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Reconstruction of a maxillary defect using the remnant bone of mandibular angle ostectomy
Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, e189ee192
CASE REPORT
Reconstruction of a maxillary defect using the remnant bone of mandibular angle ostectomy Sang Wha Kim a, Yong Woo Lee b, Jeong Tae Kim b, Youn Hwan Kim b,* a
Department of Plastic and Reconstructive Surgery, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea b Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, 17 Haengdang-Dong, Seongdong-Gu, Seoul 133-792, Republic of Korea Received 6 January 2012; accepted 29 January 2012
KEYWORDS Maxillary fractures; Fractures; Comminuted; Fracture; Fixation
Summary The buttress is the cornerstone of the midface both functionally and aesthetically. Therefore, fracture of the buttress requires surgery. A patient wanted cosmetic surgery simultaneously with a reduction of facial bone fracture. To achieve this, we reconstructed the defect of the maxillary buttress using the remnant bone of the mandible angle ostectomy. A 27-year-old man presented with a left maxilla fracture and defect at the maxillary buttress. Since the patient was considering cosmetic surgery to alter his square face, we planned a mandibular angle ostectomy and used the remnant bone as an onlay bone graft for maxillary reconstruction. There was no complication and the patient was satisfied with both the functional and aesthetical look of the reconstructive surgery. We reconstructed the defect of the maxillary buttress successfully using the remnant bone of the mandible angle ostectomy. Although this technique cannot be applied to every patient, reconstruction of facial bone defects with the remnant bone of the mandibular angle ostectomy may be a potential option in some cases. ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Most midface fractures involve injury of the buttress. Fracture of the buttress often requires surgery since it is the cornerstone of the midface and functions to protect against external impact as well as aesthetically to maintain
the facial contour. Some patients who require surgery for the treatment of facial bone fractures also want cosmetic surgery, which is irrelevant to the fracture site or to the management of the fracture. Thus, in some cases, it may be
* Corresponding author. Tel.: þ82 2 2290 8560. E-mail address: [email protected] (Y.H. Kim). 1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2012.01.023
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S.W. Kim et al.
Figure 1 (a). A 27-years-old man presented with left maxilla fracture. The patient wanted to have the cosmetic surgery for square face at the same time. (b) Follow-up at 3 month, the patient satisfied functionally and aesthetically. (c) Radiologic examination revealed the large defect at maxillary buttress due to comminuted fracture. (d) 3 months after the operation, the defect of maxillary buttress was reconstructed successfully using the remnant bone of the mandible angle ostectomy. (e) The remnant bone from both mandibular angle. The size was enough to cover the defect of the maxillary buttress. (f). The outer cortex of remnant bone of mandible angle ostectomy was spitted and trimmed to appropriate size. Then it was fixed to the defect of maxilla using absorbable miniplate and screws.
Reconstruction of maxilla using bone after angle reduction
e191
advantageous for the patient to simultaneously undergo surgery for both cosmetic reasons and to treat the fracture, which could save time and money. We reconstructed the defect of the maxillary buttress due to comminution fractures successfully using the remnant bone of the mandible angle ostectomy.
reconstruction of maxillary bone defects smaller than 5 cm using a cortico-cancellous iliac crest bone graft.2 However, a bone graft from other parts requires additional surgical procedures, which result in a longer operating time and hospitalisation and donor-site morbidity cannot be avoided. In our case, we planned and recommend that the patient undergo open reduction and internal fixation with an onlay graft to treat the defect and the patient wanted to simultaneously alter his square jaw. Therefore, we used the remnant bone of the mandibular angle ostectomy to treat the fracture. Mandibular angle ostectomy and reconstruction of the maxillary bone was an easier approach than obtaining bone grafts from other sites since both operations were performed using the intraoral approach. The scar was invisible and, by using the remnant bone, donor-site morbidity was minimised. The remnant bone from the mandibular angle was enough in size to cover the defect of the maxillary buttress. Because the remnant bone mainly consists of cortical bone, it can endure the pressure from the outside even after it was trimmed to fit the defect. In addition, it can easily be fixed by screws when compared with the laminar bone. Moreover, cortical bone is less likely to have osteomyelitis than medullary bone, which makes it suitable as the donor of the onlay bone graft.3 The square face with prominent mandibular angles projects a strong and masculine impression but these facial contours are not appealing to many East Asians, who prefer a slender and oval face with smooth curves and outlines.4 There have been some reports where the remnant bone after mandibular angle ostectomy or zygoma reduction was used to augment the malar area or chin for aesthetic purposes. However, to the best of our knowledge, this is the first report where the remnant bone was used for the reconstruction of the maxillary defect after trauma.5 Although this technique cannot be applied to every patient, it is appropriate for patients who desire mandible angle ostectomy, reconstruction of a facial bone defect, which not only minimises donor-site morbidity of the bone graft but also achieves aesthetic satisfaction. We successfully reconstructed the defect of the maxillary buttress using the remnant bone of the mandible angle ostectomy. Although this case involved a defect in the maxillary anterior wall, we believe similar good functional and aesthetic results could be achieved when this approach is applied to other facial bone defects, such as defects in the orbital rim.
