- Email: [email protected]
Reconstruction of a Post-Traumatic Maxillary Ridge Using a Radial Forearm Free Flap and Immediate Tissue Engineering (Bone Morphogenetic Protein, Bone Marrow Aspirate Concentrate, and Cortical-Cancellous Bone): Case Report
Accepted Manuscript Reconstruction of a post-traumatic maxillary ridge using a radial forearm free flap and immediate tissue engineering (Bone Morphogenetic Protein, Bone Marrow Aspirate concentrate and Cortical-cancellous Bone). Case report James C. Melville, DDS FACS, Ramzey Tursun, DDS, J. Marshall Green, III, DDS, Robert E. Marx, DDS PII:
S0278-2391(16)31098-9
DOI:
10.1016/j.joms.2016.11.001
Reference:
YJOMS 57533
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 16 August 2016 Revised Date:
1 November 2016
Accepted Date: 1 November 2016
Please cite this article as: Melville JC, Tursun R, Green III JM, Marx RE, Reconstruction of a posttraumatic maxillary ridge using a radial forearm free flap and immediate tissue engineering (Bone Morphogenetic Protein, Bone Marrow Aspirate concentrate and Cortical-cancellous Bone). Case report, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.11.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
RI PT
Reconstruction of a post-traumatic maxillary ridge using a radial forearm free flap and immediate tissue engineering (Bone Morphogenetic Protein, Bone Marrow Aspirate concentrate and Cortical-cancellous Bone). Case report. James C. Melville DDS FACS, Ramzey Tursun DDS, J. Marshall Green, III DDS, Robert E Marx DDS
M AN U
SC
James C. Melville, DDS FACS* University of Texas Health Sciences Center at Houston School of Dentistry Assistant Professor Oral and Maxillofacial Surgery Head and Neck Oncology and Microvascular Surgery 7500 Cambridge St Suite 6510 Houston, TX 77054 [email protected]
TE D
Ramzey Tursun, DDS University of Miami/Jackson Memorial Hospital Assistant Professor Oral and Maxillofacial Surgery
EP
J. Marshall Green III, DDS Staff Surgeon, Naval Medical Center Portsmouth, Portsmouth, VA; Assistant Professor of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
AC C
Robert E. Marx, DDS University of Miami/Jackson Memorial Hospital Professor and Chief Oral and Maxillofacial Surgery
*Corresponding author Disclosure: Dr. Robert E. Marx is a consultant of Medtronics and Harvest Technologies Scientific Poster was presented at the 97th American Association of Oral and Maxillofacial Surgeons Conference in Washington DC on September 28 to October 3, 2015
ACCEPTED MANUSCRIPT
RI PT
Reconstruction of a post-traumatic maxillary ridge using a radial forearm free flap and immediate tissue engineering (Bone Morphogenetic Protein, Bone Marrow Aspirate concentrate and Cortical-cancellous Bone). Case report. James C. Melville DDS FACS, Ramzey Tursun DDS, Marshall Green, J. III,
SC
Robert E Marx DDS
M AN U
Introduction
The purpose of this case report is to describe a reconstruction of a post traumatic maxillary alveolar ridge defect using a microvascular free flap combined with an immediate avascular allogeneic bone graft with bone morphogenetic protein (rhBMP-2)
TE D
and bone marrow aspirate concentrate (BMAC). We believe this is the first published case describing such a technique to reconstruct a maxillary alveolus. Per the University of Miami Institutional Review Board (IRB) policy, case reports and case series of 3 patients
EP
or less are exempt and do not require IRB approval. Appropriate consents were obtained
AC C
from the patient in this case report.
