeling
tissue defects. At the same time, various augmentation measures can allows the preoperative definition of cutting paths and angles at the
treat more minor imperfections of the mandible and the maxilla, for resection site and of the graft, as well as the shape of the osteosynthe-
the large defects needing bone support, that is, after hemimandibulec- sis material.185,186 This process can either be done via commercial plat-
tomy or hemimaxillectomy. Various augmentation measures can be forms or the clinic itself, depending on the available resources. On the
employed for treatment of minor defects of the mandible and the max- one hand, this increases accuracy and reduces operation times.186 On
illa. However, for large defects needing significant bone support, such the other hand, intraoperative alterations of the surgical plan might be
as after (hemi)mandibulectomy or (hemi)maxillectomy, microvascular complex, and computer-aided surgery adds high additional costs.187,188
grafts have been recommended. They provide immediate vascular sup-
ply to the transplanted bone and soft tissue, resulting in fast healing
and resistance to infection and radiation effects. Flap harvesting and 7 | A LTE R N ATI V E S
its defined vasculature, and re-suturing of the transplants' vessels to
vessels near the recipient bed, are needed. These techniques require 7.1 | Alloplastic reconstruction
advanced skills, technology, infrastructure, and materials.170 However,
relevant donor site morbidity, a notable rate of flap complications, in- Continuity-interrupting mandibular defects have always been prob-
cluding transplant losses, were described.176–178 lematic, and autologous (simultaneous) reconstruction is the up-to-date
Mostly, grafts from the fibula, the iliac crest, and the scapula standard therapy.188 However, not all patients might be suitable for
are used for bone reconstruction of large bone defects. Each donor bony reconstruction, either nonvascular or microvascular.189 Alloplas-
site offers unique characteristics, including of large bone defects tic reconstruction with rigid osteosynthesis plates is a treatment alter-
and soft tissue, quality, and specific donor site morbidity. The fib- native in those cases, leading to a 40%–60% survival rate after 5 years,
ula flap currently dominates mandibular and maxillary reconstruc- with most complications occurring within the first year.30,190,191 Even
tion with its considerable length of up to 25 cm, its long and wide so, dehiscence of the soft tissue, loosened screws and fractures of the
vascular pedicle, and its location allowing a two-team approach plates are common.30,191 Wound infections are known to increase the
179
(Figure 9A–E). First, it will enable dental implant placement with risk of plate exposure by 6.3% (Figures 10 and 11).192
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F I G U R E 9 Female patient with vast

destruction of the mandible because
of medication-related osteonecrosis of
the jaws. (A) 3D reconstruction of the
preoperative CT scan. The bone was
removed, and primary reconstruction
with a fibula-free flap was carried out.
(B) 3D reconstruction of a CT scan after
fibula flap transfer. (C) Panoramic X-ray
after insertion of dental implants. (D and
E) Clinical photographs of the final result.
3D, three-dimensional; CT, computerized
tomography.
F I G U R E 1 1 Panoramic X-ray of a fractured alloplastic