Case report A 27-year-old man presented with left maxilla fracture and a blowout fracture after trauma. Radiologic examination revealed the presence of a large defect at the maxillary buttress due to a comminuted fracture, which required an onlay bone graft for reconstruction. The patient was also considering cosmetic surgery to alter his square face and requested cosmetic surgery at the same time as the surgery required to treat the fracture. Therefore, we planned a mandibular angle ostectomy and an onlay bone graft using the remnant bone for maxillary reconstruction. The mandible angle ostectomy was performed under general anaesthesia using the intraoral approach. A 4 2 cm sized bone was removed. The maxillary fracture was also exposed using the intraoral approach. Using a reciprocating saw, the outer cortex of the remnant bone of the mandible angle ostectomy was spitted and trimmed to the appropriate size. It was then fixed to the defect of the maxilla using absorbable miniplate and screws (Figure 1). There was no infection or complications and the patient was discharged on the seventh day after the surgery. During a 3-month follow-up, no complications were observed and the patient was satisfied with both the functional and aesthetic look of the reconstructive surgery.
Discussion The shape and symmetry of the maxillary bone maintain the facial contour, which is important aesthetically. The anterior sinus wall of the maxilla consists of a thin bone that is not strong enough for loading. However, the inner wall of the sinus, lined by the mucosa, plays an important role in ventilation function and, if disrupted, complications, such as sinusitis or rhinitis, may result. On the other hand, the buttress of the maxillary bone functions as a strong support to protect important inner neurovascular structures, including the brain, from external force.1 Fracture of the maxillary bone is most frequently involved in midface trauma and the continuity and stability of this bone can be restored by open reduction and internal fixation using metallic or absorbable plates and screws. However, severe trauma can result in defects of the maxillary bone and even if without the defect, small bony pieces after comminuted fracture are difficult to fixate, which lead to defects of the bone. To cover the defect, bony lamella is rebuilt in some cases when the defect is small, but the defect is more commonly consolidated with a combination of connective and scar tissue. However, this is unstable and unsuitable especially for the buttress, which requires a strong support.1 To re-establish bony continuity and stability, onlay bone grafts, such as an iliac crest bone graft, calvarial bone graft and rib bone graft, have been used. Pedro et al. reported successful
Financial disclosure The authors have no financial interest in the products, devices or drugs mentioned in this article.
Acknowledgement None.
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References 1. Ballon A, Landes CA, Zeilhofer HF, et al. The importance of the primary reconstruction of the traumatized anterior maxillary sinus wall. J Craniofac Surg 2008;19: 505e9. 2. Infante-Cossı´o P, Martı´nez-de-Fuentes R, Garcı´a-Perla-Garcı´a A, Jime ´nez-Castellanos E, Go ´mez-Izquierdo L. Myxofibroma of the maxilla. Reconstruction with iliac crest graft and dental
S.W. Kim et al. implants after tumor resection. Med Oral Patol Oral Cir Bucal 2011;16:e532e6. 3. Dalgorf D, Higgins K. Reconstruction of the midface and maxilla. Curr Opin Otolaryngol Head Neck Surg 2008;16:303e11. 4. Khadka A, Hsu Y, Hu J, et al. Clinical observations of correction of square jaw in East Asian individuals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:428e34. 5. Layoun W, Guyot L, Richard O, Gola R. Augmentation of cheek bone contour using malar osteotomy. Aesthetic Plast Surg 2003; 27:269e74.