Case Presentation
A 45-year -old female presented to the University of Miami/ Jackson Memorial Hospital Department of Oral and Maxillofacial Surgery four months after a motor vehicle accident and subsequent repair of her facial fractures at another institution. On initial presentation to our department, the patient was noted to have deficient projection of the left malar
1
ACCEPTED MANUSCRIPT
region, loss of left maxillary ridge alveolar bone, loss of dentition and upper eyelid ptosis, and lower eyelid ectropion. A series of surgeries were planned for the complete reconstruction of her facial cosmesis but the first planned surgery was to reconstruct her
RI PT
alveolar bone height and restore her dentition with endosteal implants. Due to her
alvusive injury to her anterior left maxillary alveolus she was missing teeth #9 thru #13 (left maxillary central incisor thru second premolar) . (Fig. 1A) (Fig 1B) (Fig. 2) She
SC
also lacked the soft tissue for a tradition block bone graft or an only graft. A thorough
discussion of treatment options including All-on-4 restoration option verses full mouth
M AN U
extraction and complete dentures verses bone grafting and placement of implants. The patient opted for the bone graft since she would not agree to having her remaining teeth extracted.
TE D
Various osteocutaneous microvascular flaps were considered such as the free fibula flap and osteocutaneous radial forearm flap but all were too bulky and or incorrect geometric shape for the defect. After careful consideration and a thorough discussion with the
EP
patient we decided on a novel reconstruction using a radial forearm free flap combined with a tissue engineered bone graft consisting of allogeneic bone, rhBMP-2 and BMAC.
AC C
A modified Allen’s test was preformed to confirm that the ulnar artery had adequate perfusion for the entire hand, which was positive (normal). The surgery consisted of 2 teams, one exposing and preparing the alveolar defect as well as harvesting the BMAC form the iliac crest. The second team harvesting the radial form arm which was under tourniquet pressure to minimize blood loss and maximize visualization. The radial forearm skin paddle and pedicle (radial artery and vena commitants) were raised
2
ACCEPTED MANUSCRIPT
inbetween the brachioradialis muscle and flexor carpi radialis to the antidecubital fossa to gain adequate pedicle length. Once the radial forearm flap was harvested the radial artery was anastomosed to left facial artery and vena commitants anastomosed to the facial vein.
RI PT
The area of the left maxillary ridge was denuded of its scar tissue and remaining bone was exposed (Fig 3). 30 mL of crushed corticocancellous bone (University of Miami Tissue Bank, Miami, FL), a small rh-BMP2 (Infuse) kit (Medtronic Sofamor Danek,
SC
Memphis, TN) was mixed with 60 BMAC. The tissue engineered graft was placed and
packed on to the defect with SonicWeld Resorb x®, a 100 % amorphous, non-crystalline
M AN U
poly D, L-lactic acid (PDLLA) mesh (KLS Martin, Jacksonville, FL). (Fig. 4) (Fig .5) The radial forearm flap was then sutured around and over the graft (Fig. 6). With an uneventful post-op course the patient was discharged in 6 days. After 6 months, the bone graft demonstrated ossification and consolidation on CBCT for placement of
TE D
dental implants. The flap was viable with good perfusion and Doppler signal through out the 6 months. Clinically, the reconstructed alveolar ridge showed excellent height and ridge, and the skin of the radial forearm flap mucosalized (Fig.
EP
6). (Fig. 7) Three dental implants were placed in solid bone (Fig. 8) (Fig. 9); at the same time a vestibuloplasty was preformed using a split thickness skin graft from
AC C
the thigh. (Fig. 10)(Fig. 11) The patient was referred to a maxillofacial prosthodontist for a fixed partial denture for the reconstructed ridge.
Discussion
3
ACCEPTED MANUSCRIPT
The treatment plan for maxillary defects, both post-traumatic and post-oncologic, is determined by the amount of tissue loss and the location of the defect. Nonvascularized alveolar block bone grafts have been successful but requires adequate soft
RI PT
tissue1,2.
Composite free vascular grafts, such as the fibula3,4,5 and the DCIA (deep circumflex
for segmental alveolar ridge reconstruction.
