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A bone graft condensing syringe system for maxillofacial reconstructive surgery
270
1
I
A bone graft condensing syringe system for maxillofacial reconstructive surgery L.K. Cheung, N. Samman, T.W. Chow, R.K.F. Clark, H. Tideman Department of Oral and Maxilloj2zciul Surgery and Depurtment of Prosthetic Dentistry, University qf Hong Kong, Hong Kong
SUMMAR Y. A new system of metallic syringes and pluggers specifically designed for delivery and condensation of particulate bone graft is reported, and the clinical application in maxillofacial reconstructive surgery is described. This bone graft condensing system has advantages over the conventional plastic injection syringes in enabling much better bone graft condensation as well as easier bone delivery and insertion of the syringe to the depth of the reconstruction crib.
INTRODUCTION
of stainless steel of surgical quality (304 stainless steel). There are 2 patterns of bone syringes available, both are of similar design and length but of different diameter. The basic design of the syringe has 3 components: a cylindrical body, a plunger, and a screw-on cap (Fig. 1 A & B). The syringe body is 10 cm long in the form of a hollow tube with a smooth internal surface and a screw thread design on its mid external surface. The plunger fits into the whole length of the syringe body and has a flat arm on its end to facilitate its plunging action. The. cap fits on the opposite end and has a few internal threads which couple with the thread on the external syringe body. The cap has a small nozzle of 2 mm internal diameter at its end to facilitate extrusion of air and marrow fluid during loading. The syringes are of 2 sizes, the internal body diameter of the small syringe is 7 mm and that of the large syringe is 14 mm (Fig. 1C). The set has 6 bone syringes of which 4 are small and 2 are large. A metallic funnel which fits on the plunger end of the syringe is designed to speed up the loading of bone chips into the syringe. The plugger design is simple, and has a tapered hexagonal handle and a solid cylindrical tube of 8 cm attached to its end. The pluggers are either straight or curved. The set has 5 straight pluggers of different diameters: 3, 5, 7, 10, and 14 mm; and the 2 curved pluggers are 3 and 5 mm in diameter (Fig. 1D). The clinical application of this bone graft condensing syringe system is facilitated by having 2 surgical teams. The team which has completed harvesting the autogenous bone will prepare the graft by chipping it into particulate form with bone shears. The cap is initially screwed on the syringe and the funnel is fitted on the plugger end. The bone chips are then poured into the funnel and gradually condensed with the plunger. The same process is repeated for the other small syringes. If the large syringes are to be used, the chips can easily be placed into the syringe body directly. When the jaw crib is stabilised into position
In osseous reconstruction of the jaws with a crib system, good condensation of the particulate bone is essential for a successful outcome.1-4 The harvested autogeneous bone graft is usually chipped into particulate form either by cutting shears or by bone milling machine. These bone chips are traditionally transferred to the reconstructive area by bone currettes and condensed with hand instruments. Plastic injectional syringes have been employed to deliver the bone particles, with the added advantage of condensing the bone chips prior to transfer to the recipient site. Following the condensing action by pressing the plunger and expressing the marrow Auid out from the syringe nozzle, the syringe end is cut open with a pair of large bone shears since the syringe plastic is too tough to cut even by surgical scalpel. This manoevure is quite forceful and results in a ragged syringe end and wastage of some of the bone chips. The size of these syringes also does not adapt well to reconstruction of the jaws. Although the diameter of a 10 ml syringe allows its insertion into the crib, the length is too short and may not reach the required depth, also, the volume of bone chips delivered at each transfer is small. On the other hand, a 20 ml syringe may deliver more bone, but the diameter is too large to insert into the crib causing the bone chips to be extruded outside the crib opening, to be then pushed into the crib by hand instruments thus losing the condensation effect. To our knowledge, no bone syringe system is available on the market, hence a set of metallic syringes and pluggers has been specifically designed for maxillofacial reconstructive surgical procedures. MATERIALS
AND METHODS
The bone graft condensing syringe system consists of 6 metallic syringes and 7 pluggers. They are all made 261
268
British
Journal
of Oral
and Maxillofacial
Surgery
Fig. 1 - Bone graft condensing syringe system. Fig. 1(A) - A standard bone syringe consists of a body, cap and plunger. Fig. 1 (B) - A cross-sectional diagram of a bone syringe. Fig. l(C) - From the left to right, a small syringe fitted with a funnel, a small syringe, and a large syringe. Fig. l(D) - A standard set consists of 5 straight and 2 curved pluggers of varying sizes.