CASE REPORT
Reconstruction of a maxillary defect using the remnant bone of mandibular angle ostectomy Sang Wha Kim a, Yong Woo Lee b, Jeong Tae Kim b, Youn Hwan Kim b,* a
Department of Plastic and Reconstructive Surgery, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea b Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, 17 Haengdang-Dong, Seongdong-Gu, Seoul 133-792, Republic of Korea Received 6 January 2012; accepted 29 January 2012
KEYWORDS Maxillary fractures; Fractures; Comminuted; Fracture; Fixation
Summary The buttress is the cornerstone of the midface both functionally and aesthetically. Therefore, fracture of the buttress requires surgery. A patient wanted cosmetic surgery simultaneously with a reduction of facial bone fracture. To achieve this, we reconstructed the defect of the maxillary buttress using the remnant bone of the mandible angle ostectomy. A 27-year-old man presented with a left maxilla fracture and defect at the maxillary buttress. Since the patient was considering cosmetic surgery to alter his square face, we planned a mandibular angle ostectomy and used the remnant bone as an onlay bone graft for maxillary reconstruction. There was no complication and the patient was satisfied with both the functional and aesthetical look of the reconstructive surgery. We reconstructed the defect of the maxillary buttress successfully using the remnant bone of the mandible angle ostectomy. Although this technique cannot be applied to every patient, reconstruction of facial bone defects with the remnant bone of the mandibular angle ostectomy may be a potential option in some cases. ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Most midface fractures involve injury of the buttress. Fracture of the buttress often requires surgery since it is the cornerstone of the midface and functions to protect against external impact as well as aesthetically to maintain
the facial contour. Some patients who require surgery for the treatment of facial bone fractures also want cosmetic surgery, which is irrelevant to the fracture site or to the management of the fracture. Thus, in some cases, it may be
* Corresponding author. Tel.: þ82 2 2290 8560. E-mail address: [email protected] (Y.H. Kim). 1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2012.01.023
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S.W. Kim et al.
Figure 1 (a). A 27-years-old man presented with left maxilla fracture. The patient wanted to have the cosmetic surgery for square face at the same time. (b) Follow-up at 3 month, the patient satisfied functionally and aesthetically. (c) Radiologic examination revealed the large defect at maxillary buttress due to comminuted fracture. (d) 3 months after the operation, the defect of maxillary buttress was reconstructed successfully using the remnant bone of the mandible angle ostectomy. (e) The remnant bone from both mandibular angle. The size was enough to cover the defect of the maxillary buttress. (f). The outer cortex of remnant bone of mandible angle ostectomy was spitted and trimmed to appropriate size. Then it was fixed to the defect of maxilla using absorbable miniplate and screws.
Reconstruction of maxilla using bone after angle reduction
e191
advantageous for the patient to simultaneously undergo surgery for both cosmetic reasons and to treat the fracture, which could save time and money. We reconstructed the defect of the maxillary buttress due to comminution fractures successfully using the remnant bone of the mandible angle ostectomy.
reconstruction of maxillary bone defects smaller than 5 cm using a cortico-cancellous iliac crest bone graft.2 However, a bone graft from other parts requires additional surgical procedures, which result in a longer operating time and hospitalisation and donor-site morbidity cannot be avoided. In our case, we planned and recommend that the patient undergo open reduction and internal fixation with an onlay graft to treat the defect and the patient wanted to simultaneously alter his square jaw. Therefore, we used the remnant bone of the mandibular angle ostectomy to treat the fracture. Mandibular angle ostectomy and reconstruction of the maxillary bone was an easier approach than obtaining bone grafts from other sites since both operations were performed using the intraoral approach. The scar was invisible and, by using the remnant bone, donor-site morbidity was minimised. The remnant bone from the mandibular angle was enough in size to cover the defect of the maxillary buttress. Because the remnant bone mainly consists of cortical bone, it can endure the pressure from the outside even after it was trimmed to fit the defect. In addition, it can easily be fixed by screws when compared with the laminar bone. Moreover, cortical bone is less likely to have osteomyelitis than medullary bone, which makes it suitable as the donor of the onlay bone graft.3 The square face with prominent mandibular angles projects a strong and masculine impression but these facial contours are not appealing to many East Asians, who prefer a slender and oval face with smooth curves and outlines.4 There have been some reports where the remnant bone after mandibular angle ostectomy or zygoma reduction was used to augment the malar area or chin for aesthetic purposes. However, to the best of our knowledge, this is the first report where the remnant bone was used for the reconstruction of the maxillary defect after trauma.5 Although this technique cannot be applied to every patient, it is appropriate for patients who desire mandible angle ostectomy, reconstruction of a facial bone defect, which not only minimises donor-site morbidity of the bone graft but also achieves aesthetic satisfaction. We successfully reconstructed the defect of the maxillary buttress using the remnant bone of the mandible angle ostectomy. Although this case involved a defect in the maxillary anterior wall, we believe similar good functional and aesthetic results could be achieved when this approach is applied to other facial bone defects, such as defects in the orbital rim.