SC
iliac artery) flap,6 have a solid track record for reconstruction of maxilla but are too large
The osteocutanous radial forearm free flap has been used to reconstruct limited
M AN U
low-level defects with a considerable soft tissue component.7 However, the flap’s inadequacy to repair large volume defects and limited bone stock (recommendations have been made to take only 30% of the cross-sectional area to avoid post-operative radius fracture) make it less than ideal for the placement of dental implants and prevent it from
TE D
being the first choice in many maxillary reconstructions.8,9
Our choice for reconstruction was the radial forearm fasciocutaneous flap combined with an immediate tissue engineered graft using allogeneic bone, BMP and
EP
BMAC. This combination provides us ample soft tissue with the ability mold to the exact specifications of our defect. The radial forearm fasciocutaneous flap is the most reliable
AC C
and versatile flap for head and neck reconstruction of small to medium defects10. The radial forearm flap was first developed and described by Song, et el., in China as a fasciocutaneous flap in 198211. It also has proven track record for soft tissue maxillary reconstruction12,13. The desirable traits of the flap include ease of harvest, low donor morbidity, flap skin is thin and pliable and the vessels (radial artery, cephalic vein and or vena comitantes) that are long pedicle and large in caliber14. The Allen test is the most
4
ACCEPTED MANUSCRIPT
important preoperative evaluation to assess the adequacy of the circulation to the hand through the ulnar artery in avoiding the catastrophic complication of an ischemic hand15. The use of in-situ tissue engineered graft containing allogeneic bone, BMP and
RI PT
BMAC reported extensively for both immediate maxillofacial reconstruction,16,17 but use of it combined with a free flap is limited. Kim, et al, described a technique of using a fibula free flap combined with tissue engineering to reconstruct after resection of a
SC
ameloblastoma18. Warnke et al. described a use of a tissue-engineered graft implanted in the latissumus dorsi to create a prefabricated vascular graft to reconstruct a mandible19.
M AN U
The biggest concern with the combination of a graft continuing BMP and a free flap is the postoperative edema20 that can cause an increase in vascular resistance leading to flap failure. Due to the pliability of the skin and large caliber vessel the radial forearm is more accommodating to the edema. There was no compromise in vascular perfusion and the
TE D
viability of the flap through out its post op course.
Although the radial forearm is the most reliable flap in head and neck reconstruction, it is critically important to have a thorough discussion of the associated
EP
risks, complications and alternatives before proceeding with the procedure. The complications include unsightly scar of the donor site, skin graft failure, tendon
AC C
exposure, dysesthesia, reduced strength and sensation, motor nerve damage to the hand, cold-induced symptoms, swelling of the hand, stiffness of joints and fractures of the radius and ischemic hand.21,22 A post-traumatic maxillary alveolar ridge can be a challenge to reconstruct due to the lack of healthy soft tissue, fibrosis of existing tissue, and the proximity of the nasal floor. A traditional reconstruction technique such as avascular bone grafting requires soft
5
ACCEPTED MANUSCRIPT
tissue to adequately cover the graft. Unfortunately, the remaining soft tissue is often scarred, inadequate, or absent in post-traumatic or post-oncologic defects. Alternatively, osteocutaneous flaps such as the free fibula provide both vascular soft
RI PT
tissue and bone, but these flaps often contain too much bulk for proper prosthetic
restoration. This case report demonstrates a novel technique for reconstructing these
difficult defects with a combination of free vascular tissue transfer and avascular bone
M AN U
into the correct anatomic position for restorative needs.
SC
graft utilizing in situ tissue engineering, allowing the bone to be molded and contoured
Disclosure:
1
TE D
Dr. Robert E. Marx is a consultant of Medtronics and Harvest Technologies
Barone, Antonio, and Ugo Covani. "Maxillary alveolar ridge reconstruction with nonvascularized autogenous block bone: clinical results." Journal of Oral and Maxillofacial Surgery 65.10 (2007): 2039-2046. 2
3
EP
Schwartz-Arad, Devorah, and Liran Levin. "Intraoral autogenous block onlay bone grafting for extensive reconstruction of atrophic maxillary alveolar ridges." Journal of periodontology 76.4 (2005): 636-641.
4
AC C
Schwartz-Arad, Devorah, and Liran Levin. "Intraoral autogenous block onlay bone grafting for extensive reconstruction of atrophic maxillary alveolar ridges." Journal of periodontology 76.4 (2005): 636-641. Wei, Fu-Chan, et al. "Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects." Plastic and reconstructive surgery 93.2 (1994): 294-304. 5
Futran, Neal D., et al. "Midface reconstruction with the fibula free flap." Archives of Otolaryngology–Head & Neck Surgery 128.2 (2002): 161-166. 6
Maranzano, Massimo, and Andrea Atzei. "The versatility of vascularized iliac crest with internal oblique muscle flap for composite upper maxillary reconstruction." Microsurgery 27.1 (2007): 37-42.