after the resection, the bone graft team will transfer the syringes filled with bone one by one to the reconstruction team, who will then deliver the graft to the recipient site. Immediately prior to the transfer, the caps are unscrewed and taken away from the syringes. The reconstructive surgeon then compresses the syringe and expresses the graft out by filling initially at the crib-residual bone junction. The bone is delivered in bolus form, and this is immediately followed by further condensation with a suitable sized plugger. The reconstructive crib of either the maxilla or mandible will be gradually packed from its depth to the surface in an alternating sequence of bone delivery and condensation (Figs 2 & 3). DISCUSSION
There are good biological reasons for having a bone graft syringe system which is able to condense the graft to a high density in jaw reconstruction. The two-phase theory of osteogenesis, originally proposed by Axhausen,’ is still well supported. This theory stated that bone regeneration in autogenous grafting is initiated by having osteoblasts which survive through the transplantation procedure and on to form new osteoid. The bone formed during this first phase is immature and arranged in a haphazard
manner. The second phase consists of osteogenesis derived from cells of the connective tissue bed and residual bone at the recipient site. The second phase involves resorption and remodelling, whereby the immature bone formed in phase one is replaced by mature organized osteons. The first phase of bone regeneration is clinically important because it dictates the ultimate quantity of bone that the graft will form.’ The second phase does not actually produce further bone volume, but rather just replaces the phase-one bone. The surgeon can therefore enhance phase-one bone formation by condensing the graft material to a high cellular and bone density during the reconstruction procedure which will lead to an improved result. This metallic syringe system has significant advantages over the plastic injection syringes in enabling much better bone graft condensation by easier bone delivery and insertion of the syringe to the depth of the reconstruction crib. Furthermore, there is added advantage in having a set of custom designed pluggers to facilitate further bony condensation in the crib. Counter support with the other hand during the condensing action is important to minimise loosening of the crib and shifting of the occlusion despite inter-maxillary fixation. The curved plugger is found useful particularly when bone has to be condensed around the corner through a window in the crib. This
A bone graft
condensing
Fig. 2 -Osseous reconstruction after maxillectomy via transoral approach. Fig. 2(A) - The right posterior maxilla was fitted with a custom-made titanium tray. Fig. 2(B) -Delivery of bone chips by metallic syringe via a tray window. Fig. 2(C) -The metallic crib is filled with well condensed bone chips.
bone syringe system is thought to be a convenient and useful additional option in the armamentarium of the maxillofacial reconstructive surgeon. Acknowledgement We would like to acknowledge Mr Material Science Unit in manufacturing
Tony Yuen the syringe
of the Dental system.
References 1. Marx RE, Kline S. Principles and methods of osseous reconstruction. Int Adv Surg Oncol 1983; 6: 167-228.
syringe
system
for maxillofacial
reconstructive
surgery
269
Fig. 3 -Osseous reconstruction after mandibulectomy via submandibular approach. Fig. 3(A) - Delivery of bone chips by syringe through a tray window to the depth of the metallic crib. Fig. 3(B) - Further condensation of bone chips with a curved plugger. Fig. 3(C) - Completion of osseous filling and the tray window closed by titanium wires.
2. Dumbach J, Steinhauser EW. Wiederherstellung der kontinuitat des unterkiefers mit dem Titan-Mesh System nach knochen-und weichteilnfektionen. Fortschr Kiefer Gesichtschir 1984; 29: 55557. 3. Tideman H, Samman N, Cheung LK. Immediate reconstruction following maxillectomy: a new method. Int J Oral Maxillofac Surg 1993; 22: 221-225. 4. Cheung LK, Samman N, Tong ACK, Tideman H. Mandibular reconstruction with the Dacron urethane tray: a radiologic assessment of bone remodelling. J Oral Maxillofac Surg 1994; 52: 373.-380. 5. Axhausen W. The osteogenetic phases of regeneration of bone,
270
British
Journal
of Oral
and Maxillofacial
Surgerv
a historical and experimental study. J Bon Jt Surg 1956; 38A: 593-601.
The Authors L.K. Cheung BDS, FDSRCS, FDSRCPS, FHKAM, FRACDS(OMS) Senior Lecturer, Department of Oral & Maxillofacial Surgery N. Samman BDS, LRCP, MRCS, FDSRCS, FHKAM Senior Lecturer, Department of Oral & Maxillofacial Surgery T.W. Chow BDS, MSc, LDS, DRDRCS, FRACDS, FHKAM Senior Lecturer, Department of Prosthetic Dentistry
R.K.F. Clark BDS, PhD, FDSRCPS, FHKAM Professor, Department of Prosthetic Dentistry H. Tideman MD, DDS, PhD, FRACDS, FHKAM Professor, Department of Oral & Maxillofacial Surgery University of Hong Kong Hong Kong Correspondence and requests for offprints to Dr L.K. Cheung, Department of Oral & Maxillofacial Surgery, University of Hong Kong, Hong Kong Paper received 24 May 1995 Accepted 7 December 1995
1
I
A bone graft condensing syringe system for maxillofacial reconstructive surgery L.K. Cheung, N. Samman, T.W. Chow, R.K.F. Clark, H. Tideman Department of Oral and Maxilloj2zciul Surgery and Depurtment of Prosthetic Dentistry, University qf Hong Kong, Hong Kong
SUMMAR Y. A new system of metallic syringes and pluggers specifically designed for delivery and condensation of particulate bone graft is reported, and the clinical application in maxillofacial reconstructive surgery is described. This bone graft condensing system has advantages over the conventional plastic injection syringes in enabling much better bone graft condensation as well as easier bone delivery and insertion of the syringe to the depth of the reconstruction crib.
