Günter Schultes, DMD, MD,* Hans Kärcher, DMD, MD,† and
Lucia Gerzanic, DMD, MD‡
Purpose: Our aim was to augment the extremely atrophic mandibular alveolar crest with a pedicledtransplant as the best option for a satisfactory preprosthetic outcome.
Materials and Methods: After computed tomography of the mandible, a model was milled for 6patients. The iliac crest transplant with its vascular pedicle was harvested and, after preliminarypreparation, fixed to the model. The transplant was then placed in the axilla. After 3 months, the graftwas removed and fixed to the mandible.
Results: The prefabricated transplant fit exactly in all 6 patients. The length of the pedicle and coveragewith the newly developed alveolar mucous membrane were satisfactory. The grafts allowed prostheticreconstruction with good functional outcomes. No bone loss was observed during 7 years of follow-up.Additionally, indocyanine green angiography showed good perfusion in 4 patients after 6 months.
estoring the severely edentulous mandible remains aajor challenge. Implants typically cannot be used
ecause of an insufficient bone volume and the risk ofnferior alveolar nerve injury (Fig 1). A prosthesis canolve this problem,1-3 but it creates a distinct distance
between the upper and lower alveolar crests that, ifcorrected by such a prosthesis, would not be durable,functional, or esthetically pleasing. Thus, the mostphysiologic solution is augmentation of the alveolarcrest. Avascular bone augmentations are satisfactory;however, when extreme atrophy of mandibular alve-olar crests4 requires augmentation of more than 10mm, only a pedicled transplant can allow sufficientblood flow without high resorption of the augmentedbone.5,6 Kärcher7,8 has innovatively used distraction
steogenesis and bone-inducing factors to improveone quality in difficult cases. Because animal studiesave clearly shown better bone structure with pedi-
Received from Department of Oral and Cranio-Maxillofacial Sur-
gery, Medical University of Graz, Graz, Austria.
*University Professor.
†University Professor.
‡University Assistant.
Address correspondence and reprint requests to Dr Schultes:
Department of Oral and Cranio-Maxillofacial Surgery, Medical Uni-
versity of Graz, Auenbruggerplatz 7, Graz 8036 Austria; (e-mail:
led bone transplantation,3 bone transplants have beentaken from the iliac crest, scapula, and fibula6,9-11 for
edicled augmentation to achieve good perfusion ofhe transplant, and thus improve bone quality.
Fitting transplants to the arches of the maxilla andandible9 poses an unsolved problem. The pedicle of
he iliac crest transplant for the mandible is so short thatension occurs in the anastomosis in the head and neckegion. With the mandible, covering the bony transplantith vestibular mucous membrane means sacrificing ahysiologically and esthetically valuable vestibulum. Wesed prefabricated bony augments to avoid these prob-
ems with pedicled transplants. Prefabrication of theucous membrane has been previously described.1,10
Our aim was to augment the extremely atrophicmandibular alveolar crest with a pedicled transplantas the best option for a satisfactory preprostheticsituation, although exact adaptation of the transplantto the mandible was often challenging.
Materials and Methods
After all other treatment options had failed, 6 pa-tients (mean age 35 years, range 26 to 58; 4 womenand 2 men) with extreme atrophy of the mandibularalveolar crest underwent pedicled augmentation withan iliac crest transplant. The average height of thealveolar crest was only 4 mm in the region 35 to 45,which would not allow insertion of implants or alve-
Preoperatively, all patients underwent 3-dimen-sional electron beam computed tomography (Evolu-tion CT, Siemens, Erlangen, Germany). The bonystructures were then outlined with an Endoplan work-station. Six polyurethane mandible models (Fig 2) weremilled and then duplicated in a dental laboratory (Fig3) as mandible models made of biocompatible poly-mer (Paladon, Degussa, Wertheim, Germany) that ex-actly reproduced the shape of the individual mandi-ble. The mandible and maxilla models were fixed in aSam articulator (SAM, Konstanz, Germany), and theheight and width of the augment were establishedwith wax. A 1-mm plastic film was placed over thisfixed wax augment; the hollow space left after theaugment was removed then showed the size of theiliac crest transplant to be prefabricated.
FIGURE 1. Radiograph showi
chultes, Kärcher, and Gerzanic. Prefabricated Iliac Crest Transp
FIGURE 2. Milled model of the extremely atrophied mandible.
chultes, Kärcher, and Gerzanic. Prefabricated Iliac Crest Trans-
lant. J Oral Maxillofac Surg 2013.
A pedicled iliac crest transplant was harvested,manually fitted, and fixed to the mandible model (Fig 4).
he film was screwed to the mandible model. In thexilla, the iliac crest transplant was anastomosed tohe thoracodorsal artery and vein (Fig 5) and theound closed. Three months later, after uneventfulealing, the prefabricated transplant was harvested.emoval of the film exposed a whitish membraneovering the transplanted bone (Fig 6). This tissue
eme atrophy of the mandible.
Oral Maxillofac Surg 2013.
FIGURE 3. Biocompatible polymer (Paladon) model, with the film(1) and for transposition of the preoperatively planned augmenta-tion to the surgical site (2).