6
ACCEPTED MANUSCRIPT
7
Villaret, Douglas B., and Neal A. Futran. "The indications and outcomes in the use of osteocutaneous radial forearm free flap." Head & neck 25.6 (2003): 475-481. 8
RI PT
Cordeiro, Peter G., Norma Bacilious, and Ronald Spiro. "The radial forearm osteocutaneous" sandwich" free flap for reconstruction of the bilateral subtotal maxillectomy defect." Annals of plastic surgery 40.4 (1998): 397-402. 9 Triana, Rudy J., et al. "Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects." Archives of facial plastic surgery 2.2 (2000): 91-101. 10
Soutar, D. S., et al. "The radial forearm flap: a versatile method for intra-oral reconstruction." British journal of plastic surgery 36.1 (1983): 1-8. Song R, Gao Y, Song Y, Y Yum, Song Y. The forearm flap. Clin. Plast. Surg. 1982;9:21–26
SC
11
12
M AN U
Genden, Eric M., et al. "Reconstruction of the hard palate using the radial forearm free flap: indications and outcomes." Head & neck 26.9 (2004): 808-814. 13
Muzaffar, Arshad R., et al. "Maxillary reconstruction: functional and aesthetic considerations." Plastic and reconstructive surgery 104.7 (1999): 2172-2183. 14
Moscoso, Juan F., and Mark L. Urken. "Radial forearm flaps." Otolaryngologic clinics of North America 27.6 (1994): 1119-1140. 15
Urken ML, Cheney ML, Sullivan MJ, Biller HF, Habal MB. Atlas of regional and free flaps for head and neck reconstruction. Journal of Craniofacial Surgery. 1995 Sep 1;6(5):424. 16
17
TE D
Spagnoli, Daniel B. "The application of recombinant human bone morphogenetic protein on absorbable collagen sponge (rhBMP-2/ACS) to reconstruction of maxillofacial bone defects." Bone Morphogenetic proteins: from local to systemic therapeutics. Birkhäuser Basel, 2008. 4370.
18
EP
Marx, Robert E., and David B. Harrell. "Translational research: The CD34+ cell is crucial for large-volume bone regeneration from the milieu of bone marrow progenitor cells in craniomandibular reconstruction." Oral & Craniofacial Tissue Engineering 2.4 (2012).
19
AC C
Kim, Beomjune. "Hybrid mandibular reconstruction technique: Preliminary case series of prosthetically-driven vascularized fibula free flap combined with tissue engineering and virtual surgical planning." 2014 Annual Meeting. AAOMS, 2014. Warnke PH, Springer IN, Wiltfang J, Acil Y, Eufinger H, Wehmoller M, et al. Growth and transplantation of a custom vascularised bone graft in a man. Lancet 364:766-770. 2004 20 Perri, Brian, et al. "Adverse swelling associated with use of rh-BMP-2 in anterior cervical discectomy and fusion: a case study." The Spine Journal 7.2 (2007): 235-239. 21
Timmons, M. J., et al. "Complications of radial forearm flap donor sites." British journal of plastic surgery 39.2 (1986): 176-178. 22
Swanson, Eric, J. Brian Boyd, and Ralph T. Manktelow. "The radial forearm flap: reconstructive applications and donor-site defects in 35 consecutive patients." Plastic and reconstructive surgery 85.2 (1990): 258-272.
7
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ACCEPTED MANUSCRIPT
FIGURE LEGAND
SC
Figure 1 A: Loss of left maxillary alveolar ridge with teeth #9 thru #13 (left maxillary central incisor thru second premolar)
M AN U
Figure 1B: Post-traumatic defect with fibrous scar tissue Figure 2: Panorex on initial visit
Figure 3: Exposure of alveolar defect
Figure 4: Poly-DL-Lactic Acid mesh carrier
TE D
Figure 5: BMP+BMAC+allogeneic bone
Figure 6: Radial forearm flap positioned over the tissue engineered bone graft
AC C
EP
Figure 7: Cone beam computed tomography 5 months post-op imaging demonstrating consolidation and maturation of avascular bone graft underneath radial forearm flap Figure 8: 6 months s/p RFFF+bone graft+BMP+BMAC Figure 9: Debulking of skin paddle showing excellent ridge formation Figure 10: Placement of 3 endosteal implants into the reconstructed alveolar ridge Figure 11: Cone beam computed tomography of endosteal implants in reconstructed maxillary ridge, 1-week post op.