INTRODUCTION
of stainless steel of surgical quality (304 stainless steel). There are 2 patterns of bone syringes available, both are of similar design and length but of different diameter. The basic design of the syringe has 3 components: a cylindrical body, a plunger, and a screw-on cap (Fig. 1 A & B). The syringe body is 10 cm long in the form of a hollow tube with a smooth internal surface and a screw thread design on its mid external surface. The plunger fits into the whole length of the syringe body and has a flat arm on its end to facilitate its plunging action. The. cap fits on the opposite end and has a few internal threads which couple with the thread on the external syringe body. The cap has a small nozzle of 2 mm internal diameter at its end to facilitate extrusion of air and marrow fluid during loading. The syringes are of 2 sizes, the internal body diameter of the small syringe is 7 mm and that of the large syringe is 14 mm (Fig. 1C). The set has 6 bone syringes of which 4 are small and 2 are large. A metallic funnel which fits on the plunger end of the syringe is designed to speed up the loading of bone chips into the syringe. The plugger design is simple, and has a tapered hexagonal handle and a solid cylindrical tube of 8 cm attached to its end. The pluggers are either straight or curved. The set has 5 straight pluggers of different diameters: 3, 5, 7, 10, and 14 mm; and the 2 curved pluggers are 3 and 5 mm in diameter (Fig. 1D). The clinical application of this bone graft condensing syringe system is facilitated by having 2 surgical teams. The team which has completed harvesting the autogenous bone will prepare the graft by chipping it into particulate form with bone shears. The cap is initially screwed on the syringe and the funnel is fitted on the plugger end. The bone chips are then poured into the funnel and gradually condensed with the plunger. The same process is repeated for the other small syringes. If the large syringes are to be used, the chips can easily be placed into the syringe body directly. When the jaw crib is stabilised into position
In osseous reconstruction of the jaws with a crib system, good condensation of the particulate bone is essential for a successful outcome.1-4 The harvested autogeneous bone graft is usually chipped into particulate form either by cutting shears or by bone milling machine. These bone chips are traditionally transferred to the reconstructive area by bone currettes and condensed with hand instruments. Plastic injectional syringes have been employed to deliver the bone particles, with the added advantage of condensing the bone chips prior to transfer to the recipient site. Following the condensing action by pressing the plunger and expressing the marrow Auid out from the syringe nozzle, the syringe end is cut open with a pair of large bone shears since the syringe plastic is too tough to cut even by surgical scalpel. This manoevure is quite forceful and results in a ragged syringe end and wastage of some of the bone chips. The size of these syringes also does not adapt well to reconstruction of the jaws. Although the diameter of a 10 ml syringe allows its insertion into the crib, the length is too short and may not reach the required depth, also, the volume of bone chips delivered at each transfer is small. On the other hand, a 20 ml syringe may deliver more bone, but the diameter is too large to insert into the crib causing the bone chips to be extruded outside the crib opening, to be then pushed into the crib by hand instruments thus losing the condensation effect. To our knowledge, no bone syringe system is available on the market, hence a set of metallic syringes and pluggers has been specifically designed for maxillofacial reconstructive surgical procedures. MATERIALS
AND METHODS
The bone graft condensing syringe system consists of 6 metallic syringes and 7 pluggers. They are all made 261
268
British
Journal
of Oral
and Maxillofacial
Surgery
Fig. 1 - Bone graft condensing syringe system. Fig. 1(A) - A standard bone syringe consists of a body, cap and plunger. Fig. 1 (B) - A cross-sectional diagram of a bone syringe. Fig. l(C) - From the left to right, a small syringe fitted with a funnel, a small syringe, and a large syringe. Fig. l(D) - A standard set consists of 5 straight and 2 curved pluggers of varying sizes.