Schultes, Kärcher, and Gerzanic. Prefabricated Iliac Crest Trans-
ng extr
plant. J Oral Maxillofac Surg 2013.
b
Sp
430 PREFABRICATED ILIAC CREST TRANSPLANT
layer could be used as a mucous membrane and wassutured to the vestibular mucous membrane (Fig 7)after the transplant had been fixed to the mandible.The bony transplant fitted well and was fixed to themandible with miniosteosynthesis plates. The pediclewas tunneled from the floor of the mouth to the neckand anastomosed to the upper thyroid artery andvein. The institutional ethics committee was informedof our project and approved it as a retrospective
FIGURE 4. Adaptation of the transplant (1) consisting of the iliaccrest bone (2) and vessels (3) covered with the film (4) to theiocompatible polymer model (5).
FIGURE 5. Situation before insertion of the pedicled transplant inthe axilla (mandible shown from the front: 1, iliac crest bonecovered with the film; 2, biocompatible polymer model; 3, elasticsfixing the transplant to the model; and 4, screws fixing the trans-plant to the model.
Schultes, Kärcher, and Gerzanic. Prefabricated Iliac Crest Trans-
plant. J Oral Maxillofac Surg 2013.
study. The Helsinki Declaration guidelines were fol-lowed in the present investigation.
Results
All 6 prefabricated transplants healed well in theaxilla, with good perfusion and without inflammation.The transplant showed a good fit and size when it wastransposed from the axilla to the mandible. Histologicexamination of the newly formed membrane betweenthe film and transplant showed collagen-rich connec-tive tissue with a slight chronic, mostly inactive, in-flammation with focal synovial metaplasia on the sur-face. The healing of the transplant on the mandible wasuncomplicated, and perfusion in the prefabricated trans-plant was easily evaluated visually. Additional indocya-
FIGURE 6. The situation after harvesting of the prefabricatedtransplant from the axillary region (1, prefabricated iliac crestbone; 2, prefabricated, newly formed mucosa; 3, newly formedand prefabricated vestibulum) after removal of the film and bio-compatible polymer model.
FIGURE 7. Intraoral view showing the situation after transpositionof the transplant to the mandible (1, tongue; 2, inserted prefabri-cated iliac crest transplant; 3, lip).
Schultes, Kärcher, and Gerzanic. Prefabricated Iliac Crest Trans-
plant. J Oral Maxillofac Surg 2013.
lant. J
SCHULTES, KÄRCHER, AND GERZANIC 431
nine green angiography showed good perfusion in 4patients. The prefabricated transplant fit all 6 patientsperfectly, and the pedicle was sufficiently long. The newmembrane grew to cover the transplant with the mu-cous membrane, and the vestibule was preserved. After6 months, implants were inserted into the lower jaw ofall 6 patients (Fig 8); 3 months later, the prostheses weremounted on the implants.
At 8 months after implantation of the prostheses inthe graft, the correction of the defect was completedin all 6 patients, with the insertion of artificial teeth inthe prostheses.
During a 7-year follow-up period (2004 to 2011), nosignificant resorption of the prefabricated iliac crestbone had occurred and no implants had been lost.
Discussion
Many approaches have been taken to create trans-plants that fit precisely into a defect in various parts ofthe body.
With extreme atrophy of the mandibular alveolarcrest, augmentation with a pedicled transplant mightbe the only method to prepare for prosthetic treat-ment. We have described bone augmentation with apedicled iliac crest transplant in an atrophic lowerjaw.12 A first operation in 1994 involved prefabrica-tion of a transplant using bone from the iliac crest thatwas transplanted into the axilla with microvascular
FIGURE 8. Radiograph showing insertion of implants in the lowewith microvascular anastomosis from the axilla to the mandibular
Schultes, Kärcher, and Gerzanic. Prefabricated Iliac Crest Transp
anastomoses to the thoracodorsal artery and vein.13
Bony prefabrications are often placed in a well-vascularized site to heal in; however, because of thelower risk of atrophy, a vascular pedicled transplant ispreferable to a nonpedicled transplant. Another prob-lem is covering the bony transplant with the localmucous membrane. A prefabricated transplant with avascularized pedicle meets both of these needs. Forpatients requiring intraoral reconstruction with bonyaugmentation, a precise fit will help to prevent func-tional problems with speech and swallowing.
Our new method combines established techniquesof maxillofacial and plastic surgery with modern mi-crosurgery. Angiography is not needed for preopera-tive planning of the microsurgical bone transplants.Postoperative monitoring of the anastomosed trans-plants used to be problematic. Laser Doppler sonog-raphy does not always provide accurate results withosseous grafts, and skin supplied with blood must notbe closed over an osseous graft with a deep bloodsupply. With our methods, perfusion of the graft canbe monitored with electron beam computed tomog-raphy. Indocyanine green angiography provides moredetailed information on occlusion of the graft vesselsand can be used as needed.
Because defect reconstructions involving the mouth,jaw, and face are psychologically stressful for the pa-tient, special attention should be given to the estheticconsiderations, which demand very precise reconstruc-
months after transplantation of the prefabricated iliac crest bone
Oral Maxillofac Surg 2013.
r jaw 6region.
tion of the defect. Our method of prefabrication of
432 PREFABRICATED ILIAC CREST TRANSPLANT
individual, anatomically customized models is 1 methodto meet this challenge.
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