8
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EP
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SC
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ACCEPTED MANUSCRIPT
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S0278-2391(16)31098-9
DOI:
10.1016/j.joms.2016.11.001
Reference:
YJOMS 57533
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 16 August 2016 Revised Date:
1 November 2016
Accepted Date: 1 November 2016
Please cite this article as: Melville JC, Tursun R, Green III JM, Marx RE, Reconstruction of a posttraumatic maxillary ridge using a radial forearm free flap and immediate tissue engineering (Bone Morphogenetic Protein, Bone Marrow Aspirate concentrate and Cortical-cancellous Bone). Case report, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.11.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
RI PT
Reconstruction of a post-traumatic maxillary ridge using a radial forearm free flap and immediate tissue engineering (Bone Morphogenetic Protein, Bone Marrow Aspirate concentrate and Cortical-cancellous Bone). Case report. James C. Melville DDS FACS, Ramzey Tursun DDS, J. Marshall Green, III DDS, Robert E Marx DDS
M AN U
SC
James C. Melville, DDS FACS* University of Texas Health Sciences Center at Houston School of Dentistry Assistant Professor Oral and Maxillofacial Surgery Head and Neck Oncology and Microvascular Surgery 7500 Cambridge St Suite 6510 Houston, TX 77054 [email protected]
TE D
Ramzey Tursun, DDS University of Miami/Jackson Memorial Hospital Assistant Professor Oral and Maxillofacial Surgery
EP
J. Marshall Green III, DDS Staff Surgeon, Naval Medical Center Portsmouth, Portsmouth, VA; Assistant Professor of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD
AC C
Robert E. Marx, DDS University of Miami/Jackson Memorial Hospital Professor and Chief Oral and Maxillofacial Surgery
*Corresponding author Disclosure: Dr. Robert E. Marx is a consultant of Medtronics and Harvest Technologies Scientific Poster was presented at the 97th American Association of Oral and Maxillofacial Surgeons Conference in Washington DC on September 28 to October 3, 2015
ACCEPTED MANUSCRIPT
RI PT
Reconstruction of a post-traumatic maxillary ridge using a radial forearm free flap and immediate tissue engineering (Bone Morphogenetic Protein, Bone Marrow Aspirate concentrate and Cortical-cancellous Bone). Case report. James C. Melville DDS FACS, Ramzey Tursun DDS, Marshall Green, J. III,
SC
Robert E Marx DDS
M AN U
Introduction
The purpose of this case report is to describe a reconstruction of a post traumatic maxillary alveolar ridge defect using a microvascular free flap combined with an immediate avascular allogeneic bone graft with bone morphogenetic protein (rhBMP-2)
TE D
and bone marrow aspirate concentrate (BMAC). We believe this is the first published case describing such a technique to reconstruct a maxillary alveolus. Per the University of Miami Institutional Review Board (IRB) policy, case reports and case series of 3 patients
EP
or less are exempt and do not require IRB approval. Appropriate consents were obtained
AC C
from the patient in this case report.
Case Presentation
A 45-year -old female presented to the University of Miami/ Jackson Memorial Hospital Department of Oral and Maxillofacial Surgery four months after a motor vehicle accident and subsequent repair of her facial fractures at another institution. On initial presentation to our department, the patient was noted to have deficient projection of the left malar
1
ACCEPTED MANUSCRIPT
region, loss of left maxillary ridge alveolar bone, loss of dentition and upper eyelid ptosis, and lower eyelid ectropion. A series of surgeries were planned for the complete reconstruction of her facial cosmesis but the first planned surgery was to reconstruct her
RI PT
alveolar bone height and restore her dentition with endosteal implants. Due to her
alvusive injury to her anterior left maxillary alveolus she was missing teeth #9 thru #13 (left maxillary central incisor thru second premolar) . (Fig. 1A) (Fig 1B) (Fig. 2) She
SC
also lacked the soft tissue for a tradition block bone graft or an only graft. A thorough
discussion of treatment options including All-on-4 restoration option verses full mouth
M AN U
extraction and complete dentures verses bone grafting and placement of implants. The patient opted for the bone graft since she would not agree to having her remaining teeth extracted.
