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Ridge augmentation with the coronoid-temporalis muscle pedicled flap
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British Journal of Oral and Maxillofacial Surgery 48 (2010) 656–657
Technical note
Ridge augmentation with the coronoid-temporalis muscle pedicled flap Nima Moharamnejad a,∗ , Mohammad Bayat b , Behnam Bohluli c a b c
Faculty of Dentistry, Azad University, Tehran, Iran Department of Oral and Maxillofacial Surgery, Shariati General Hospital, Tehran University of Medical Sciences, Tehran, Iran Department of Oral and Maxillofacial Surgery, Buali Hospital, Azad University, Tehran, Iran
Accepted 4 February 2010 Available online 3 March 2010 Keywords: Bone grafting; Pedicled flap; Dental implant
Many techniques are available for augmentation of the alveolar ridge before an implant is placed. Distraction osteogenesis and microvascular reconstruction give good results but other techniques are unpredictable. The coronoid process is developed from secondary proliferation of mandibular cartilage and is one of the sources of bone for reconstruction of the orbital floor.1 Our aim was to describe a new technique for augmentation of the posterior of maxilla with a temporalis myo-osseous pedicled flap, which has been used by some authors for difficult reconstructions.
The crestal incision is made over the edentulous ridge of the posterior maxilla and the buccal mucoperiosteal flap is raised to gain access to the alveolar bone and lateral wall of the maxillary sinus. We used a curved blunt instrument to make a submucosal tunnel wider than the process, through which the myo-osseous pedicled flap is transferred (Fig. 3). The coronoid process is immobilised with titanium screws in its proper place and the anchoring screw is removed. The mucoperiosteal flap is repositioned over the residual ridge and donor site and sutured carefully. The muscular pedicle does not usually need further release.
Technique The procedure can be done under local anaesthesia, but because of the complexity of the operation and to achieve maximum relaxation general anaesthesia may be preferred. The coronoid process is approached through a vertical intraoral incision, which can be continued down to the ramus if additional bone is to be harvested. The periosteum is raised carefully from the bottom of the coronoid process on both sides, and the coronoid process is then secured in the sagittal plane with a mini screw and wires (Figs. 1 and 2).2 A reciprocating saw is used for the osteotomy.
∗ Corresponding author at: Faculty of Dentistry, Azad University of Tehran, PO Box: 14515-659, Tehran, Iran. Tel.: +98 21 44642320; fax: +98 21 44646879. E-mail address: nima [email protected] (N. Moharamnejad).
Fig. 1. The coronoid process secured in the sagittal plane with a miniscrew and wiring (to the anterior aspect). The dotted line indicates the line of the osteotomy.
0266-4356/$ – see front matter © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2010.02.003
N. Moharamnejad et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 656–657
657
Discussion Patients who have compromised vascularity of tissue are vulnerable to failure of free bone grafts.3 This method could be an alternative procedure for them. Muscle is a source of multipotential stem cells, which can migrate to a bone graft if the muscle is inserted near the grafted bone.4 This characteristic of temporalis muscle, and it being a vascular bed for a bone graft, may make it a good choice to cover the lateral window after open raising of the sinus wall. Haemorrhage could be a complication, as osteotomies that are too posterior and near the sigmoid notch may damage the maxillary artery.5 Trismus and paraesthesia are other complications that could be prevented. In conclusion, the coronoid-temporalis muscle flap could be useful in horizontal and vertical augmentation of the alveolar ridge, raising the sinus floor, and obturation of an oroantral fistula.
Conflict of interest statement There is no conflict of interest regarding the material discussed in the manuscript. Fig. 2. The coronoid process secured in the sagittal plane with a miniscrew and wiring (to the inferolateral aspect). The dotted line indicates the osteotomy.
References 1. Pryor SG, Moore EJ, Kasperbauer JL, Hayden RE, Strome SE. Coronoidtemporalis pedicled rotation flap for orbital floor reconstruction of the total maxillectomy defect. Laryngoscope 2004;114:2051–5. 2. Yoshida H, Sako J, Tsuji K, et al. Securing the coronoid process during a coronoidotomy. Int J Oral Maxillofac Surg 2008;37:181–2. 3. Schwartz-Arad D, Levin L, Sigal L. Surgical success of intraoral autogenous block onlay bone grafting for alveolar ridge augmentation. Implant Dent 2005;14:131–8. 4. Usas A, Huard J. Muscle-derived stem cells for tissue engineering and regenerative therapy. Biomaterials 2007;28:5401–6. 5. Fujimura K, Segami N, Kobayashi S. Anatomical study of the complications of intraoral vertico-sagittal ramus osteotomy. J Oral Maxillofac Surg 2006;64:384–9.
Fig. 3. The coronoid-temporalis muscular pedicled flap transferred to the recipient site.