reconstruction plate.
F I G U R E 1 0 Extraoral perforation of an alloplastic phase.198 Because case series also show high failure rates (3/7199),
reconstruction plate. more studies are needed. In addition, current concepts of alloplas-
tic reconstruction allow essential functions, but dental restoration
The influence of radiation on the plate complication rate is might be challenging. If this is the primary aim, osseous recon-
still controversial, as some researchers found a correlation, while struction is needed.
others did not.191,193–195 With large bone defects (> 10 teeth
units), involvement of the mandibular midline and smoking seem
to influence the occurrence of complications. 30,189–191,193,196,197 7.2 | Zygomatic implants
Patient-specific reconstruction plates are also used. With those,
no further bending is necessary, and areas with high-s tress levels At the time of the first description of zygomatic implants, they
can be avoided because of finite element analysis in the planning were used in patients after maxillectomies to restore function and
|
esthetics. As a result, 52 zygomatic implants were reported with a telescopic attachments, 215,216 or different complex superstruc-
success rate of 96% and a follow-up period of more than 5 years. 200 tures. 216 Considering the risks and costs of reconstructive surgery,
Since then, various modifications in materials and techniques have this appears to be the preferred treatment modality for many pa-
been described, also leading to a safe and reliable treatment option tients after maxillectomy that improves masticatory performance
for patients with an atrophic upper jaw. 201–203 Overall, current re- and esthetics217; Buurman et al. 217 reported on 11 patients with
views indicate cumulative survival rates for zygomatic implants of reconstructed maxilla and compared those with nine obturator
more than 95% with follow-up periods of more than 5 years. 203–206 patients. They did not show significant differences in masticatory
Patients rehabilitated with zygomatic implant-supported prosthetic performance or oral health-related quality of life. Besides, in onco-
superstructures report significant improvements in oral quality of logical cases, easy access to the resection defect offers advantages
207
life and overall satisfaction (Figure 12). in follow-up examinations (Figure 13).
Compared with traditional implant treatment of the atrophic
maxilla, the most notable advantage of augmentation-free zygomatic
implant placement is immediate loading to restore the patient's oral 7.4 | Distraction
208,209
function and esthetics after surgery. In the literature, a preva-
lence of 22%–90% is given for immediate loading, with more recent Distraction osteogenesis was initially described for mandibular defi-
studies showing a clear trend toward immediate restoration without ciencies but has also been used in cases of maxillary hypoplasia. 218–220
210,211
significant differences in implant survival. Compared with tra- It consists of the phases osteotomy, latency, distraction, and con-
ditional implants, zygomatic implants require experienced surgeons solidation. 221 During distraction osteogenesis, new bone forma-
and prosthodontists to successfully perform this treatment at the tion occurs between the two segments, continuing until the callus
highest level. In addition, the placement of zygomatic implants im- tissue gradually distracts. Accordingly, a new bone will be formed
pressively demonstrates the benefit of navigated surgery, which parallel to the distractions' vectors. 222 Distraction osteogenesis is
should be seen here as a reliable approach to improving accuracy mainly used to correct congenital or acquired craniomaxillofacial de-
and avoiding surgical complications. 212 However, it must be noted formities. The literature on the reconstruction of defects of the jaw
that using zygomatic implants also carries risks, such as the develop- mainly consists of cases or case series and small comparative stud-
ment of maxillary sinusitis, oroantral fistulas, infraorbital paresthe- ies, in which vertical gains of up to 15 mm together with progres-
sia, and difficult prosthetic fitting. sive elongation of surrounding soft tissues were described. 223–226
Overall, distraction osteogenesis is reliable with good clinical results.
However, several drawbacks have to be taken into consideration as
7.3 | Obturators distraction osteogenesis. Distraction osteogenesis may not simulta-
neously allow the correction of horizontal and vertical deficiencies,
Depending on the size and geometry of the defects, the therapeu- and the dimensions of the osteotomies and the distraction devices
tic options as well as the number and distribution of the remaining may limit its use. Besides, fractured devices and problems with the
teeth, an obturator may retain and seal the defect with or even with- planned vectors may occur. Lastly, the device usually needs removal
213 214
out other implants, including elements such as locator, bar, after the consolidation phase.
F I G U R E 1 2 Patient with a defect

after resection of a benign tumor of the
maxilla. He decided against microvascular
reconstruction and for reconstruction
using zygomatic implants. (A) 3D
reconstruction of the preoperative
CT scan; (B) 3D reconstruction of
the postoperative CT scan after the
insertion of two zygomatic implants. 3D,
three-dimensional; CT, computerized
tomography.
|
F I G U R E 1 3 Clinical picture of
(A) A maxillary defect; and (B) The
corresponding obturator prosthesis.
F I G U R E 1 4 Subjective decision
tree for extensive maxillomandibular
reconstructions. GBR, guided bone
regeneration.
8 | C LI N I C A L I M PLI C ATI O N S procedure and situation needs clinical analysis and informed con-
sent for clinical decision-making as there is no clear evidence of a
• The planning phase should consider the vitality, regenerative ca- favorable technique and material for reconstruction. A subjective
pacity of the recipient bone bed, soft tissue coverage, and patient- decision tree is demonstrated in Figure 14. Clinical decision-making
specific medical conditions. includes local/systemic factors and incision designs, but the choice
• Larger defects and/or defects in compromised patients usually of material, grafting technique, and donor site morbidity is highly rel-
require extraoral autologous grafts, either nonvascularized or evant. Whereas stabilization of particulated grafts—that is, via stable
vascularized. mechanical meshes or shells—might allow a horizontal and vertical
• Stabilization of particulated grafts can rely on different technolo- augmentation of more than 3–4 mm, larger defects usually need ex-
gies (membranes/meshes/shells). traoral harvested autologous bone blocks. The anterior iliac crest is
• In selected cases, alternatives to osseous reconstruction often used for nonvascularized augmentation, whereas significant
(dimension-reduced implants, zygomatic implants, obturators, defects requiring bone support need microvascular reconstruction.
and alloplastic reconstructions) may be considered. For this purpose, the fibula flap has become the main workhorse,
• Three-dimensional planning options allow analysis, choice of treat- even if other techniques may offer better results, such as morbidity.
ment options, patient information, and prefabrication of templates Recent alternatives that should be considered and discussed with
the patient include alloplastic reconstruction using osteosynthesis
plates, zygomatic implants, obturators, and distraction osteogenesis.
9 | CO N C LU D I N G R E M A R K S In addition, traditional free-hand techniques are increasingly
being replaced by virtual planning and computer-aided surgery
The reconstruction of large maxillomandibular defects is a chal- with computer-aided personalized devices, such as guide-based
lenge that has been much discussed over the last few decades. Each osteotomies and other surgical guides. The combination of virtual/
|
allogeneic and 70 cases with autogenous bone blocks. J Clin Med.