TE D
Various osteocutaneous microvascular flaps were considered such as the free fibula flap and osteocutaneous radial forearm flap but all were too bulky and or incorrect geometric shape for the defect. After careful consideration and a thorough discussion with the
EP
patient we decided on a novel reconstruction using a radial forearm free flap combined with a tissue engineered bone graft consisting of allogeneic bone, rhBMP-2 and BMAC.
AC C
A modified Allen’s test was preformed to confirm that the ulnar artery had adequate perfusion for the entire hand, which was positive (normal). The surgery consisted of 2 teams, one exposing and preparing the alveolar defect as well as harvesting the BMAC form the iliac crest. The second team harvesting the radial form arm which was under tourniquet pressure to minimize blood loss and maximize visualization. The radial forearm skin paddle and pedicle (radial artery and vena commitants) were raised
2
ACCEPTED MANUSCRIPT
inbetween the brachioradialis muscle and flexor carpi radialis to the antidecubital fossa to gain adequate pedicle length. Once the radial forearm flap was harvested the radial artery was anastomosed to left facial artery and vena commitants anastomosed to the facial vein.
RI PT
The area of the left maxillary ridge was denuded of its scar tissue and remaining bone was exposed (Fig 3). 30 mL of crushed corticocancellous bone (University of Miami Tissue Bank, Miami, FL), a small rh-BMP2 (Infuse) kit (Medtronic Sofamor Danek,
SC
Memphis, TN) was mixed with 60 BMAC. The tissue engineered graft was placed and
packed on to the defect with SonicWeld Resorb x®, a 100 % amorphous, non-crystalline
M AN U
poly D, L-lactic acid (PDLLA) mesh (KLS Martin, Jacksonville, FL). (Fig. 4) (Fig .5) The radial forearm flap was then sutured around and over the graft (Fig. 6). With an uneventful post-op course the patient was discharged in 6 days. After 6 months, the bone graft demonstrated ossification and consolidation on CBCT for placement of
TE D
dental implants. The flap was viable with good perfusion and Doppler signal through out the 6 months. Clinically, the reconstructed alveolar ridge showed excellent height and ridge, and the skin of the radial forearm flap mucosalized (Fig.
EP
6). (Fig. 7) Three dental implants were placed in solid bone (Fig. 8) (Fig. 9); at the same time a vestibuloplasty was preformed using a split thickness skin graft from
AC C
the thigh. (Fig. 10)(Fig. 11) The patient was referred to a maxillofacial prosthodontist for a fixed partial denture for the reconstructed ridge.
Discussion
3
ACCEPTED MANUSCRIPT
The treatment plan for maxillary defects, both post-traumatic and post-oncologic, is determined by the amount of tissue loss and the location of the defect. Nonvascularized alveolar block bone grafts have been successful but requires adequate soft
RI PT
tissue1,2.
Composite free vascular grafts, such as the fibula3,4,5 and the DCIA (deep circumflex
for segmental alveolar ridge reconstruction.
