**3. Mandibular reconstruction**

For small mandibular defects and alveolar clefts, iliac bone chips and cranial bone chips are useful and mostly preferred by surgeons. In the alveolar cleft, our aim is to reconstruct the alveoli during primary cleft repair. In newborns, iliac bone chips are preferred for alveolar reconstruction. In adolescent or late repair, cranial bone chips are another useful graft material for alveolar reconstruction (**Photos 1** and **2**).

Mandibular contour defects should be reconstructed with cranial bone grafts because they have less tendency to resorb than other types of grafts do. Bone defects of the mentum should also be reconstructed with cranial bone grafts.

According to my personal experience, for full thickness defects of the mandible that are up to 10 cm in size, a nonvascularized, drilled iliac bone is the best choice.

One of the most important points when harvesting the iliac bone is to keep the muscle attachments intact and preserve all edges of the iliac bone. The iliac bone graft is harvested from the middle part of the iliac bone.

In patients with vertical mandibular asymmetry, the interpositional placement of the iliac bone graft or bone that is resected on the contralateral side is the most preferred in our prac-

Craniofacial Bone Grafting

13

http://dx.doi.org/10.5772/intechopen.78787

Mandible is the most dynamic part of the of the oral and craniomaxillofacial region. It includes and neighbors the temporomandibular joint, glenoid fossa, teeth, muscles, ligaments, salivary glands, and the tongue. It creates the boundaries of fossas (submandibular, sublingual, submental, infratemporal, pterygomandibular, submasseteric, and so on) as well. Therefore, reconstruction of the mandible requires to restore all the functional, anatomic, and

The functional considerations would include the restorations of occlusion, fonation, mastication and swallowing. Anatomic reconstruction requires adequate three-dimensional maxillomandibular relation. The esthetic outcomes would have balanced facial harmony with

Today, mandible can be reconstructed via non-vascularized bones or different types of free

The use of non-vascularized bone grafts and modified approaches for reconstruction of atrophied mandible prior to dental implant and dentures is well defined in literature. However, for larger defects after trauma or neoplasm surgery for the vitality of the bone and soft tissue of the graft is still challenging. Recently, the use of vascularized osteocutaneous free flaps has decreased the morbidity and mortality percentages, especially since the oncological cases and

flaps in association with stock or 3D custom-produced titanium screws and plates.

tice (**Photo 3**).

esthetic aspects.

symmetry and vertical dimension.

**Photo 2.** Alveolar bone grafting during the lip-nose revision.

**Photo 1.** Alveolar bone grafting during the primary cleft lip repair.

**Photo 2.** Alveolar bone grafting during the lip-nose revision.

**2. Necessity**

of cranial bone grafts.

**3. Mandibular reconstruction**

rial for alveolar reconstruction (**Photos 1** and **2**).

also be reconstructed with cranial bone grafts.

**Photo 1.** Alveolar bone grafting during the primary cleft lip repair.

middle part of the iliac bone.

10 cm in size, a nonvascularized, drilled iliac bone is the best choice.

12 Bone Grafting - Recent Advances with Special References to Cranio-Maxillofacial Surgery

Post-traumatic defects such as orbital floor fractures, postresection defects due to bone tumors, congenital bone defects, and esthetic reasons are some of the indications for the use

For small mandibular defects and alveolar clefts, iliac bone chips and cranial bone chips are useful and mostly preferred by surgeons. In the alveolar cleft, our aim is to reconstruct the alveoli during primary cleft repair. In newborns, iliac bone chips are preferred for alveolar reconstruction. In adolescent or late repair, cranial bone chips are another useful graft mate-

Mandibular contour defects should be reconstructed with cranial bone grafts because they have less tendency to resorb than other types of grafts do. Bone defects of the mentum should

According to my personal experience, for full thickness defects of the mandible that are up to

One of the most important points when harvesting the iliac bone is to keep the muscle attachments intact and preserve all edges of the iliac bone. The iliac bone graft is harvested from the

In patients with vertical mandibular asymmetry, the interpositional placement of the iliac bone graft or bone that is resected on the contralateral side is the most preferred in our practice (**Photo 3**).