after the resection, the bone graft team will transfer the syringes filled with bone one by one to the reconstruction team, who will then deliver the graft to the recipient site. Immediately prior to the transfer, the caps are unscrewed and taken away from the syringes. The reconstructive surgeon then compresses the syringe and expresses the graft out by filling initially at the crib-residual bone junction. The bone is delivered in bolus form, and this is immediately followed by further condensation with a suitable sized plugger. The reconstructive crib of either the maxilla or mandible will be gradually packed from its depth to the surface in an alternating sequence of bone delivery and condensation (Figs 2 & 3). DISCUSSION
There are good biological reasons for having a bone graft syringe system which is able to condense the graft to a high density in jaw reconstruction. The two-phase theory of osteogenesis, originally proposed by Axhausen,’ is still well supported. This theory stated that bone regeneration in autogenous grafting is initiated by having osteoblasts which survive through the transplantation procedure and on to form new osteoid. The bone formed during this first phase is immature and arranged in a haphazard
manner. The second phase consists of osteogenesis derived from cells of the connective tissue bed and residual bone at the recipient site. The second phase involves resorption and remodelling, whereby the immature bone formed in phase one is replaced by mature organized osteons. The first phase of bone regeneration is clinically important because it dictates the ultimate quantity of bone that the graft will form.’ The second phase does not actually produce further bone volume, but rather just replaces the phase-one bone. The surgeon can therefore enhance phase-one bone formation by condensing the graft material to a high cellular and bone density during the reconstruction procedure which will lead to an improved result. This metallic syringe system has significant advantages over the plastic injection syringes in enabling much better bone graft condensation by easier bone delivery and insertion of the syringe to the depth of the reconstruction crib. Furthermore, there is added advantage in having a set of custom designed pluggers to facilitate further bony condensation in the crib. Counter support with the other hand during the condensing action is important to minimise loosening of the crib and shifting of the occlusion despite inter-maxillary fixation. The curved plugger is found useful particularly when bone has to be condensed around the corner through a window in the crib. This
A bone graft
condensing
Fig. 2 -Osseous reconstruction after maxillectomy via transoral approach. Fig. 2(A) - The right posterior maxilla was fitted with a custom-made titanium tray. Fig. 2(B) -Delivery of bone chips by metallic syringe via a tray window. Fig. 2(C) -The metallic crib is filled with well condensed bone chips.
bone syringe system is thought to be a convenient and useful additional option in the armamentarium of the maxillofacial reconstructive surgeon. Acknowledgement We would like to acknowledge Mr Material Science Unit in manufacturing
Tony Yuen the syringe
of the Dental system.
References 1. Marx RE, Kline S. Principles and methods of osseous reconstruction. Int Adv Surg Oncol 1983; 6: 167-228.
syringe
system
for maxillofacial
reconstructive
surgery
269
Fig. 3 -Osseous reconstruction after mandibulectomy via submandibular approach. Fig. 3(A) - Delivery of bone chips by syringe through a tray window to the depth of the metallic crib. Fig. 3(B) - Further condensation of bone chips with a curved plugger. Fig. 3(C) - Completion of osseous filling and the tray window closed by titanium wires.
2. Dumbach J, Steinhauser EW. Wiederherstellung der kontinuitat des unterkiefers mit dem Titan-Mesh System nach knochen-und weichteilnfektionen. Fortschr Kiefer Gesichtschir 1984; 29: 55557. 3. Tideman H, Samman N, Cheung LK. Immediate reconstruction following maxillectomy: a new method. Int J Oral Maxillofac Surg 1993; 22: 221-225. 4. Cheung LK, Samman N, Tong ACK, Tideman H. Mandibular reconstruction with the Dacron urethane tray: a radiologic assessment of bone remodelling. J Oral Maxillofac Surg 1994; 52: 373.-380. 5. Axhausen W. The osteogenetic phases of regeneration of bone,
270
British
Journal
of Oral
and Maxillofacial
Surgerv
a historical and experimental study. J Bon Jt Surg 1956; 38A: 593-601.
The Authors L.K. Cheung BDS, FDSRCS, FDSRCPS, FHKAM, FRACDS(OMS) Senior Lecturer, Department of Oral & Maxillofacial Surgery N. Samman BDS, LRCP, MRCS, FDSRCS, FHKAM Senior Lecturer, Department of Oral & Maxillofacial Surgery T.W. Chow BDS, MSc, LDS, DRDRCS, FRACDS, FHKAM Senior Lecturer, Department of Prosthetic Dentistry
R.K.F. Clark BDS, PhD, FDSRCPS, FHKAM Professor, Department of Prosthetic Dentistry H. Tideman MD, DDS, PhD, FRACDS, FHKAM Professor, Department of Oral & Maxillofacial Surgery University of Hong Kong Hong Kong Correspondence and requests for offprints to Dr L.K. Cheung, Department of Oral & Maxillofacial Surgery, University of Hong Kong, Hong Kong Paper received 24 May 1995 Accepted 7 December 1995