SC
iliac artery) flap,6 have a solid track record for reconstruction of maxilla but are too large
The osteocutanous radial forearm free flap has been used to reconstruct limited
M AN U
low-level defects with a considerable soft tissue component.7 However, the flap’s inadequacy to repair large volume defects and limited bone stock (recommendations have been made to take only 30% of the cross-sectional area to avoid post-operative radius fracture) make it less than ideal for the placement of dental implants and prevent it from
TE D
being the first choice in many maxillary reconstructions.8,9
Our choice for reconstruction was the radial forearm fasciocutaneous flap combined with an immediate tissue engineered graft using allogeneic bone, BMP and
EP
BMAC. This combination provides us ample soft tissue with the ability mold to the exact specifications of our defect. The radial forearm fasciocutaneous flap is the most reliable
AC C
and versatile flap for head and neck reconstruction of small to medium defects10. The radial forearm flap was first developed and described by Song, et el., in China as a fasciocutaneous flap in 198211. It also has proven track record for soft tissue maxillary reconstruction12,13. The desirable traits of the flap include ease of harvest, low donor morbidity, flap skin is thin and pliable and the vessels (radial artery, cephalic vein and or vena comitantes) that are long pedicle and large in caliber14. The Allen test is the most
4
ACCEPTED MANUSCRIPT
important preoperative evaluation to assess the adequacy of the circulation to the hand through the ulnar artery in avoiding the catastrophic complication of an ischemic hand15. The use of in-situ tissue engineered graft containing allogeneic bone, BMP and
RI PT
BMAC reported extensively for both immediate maxillofacial reconstruction,16,17 but use of it combined with a free flap is limited. Kim, et al, described a technique of using a fibula free flap combined with tissue engineering to reconstruct after resection of a
SC
ameloblastoma18. Warnke et al. described a use of a tissue-engineered graft implanted in the latissumus dorsi to create a prefabricated vascular graft to reconstruct a mandible19.
M AN U
The biggest concern with the combination of a graft continuing BMP and a free flap is the postoperative edema20 that can cause an increase in vascular resistance leading to flap failure. Due to the pliability of the skin and large caliber vessel the radial forearm is more accommodating to the edema. There was no compromise in vascular perfusion and the
TE D
viability of the flap through out its post op course.
Although the radial forearm is the most reliable flap in head and neck reconstruction, it is critically important to have a thorough discussion of the associated
EP
risks, complications and alternatives before proceeding with the procedure. The complications include unsightly scar of the donor site, skin graft failure, tendon
AC C
exposure, dysesthesia, reduced strength and sensation, motor nerve damage to the hand, cold-induced symptoms, swelling of the hand, stiffness of joints and fractures of the radius and ischemic hand.21,22 A post-traumatic maxillary alveolar ridge can be a challenge to reconstruct due to the lack of healthy soft tissue, fibrosis of existing tissue, and the proximity of the nasal floor. A traditional reconstruction technique such as avascular bone grafting requires soft
5
ACCEPTED MANUSCRIPT
tissue to adequately cover the graft. Unfortunately, the remaining soft tissue is often scarred, inadequate, or absent in post-traumatic or post-oncologic defects. Alternatively, osteocutaneous flaps such as the free fibula provide both vascular soft
RI PT
tissue and bone, but these flaps often contain too much bulk for proper prosthetic
restoration. This case report demonstrates a novel technique for reconstructing these
difficult defects with a combination of free vascular tissue transfer and avascular bone
M AN U
into the correct anatomic position for restorative needs.
SC
graft utilizing in situ tissue engineering, allowing the bone to be molded and contoured
Disclosure:
1
TE D
Dr. Robert E. Marx is a consultant of Medtronics and Harvest Technologies
Barone, Antonio, and Ugo Covani. "Maxillary alveolar ridge reconstruction with nonvascularized autogenous block bone: clinical results." Journal of Oral and Maxillofacial Surgery 65.10 (2007): 2039-2046. 2
3
EP
Schwartz-Arad, Devorah, and Liran Levin. "Intraoral autogenous block onlay bone grafting for extensive reconstruction of atrophic maxillary alveolar ridges." Journal of periodontology 76.4 (2005): 636-641.
4
AC C
Schwartz-Arad, Devorah, and Liran Levin. "Intraoral autogenous block onlay bone grafting for extensive reconstruction of atrophic maxillary alveolar ridges." Journal of periodontology 76.4 (2005): 636-641. Wei, Fu-Chan, et al. "Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects." Plastic and reconstructive surgery 93.2 (1994): 294-304. 5
Futran, Neal D., et al. "Midface reconstruction with the fibula free flap." Archives of Otolaryngology–Head & Neck Surgery 128.2 (2002): 161-166. 6
Maranzano, Massimo, and Andrea Atzei. "The versatility of vascularized iliac crest with internal oblique muscle flap for composite upper maxillary reconstruction." Microsurgery 27.1 (2007): 37-42.
