A Textbook of Advanced Oral and Maxillofacial Surgery

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co
A Textbook of Advanced Oral

and Maxillofacial Surgery
Volume 2
Edited by Mohammad Hosein Kalantar Motamedi
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A Textbook of Advanced Oral and Maxillofacial Surgery. Volume 2

Edited by Mohammad Hosein Kalantar Motamedi
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Contents
Preface
Chapter 1 Overview of Local Anesthesia Techniques
by Mohammad Ali Ghavimi, Yosef Kananizadeh, Saied Hajizadeh
and Arezoo Ghoreishizadeh
Chapter 2 Crestal Anesthesia for Dentoalveolar Surgery
by Koroush Taheri Talesh, Shiva Solahaye Kahnamouii,
Mohammad Hosein Kalantar, Motamedi, Shahram Mehrzad
and Javad Yazdani
Chapter 3 Modified Jorgensen and Hayden Approach to Intraoral
Mandibular Anesthesia
by Flaviana Soares Rocha, Rodrigo Paschoal Carneiro,
Aparecido Eurÿpedes Honÿrio Magalhÿes, Darceny Zanetta-Barbosa,
Lair Mambrini Furtado and Marcelo Caetano Parreira da Silva
Chapter 4 Novel Modifications in Administration of Local Anesthetics
for Dentoalveolar Surgery
by Esshagh Lassemi, Fina Navi, Mohammad Hosein Kalantar Motamedi,
Seyed Mehdi Jafari, Kourosh Taheri Talesh, Kamal Qaranizade
and Reza Lasemi
Chapter 5 Orthodontic Considerations in Surgical Interventions
for Impacted Teeth
by Massoud Seifi and Mohammad Hosein Kalantar Motamedi
Chapter 6 Surgical Exposure and Orthodontic Alignment of
Impacted Teeth
by Mohammad Hosein Kalantar Motamedi
Chapter 7 Orthodontic Preparation for Orthognathic Surgery
by Abdolreza Jamilian, Alireza Darnahal and Letizia Perillo
Chapter 8 Surgically Assisted Maxillary Expansion
by Sertaÿ Aktop, Onur Gÿnuÿl, Hasan Garip and Kamil Gÿker
Chapter 9 Orthodontic Considerations in Obstructive Sleep Apnea —
State of the Art
by Hakima Aghoutan, Sana Alami, Samir Diouny and
Farid Bourzgui
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Contents
Chapter 10 Advanced Adjunct Orthosurgical Esthetic Prodedures

by Seied Omid Keyhan, Seifollah Hemmat, Peyman Mehriar,
Arash Khojasteh and Mohammad Ali Asayesh
Chapter 11 Surgical Techniques to Improve the Smile
by Mazen Almasri
Chapter 12 Surgical Treatment of Odontogenic Periapical Lesions
by Onur Gonul, Kamil Gÿker, Sertac Aktop and Hasan Garip
Chapter 13 Treatment Approaches for Odontogenic Cysts of the
Maxillary Sinus
by Hasan Garip, Sertac Aktop, Onur Gonul and Kamil Gÿker
Chapter 14 Multidisciplinary Management of Benign Jaw Tumors
in Children
by Mehmet Cemal Akay, Mert Zeytinoglu, Birant Simsek
and Isil Aras
Chapter 15 Tumor Markers in Common Oral and Maxillofacial Lesions
by Taghi Azizi
Chapter 16 Considerations for the Spread of Odontogenic Infections —
Diagnosis and Treatment
by Flaviana Soares Rocha, Jonas Dantas Batista,
Clÿudia Jordÿo Silva, Roberto Bernardino Jÿnior and
Luis Henrique Araÿjo Raposo
Chapter 17 Combined Surgical and Orthodontic Management of Maxillofacial
Deformities
by Sana Alami, Hakima Aghoutan, Samir Diouny, Farid El Quars
and Farid Bourzgui
Chapter 18 Telegnathic Surgery for Obstructive Sleep Apnea
by Dina Ameen
Chapter 19 Comprehensive Management of Temporomandibular Joint
Ankylosis — State of the Art
by Hossein Behnia, Azita Tehranchi and Farnaz Younessian
Chapter 20 Contemporary Management of Frontal Sinus Injuries and Frontal
Bone Fractures
by Petr Schuÿtz, Hussein Hassan Hamed Ibrahim and Bashar Rajab
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Contents
Chapter 21 Current Management of Frontal Sinus Injuries