British Journal of Oral and Maxillofacial Surgery 48 (2010) 656–657
Technical note
Ridge augmentation with the coronoid-temporalis muscle pedicled flap Nima Moharamnejad a,∗ , Mohammad Bayat b , Behnam Bohluli c a b c
Faculty of Dentistry, Azad University, Tehran, Iran Department of Oral and Maxillofacial Surgery, Shariati General Hospital, Tehran University of Medical Sciences, Tehran, Iran Department of Oral and Maxillofacial Surgery, Buali Hospital, Azad University, Tehran, Iran
Accepted 4 February 2010 Available online 3 March 2010 Keywords: Bone grafting; Pedicled flap; Dental implant
Many techniques are available for augmentation of the alveolar ridge before an implant is placed. Distraction osteogenesis and microvascular reconstruction give good results but other techniques are unpredictable. The coronoid process is developed from secondary proliferation of mandibular cartilage and is one of the sources of bone for reconstruction of the orbital floor.1 Our aim was to describe a new technique for augmentation of the posterior of maxilla with a temporalis myo-osseous pedicled flap, which has been used by some authors for difficult reconstructions.
The crestal incision is made over the edentulous ridge of the posterior maxilla and the buccal mucoperiosteal flap is raised to gain access to the alveolar bone and lateral wall of the maxillary sinus. We used a curved blunt instrument to make a submucosal tunnel wider than the process, through which the myo-osseous pedicled flap is transferred (Fig. 3). The coronoid process is immobilised with titanium screws in its proper place and the anchoring screw is removed. The mucoperiosteal flap is repositioned over the residual ridge and donor site and sutured carefully. The muscular pedicle does not usually need further release.
Technique The procedure can be done under local anaesthesia, but because of the complexity of the operation and to achieve maximum relaxation general anaesthesia may be preferred. The coronoid process is approached through a vertical intraoral incision, which can be continued down to the ramus if additional bone is to be harvested. The periosteum is raised carefully from the bottom of the coronoid process on both sides, and the coronoid process is then secured in the sagittal plane with a mini screw and wires (Figs. 1 and 2).2 A reciprocating saw is used for the osteotomy.
∗ Corresponding author at: Faculty of Dentistry, Azad University of Tehran, PO Box: 14515-659, Tehran, Iran. Tel.: +98 21 44642320; fax: +98 21 44646879. E-mail address: nima [email protected] (N. Moharamnejad).
Fig. 1. The coronoid process secured in the sagittal plane with a miniscrew and wiring (to the anterior aspect). The dotted line indicates the line of the osteotomy.
0266-4356/$ – see front matter © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2010.02.003
N. Moharamnejad et al. / British Journal of Oral and Maxillofacial Surgery 48 (2010) 656–657
657
Discussion Patients who have compromised vascularity of tissue are vulnerable to failure of free bone grafts.3 This method could be an alternative procedure for them. Muscle is a source of multipotential stem cells, which can migrate to a bone graft if the muscle is inserted near the grafted bone.4 This characteristic of temporalis muscle, and it being a vascular bed for a bone graft, may make it a good choice to cover the lateral window after open raising of the sinus wall. Haemorrhage could be a complication, as osteotomies that are too posterior and near the sigmoid notch may damage the maxillary artery.5 Trismus and paraesthesia are other complications that could be prevented. In conclusion, the coronoid-temporalis muscle flap could be useful in horizontal and vertical augmentation of the alveolar ridge, raising the sinus floor, and obturation of an oroantral fistula.
Conflict of interest statement There is no conflict of interest regarding the material discussed in the manuscript. Fig. 2. The coronoid process secured in the sagittal plane with a miniscrew and wiring (to the inferolateral aspect). The dotted line indicates the osteotomy.
References 1. Pryor SG, Moore EJ, Kasperbauer JL, Hayden RE, Strome SE. Coronoidtemporalis pedicled rotation flap for orbital floor reconstruction of the total maxillectomy defect. Laryngoscope 2004;114:2051–5. 2. Yoshida H, Sako J, Tsuji K, et al. Securing the coronoid process during a coronoidotomy. Int J Oral Maxillofac Surg 2008;37:181–2. 3. Schwartz-Arad D, Levin L, Sigal L. Surgical success of intraoral autogenous block onlay bone grafting for alveolar ridge augmentation. Implant Dent 2005;14:131–8. 4. Usas A, Huard J. Muscle-derived stem cells for tissue engineering and regenerative therapy. Biomaterials 2007;28:5401–6. 5. Fujimura K, Segami N, Kobayashi S. Anatomical study of the complications of intraoral vertico-sagittal ramus osteotomy. J Oral Maxillofac Surg 2006;64:384–9.
Fig. 3. The coronoid-temporalis muscular pedicled flap transferred to the recipient site.