6
ACCEPTED MANUSCRIPT
7
Villaret, Douglas B., and Neal A. Futran. "The indications and outcomes in the use of osteocutaneous radial forearm free flap." Head & neck 25.6 (2003): 475-481. 8
RI PT
Cordeiro, Peter G., Norma Bacilious, and Ronald Spiro. "The radial forearm osteocutaneous" sandwich" free flap for reconstruction of the bilateral subtotal maxillectomy defect." Annals of plastic surgery 40.4 (1998): 397-402. 9 Triana, Rudy J., et al. "Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects." Archives of facial plastic surgery 2.2 (2000): 91-101. 10
Soutar, D. S., et al. "The radial forearm flap: a versatile method for intra-oral reconstruction." British journal of plastic surgery 36.1 (1983): 1-8. Song R, Gao Y, Song Y, Y Yum, Song Y. The forearm flap. Clin. Plast. Surg. 1982;9:21–26
SC
11
12
M AN U
Genden, Eric M., et al. "Reconstruction of the hard palate using the radial forearm free flap: indications and outcomes." Head & neck 26.9 (2004): 808-814. 13
Muzaffar, Arshad R., et al. "Maxillary reconstruction: functional and aesthetic considerations." Plastic and reconstructive surgery 104.7 (1999): 2172-2183. 14
Moscoso, Juan F., and Mark L. Urken. "Radial forearm flaps." Otolaryngologic clinics of North America 27.6 (1994): 1119-1140. 15
Urken ML, Cheney ML, Sullivan MJ, Biller HF, Habal MB. Atlas of regional and free flaps for head and neck reconstruction. Journal of Craniofacial Surgery. 1995 Sep 1;6(5):424. 16
17
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Spagnoli, Daniel B. "The application of recombinant human bone morphogenetic protein on absorbable collagen sponge (rhBMP-2/ACS) to reconstruction of maxillofacial bone defects." Bone Morphogenetic proteins: from local to systemic therapeutics. Birkhäuser Basel, 2008. 4370.
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Marx, Robert E., and David B. Harrell. "Translational research: The CD34+ cell is crucial for large-volume bone regeneration from the milieu of bone marrow progenitor cells in craniomandibular reconstruction." Oral & Craniofacial Tissue Engineering 2.4 (2012).
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Kim, Beomjune. "Hybrid mandibular reconstruction technique: Preliminary case series of prosthetically-driven vascularized fibula free flap combined with tissue engineering and virtual surgical planning." 2014 Annual Meeting. AAOMS, 2014. Warnke PH, Springer IN, Wiltfang J, Acil Y, Eufinger H, Wehmoller M, et al. Growth and transplantation of a custom vascularised bone graft in a man. Lancet 364:766-770. 2004 20 Perri, Brian, et al. "Adverse swelling associated with use of rh-BMP-2 in anterior cervical discectomy and fusion: a case study." The Spine Journal 7.2 (2007): 235-239. 21
Timmons, M. J., et al. "Complications of radial forearm flap donor sites." British journal of plastic surgery 39.2 (1986): 176-178. 22
Swanson, Eric, J. Brian Boyd, and Ralph T. Manktelow. "The radial forearm flap: reconstructive applications and donor-site defects in 35 consecutive patients." Plastic and reconstructive surgery 85.2 (1990): 258-272.
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Figure 1 A: Loss of left maxillary alveolar ridge with teeth #9 thru #13 (left maxillary central incisor thru second premolar)
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Figure 1B: Post-traumatic defect with fibrous scar tissue Figure 2: Panorex on initial visit
Figure 3: Exposure of alveolar defect
Figure 4: Poly-DL-Lactic Acid mesh carrier
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Figure 5: BMP+BMAC+allogeneic bone
Figure 6: Radial forearm flap positioned over the tissue engineered bone graft
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Figure 7: Cone beam computed tomography 5 months post-op imaging demonstrating consolidation and maturation of avascular bone graft underneath radial forearm flap Figure 8: 6 months s/p RFFF+bone graft+BMP+BMAC Figure 9: Debulking of skin paddle showing excellent ridge formation Figure 10: Placement of 3 endosteal implants into the reconstructed alveolar ridge Figure 11: Cone beam computed tomography of endosteal implants in reconstructed maxillary ridge, 1-week post op.
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