Bone grafting of the jaws

Types of bone defects

Surgical tactics depend on the nature of the mandibular injury. There are two main types of bone integrity violations resulting from gunshot wounds, tumor resections, or chronic inflammation:

1. True bone defect. Tissue loss is so extensive that it exceeds the natural regenerative capacity of the body. Fragment union does not occur, and an isolated bone callus forms at the end of each fragment.
2. False joint (pseudarthrosis). Occurs with minimal bone loss (0.5 to 1.0 cm). Union is hindered by impaired osteogenesis, foreign body presence, or soft tissue interposition (e.g., muscles or adipose tissue) between the fragments. A sclerotic cortical plate forms at the fragment margins.

Preparation of the recipient site

The primary condition for a successful free bone graft is a high-quality recipient site. Soft tissues must fit as tightly as possible against the graft surface to ensure optimal conditions for its integration.

Any scars are excised, as they prevent tight contact and proper organization of the transplanted tissue. If the defect is accompanied by soft tissue loss, surgeons first restore their volume using local flaps or a Filatov tube pedicle. Only after soft tissue replacement can one proceed to the bone grafting stage.

Before surgery, complete sanitation of the oral cavity is mandatory, and jaw fragments are fixed in the correct position. For this purpose, bent dental splints with hook loops are used, or titanium mini-plates/extracorporeal fixation devices if there are insufficient anchor teeth.

Selection of grafting material

Various materials are used to replace defects, each having its own engraftment characteristics:

• Autografts. Harvested from the recipient (typically the iliac crest or the outer rib cortex). The graft serves as a reliable scaffold along which bone-forming processes occur. Over time, under the influence of functional loading, it remodels and thickens.
• Alloplasty. Transplantation of cadaveric bone tissue is limited due to tissue incompatibility—the immune system produces antibodies and destroys foreign protein. To slow down this process, donor bone undergoes lyophilization (deep freezing with vacuum drying). Such bone acts as a matrix that is gradually replaced by the patient's own regenerated tissue.
• Alloplastic (foreign) materials. Practically avoided due to the high risk of complications: pressure sores, inflammation, suppuration, and subsequent rejection.

Historical background

The development of jaw bone grafting in Russia is associated with several prominent surgeons. In 1900, V.I. Zykov performed the first free bone transplant by harvesting a fragment from the left jaw segment and bridging the defect. At the time, isolating the wound from saliva was considered the main condition for success.

In 1924, A.A. Limberg proposed a two-stage transplantation method to prevent infection: first, an autologous rib was transplanted into the soft tissues of the submandibular region, and 2–3 months later, the resulting neurovascular/pedicled complex was transferred to the jaw defect. Today, thanks to the introduction of antibiotics, single-stage free transplantation has become the standard.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Intercortical sagittal split osteotomy of the mandible according to Dal Pont
• Plastic osteotomy techniques for micrognathia (Limberg, Rudko, and Ivanov methods)
• Surgical treatment of anterior open bite in adults
• Suspension arthroplasty of the mandibular ramus according to Yovchev
• Tactics for complex multiple facial defects

Other topics in «Chapter 15. Reconstructive surgery of the face and jaws (V.N. Bogatov, S.N. Lebedev)»

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