Case report A 27-year-old man presented with left maxilla fracture and a blowout fracture after trauma. Radiologic examination revealed the presence of a large defect at the maxillary buttress due to a comminuted fracture, which required an onlay bone graft for reconstruction. The patient was also considering cosmetic surgery to alter his square face and requested cosmetic surgery at the same time as the surgery required to treat the fracture. Therefore, we planned a mandibular angle ostectomy and an onlay bone graft using the remnant bone for maxillary reconstruction. The mandible angle ostectomy was performed under general anaesthesia using the intraoral approach. A 4 2 cm sized bone was removed. The maxillary fracture was also exposed using the intraoral approach. Using a reciprocating saw, the outer cortex of the remnant bone of the mandible angle ostectomy was spitted and trimmed to the appropriate size. It was then fixed to the defect of the maxilla using absorbable miniplate and screws (Figure 1). There was no infection or complications and the patient was discharged on the seventh day after the surgery. During a 3-month follow-up, no complications were observed and the patient was satisfied with both the functional and aesthetic look of the reconstructive surgery.
Discussion The shape and symmetry of the maxillary bone maintain the facial contour, which is important aesthetically. The anterior sinus wall of the maxilla consists of a thin bone that is not strong enough for loading. However, the inner wall of the sinus, lined by the mucosa, plays an important role in ventilation function and, if disrupted, complications, such as sinusitis or rhinitis, may result. On the other hand, the buttress of the maxillary bone functions as a strong support to protect important inner neurovascular structures, including the brain, from external force.1 Fracture of the maxillary bone is most frequently involved in midface trauma and the continuity and stability of this bone can be restored by open reduction and internal fixation using metallic or absorbable plates and screws. However, severe trauma can result in defects of the maxillary bone and even if without the defect, small bony pieces after comminuted fracture are difficult to fixate, which lead to defects of the bone. To cover the defect, bony lamella is rebuilt in some cases when the defect is small, but the defect is more commonly consolidated with a combination of connective and scar tissue. However, this is unstable and unsuitable especially for the buttress, which requires a strong support.1 To re-establish bony continuity and stability, onlay bone grafts, such as an iliac crest bone graft, calvarial bone graft and rib bone graft, have been used. Pedro et al. reported successful
Financial disclosure The authors have no financial interest in the products, devices or drugs mentioned in this article.
Acknowledgement None.
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References 1. Ballon A, Landes CA, Zeilhofer HF, et al. The importance of the primary reconstruction of the traumatized anterior maxillary sinus wall. J Craniofac Surg 2008;19: 505e9. 2. Infante-Cossı´o P, Martı´nez-de-Fuentes R, Garcı´a-Perla-Garcı´a A, Jime ´nez-Castellanos E, Go ´mez-Izquierdo L. Myxofibroma of the maxilla. Reconstruction with iliac crest graft and dental
S.W. Kim et al. implants after tumor resection. Med Oral Patol Oral Cir Bucal 2011;16:e532e6. 3. Dalgorf D, Higgins K. Reconstruction of the midface and maxilla. Curr Opin Otolaryngol Head Neck Surg 2008;16:303e11. 4. Khadka A, Hsu Y, Hu J, et al. Clinical observations of correction of square jaw in East Asian individuals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:428e34. 5. Layoun W, Guyot L, Richard O, Gola R. Augmentation of cheek bone contour using malar osteotomy. Aesthetic Plast Surg 2003; 27:269e74.