augmented surgery and tissue engineering might, in the future, ex- 2022;12:6.
pand the reconstructive capabilities. 19. Granate-Marques A, Polis-Yanes C, Seminario-Amez M, Jane-Salas
E, Lopez-Lopez J. Medication-related osteonecrosis of the jaw as-
sociated with implant and regenerative treatments: systematic re-
AC K N OW L E D G M E N T S
view. Med Oral Patol Oral Cir Bucal. 2019;24:e195-e203.
Open Access funding enabled and organized by Projekt DEAL.
20. Hasegawa T, Sasaki A, Saito I, et al. Success of dental implants in
patients with large bone defect and analysis of risk factors for im-
C O N FL I C T O F I N T E R E S T S TAT E M E N T plant failure: a non-randomized retrospective cohort study. Clin
The authors report no conflict of interest. Oral Investig. 2022;26:2743-2750.
21. Moy PK, Aghaloo T. Risk factors in bone augmentation proce-
dures. Periodontol 2000. 2000;2019(81):76-90.
DATA AVA I L A B I L I T Y S TAT E M E N T 22. Tallgren A. The continuing reduction of the residual alvealar ridges
Data available on request from the authors. in complete denture wearers: a mixed-longitudinal study covering
25 years. J Prosthet Dent. 1975;27:120-132.
23. Şirin Sarıbal G, Ersu N, Canger EM. Effects of conventional com-
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229. Lizio G, Pellegrino G, Corinaldesi G, Ferri A, Marchetti C, Felice
reconstruction of extensive maxillomandibular defects in
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study. Clin Oral Implants Res. 2022;33(6):607-621. doi:10.1111/
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Received: 26 March 2023 | Revised: 21 May 2023 | Accepted: 26 May 2023

Bone reconstruction of extensive maxillomandibular defects in

Peer W. Kämmerer | Bilal Al-Nawas

Periodontology 2000. 2023;00:1–18. wileyonlinelibrary.com/journal/prd | 1

2.3 | Midface/orbital reconstruction

The transplanted bone is positioned interpositionally into the re-

F I G U R E 3 Interposition technique: the

difference in achievable vertical and horizontal gain compared with

F I G U R E 7 Principle of the block

F I G U R E 9 Female patient with vast

F I G U R E 1 1 Panoramic X-ray of a fractured alloplastic

F I G U R E 1 2 Patient with a defect

allogeneic and 70 cases with autogenous bone blocks. J Clin Med.

228. Barth A. Über histologische Befunde nach Knochenimplantation.

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Periodontology 2000 - 2023 - K mmerer

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Copyright:

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Received: 26 March 2023 | Revised: 21 May 2023 | Accepted: 26 May 2023

Bone reconstruction of extensive maxillomandibular defects in

Peer W. Kämmerer | Bilal Al-­Nawas

Periodontology 2000. 2023;00:1–18. ﻿ wileyonlinelibrary.com/journal/prd | 1

2.3 | Midface/orbital reconstruction

The transplanted bone is positioned interpositionally into the re-

F I G U R E 3 Interposition technique: the

difference in achievable vertical and horizontal gain compared with

F I G U R E 7 Principle of the block

F I G U R E 9 Female patient with vast

F I G U R E 1 1 Panoramic X-­ray of a fractured alloplastic

F I G U R E 1 2 Patient with a defect

allogeneic and 70 cases with autogenous bone blocks. J Clin Med.

228. Barth A. Über histologische Befunde nach Knochenimplantation.

You might also like

Peer W. Kämmerer | Bilal Al-Nawas

Periodontology 2000. 2023;00:1–18. wileyonlinelibrary.com/journal/prd | 1

F I G U R E 1 1 Panoramic X-ray of a fractured alloplastic