Mandible is the most dynamic part of the of the oral and craniomaxillofacial region. It includes and neighbors the temporomandibular joint, glenoid fossa, teeth, muscles, ligaments, salivary glands, and the tongue. It creates the boundaries of fossas (submandibular, sublingual, submental, infratemporal, pterygomandibular, submasseteric, and so on) as well. Therefore, reconstruction of the mandible requires to restore all the functional, anatomic, and esthetic aspects.

The functional considerations would include the restorations of occlusion, fonation, mastication and swallowing. Anatomic reconstruction requires adequate three-dimensional maxillomandibular relation. The esthetic outcomes would have balanced facial harmony with symmetry and vertical dimension.

Today, mandible can be reconstructed via non-vascularized bones or different types of free flaps in association with stock or 3D custom-produced titanium screws and plates.

The use of non-vascularized bone grafts and modified approaches for reconstruction of atrophied mandible prior to dental implant and dentures is well defined in literature. However, for larger defects after trauma or neoplasm surgery for the vitality of the bone and soft tissue of the graft is still challenging. Recently, the use of vascularized osteocutaneous free flaps has decreased the morbidity and mortality percentages, especially since the oncological cases and

**5. Fibula free flap**

tendency to resorb.

bone for nasal reconstruction.

**7. Harvesting of cranial bone graft**

from diploe obtaining pieces of split-thickness cranial bone grafts.

**6. Upper face and cranium reconstruction**

The free fibula flap has gained popularity due to its bone graft and vessel length for reconstruction of extended mandibular defects. Bone flap can be harvested with adjacent periosteum and soft tissue with or without a skin paddle. The incision starts 5 cm below the lateral epicondyle of the fibula and runs 10–15 cm in a distal direction. After elevating the skin flap anteriorly/ posteriorly, the muscle dissection through the intermuscular septum to peroneal muscle and sural muscle is performed to identify fibula. A muscle cuff of 3 mm is left along the fibula. Anterior intermuscular septum is incised by protecting the anterior tibial vessels. Then hallucis longus and tibial muscle through interosseous membrane is dissected. Proximal and distal cuts are performed around minimum 7 cm blow the proximal neck and superior to lateral malleolus according to desired bone length of the reconstruction site. The soleus, hallucis longus, and tibial muscles are dissected to elevate the peroneal vessel pedicles. At the distal site, the outward traction of the bone would help to reach tibial posterior muscle with its raphae, which help to secure the vessels when the muscle dissection is carried out along this raphae. Facial and supra thyroid arteries and external jugular vein is generally preferred for anastomoses. By osteotomy cuts on the harvested fibula, the required shape for mandibular reconstruction is achieved.

Craniofacial Bone Grafting

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http://dx.doi.org/10.5772/intechopen.78787

For the entire upper face, including the nose and the cranium, bony reconstruction and cranial bone grafting are the best choices because they are membranous structures that have less

In terms of craniofacial surgeons' preferences for cranial bone grafts, this is the gold standard. Even for dorsal nasal reconstruction, the cranial bone is the most popular in craniofacial surgery departments [6, 7]. Rib cartilage has a high rate of resorption and undesired shrinkage. Diced or blocked rib cartilage is not incorporated into the underlying nasal bones. One of the fans of rib grafts was popular rhinoplasty surgeon Jack Sheen, who turned to use the cranial

Cranial bone grafts can be harvested as split-thickness or full-thickness bone grafts according to the condition of the recipient area. In the case of full-thickness cranial bone graft harvesting, a neurosurgeon should be involved in the surgery team. The desired shape and size of the bone graft are drawn on the skull after the scalp is subperiosteally dissected. Then the neurosurgeon opens burr holes at the planned areas. The burr holes are connected by cutting the cranium with an electrical craniotome. The dura is dissected carefully, releasing the cranial bone from the brain. In most conditions, harvested full-thickness cranial bone is split

**Photo 3.** Interpositional bone grafting from left mandible to the right side.

osseointegrated dental implants that are installed on these flaps help to improve postoperative masticatory function.

Iliac crest and the fibula are the most favorable donor sides for oromandibular reconstruction with the advantages of minimal donor site morbidity, optimum pedicle length and diameter and two team approach. Various factors must be considered such as localization, residual bone dimensions with or without soft tissue defects, vessels, and bone volume for dental implant rehabilitation, when deciding which flap is the most suitable.