by Roozbeh Kahali and Alireza Tootoonchian
Chapter 22 Endoscopic Oral and Maxillofacial Surgery
by Gholamreza Shirani, Shiva Solahaye Kahnamouii and
ohammad Hosein Kalantar Motamedi
Chapter 23 Regenerative Techniques in Oral and Maxillofacial Bone Grafting
by Arash Khojasteh, Mohammad Esmaeelinejad and Farzad Aghdashi
Chapter 24 Facial Augmentation with Implants
by Farzin Sarkarat and Behnam Bohluli
Chapter 25 Management of Bone Grafting Complications in Advanced
Implant Surgery
by Mehdi Sezavar, Vahid Mesgarzadeh, Shahrouz Shafayifard
nd M. Reza Soleimanpour
Chapter 26 Reconstruction of Facial Hair Bearing Areas in the
Male Patient
by Shahram Nazerani
Chapter 27 Basics of Microvascular Reconstruction of Maxillomandibular
Defects
by Reza Tabrizi and Barbad Zamiri
Chapter 28 Reconstruction of the Face Following Cancer Ablation
by Ata Garajei, Ali Arabkheradmand, Mohammad Hosein Kalantar
Motamedi, Alex E. Pazoki and Ashkan Rashad
Chapter 29 Virtual Surgical Planning in Craniomaxillofacial
Reconstruction
by Eric Zielinski, Ryan J. Jacobs, Eric Barker, Kate Rodby
and Anuja K. Antony
Chapter 30 Reconstruction of Maxillofacial Osseous Defects with
Computer-Aided Designed/Computer-Aided Manufactured Devices
by Jan Rustemeyer
Chapter 31 Contemporary Rhinoplasty Techniques
by Payam Varedi and Behnam Bohluli
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Contents
Chapter 32 Advanced Rhinoplasty: Problems and Solutions

by Payam Varedi
Chapter 33 Rhinoplasty in Adult Patients with Cleft — Lip Nasal
Deformities
by Fereydoun Pourdanesh and Behnam Bohluli
Chapter 34 Advanced Applications of the Er:YAG Laser in Oral and
Maxillofacial Surgery
by Dragana Gabric, Anja Baraba, Goran Batinjan, Marko Blaÿkovic,
Vanja Vucicevic Boras, Irina Filipovic Zore, Ivana Miletic and
Elizabeta Gjorgievska
Chapter 35 Basics of Craniofacial Surgery
by Hamid Mahmood Hashemi, Farnoush Mohammadi, Iman Tavakoli
and Amirsalar Sayedyahossein
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Preface
The scope of OMF surgery has expanded; encompassing treatment of

diseases, disorders, defects and injuries of the head, face, jaws
and oral cavity.
This internationally-recognized specialty is evolving with advancements
in technology and instrumentation.
Specialists of this discipline treat patients with impacted teeth, facial
pain, misaligned jaws, facial trauma, oral cancer, cysts and tumors;
they also perform facial cosmetic surgery and place dental implants.
The contents of this volume essentially complements the volume 1 with
chapters that cover both basic and advanced concepts on complex topics
in oral and maxillofacial surgery.
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Chapter 1
Overview of Local Anesthesia Techniques
Mohammad Ali Ghavimi, Yosef Kananizadeh,

Saied Hajizadeh and Arezoo Ghoreishizadeh
Additional information is available at the end of the chapter
http://dx.doi.org/10.5772/59214
1. Introduction
Down through centuries, efforts have been made to use local anesthesia for treatments. In the
ancient times, the Assyrians applied pressure over the carotid artery in order to obtain a certain
degree of anesthesia, explaining why this artery is called “the artery of sleep” in the Greek
literature. In 1532, the Indians of Peru chewed the leaves of coca shrubs to relieve fatigue and
hunger and to produce a feeling of exhilaration. A chemical with some anesthetic property
was first introduced in the nineteenth century. A German chemist in 1859, however, reported
the anesthetic properties of the coca leaf. In 1859, cocaine was first extracted in its pure form
by Albert Neimann, a German chemist. In the mid-1860s, Sir Benjamin Ward Richardson
introduced the effect of ether spray for skin anesthesia. Around the same time the adverse
effects of cocaine on the mood and psyche were demonstrated. As known today, side effects
of cocaine include cardiac stimulation, peripheral vasoconstriction, excitation of the central
nervous system (CNS) and addiction. In 1943, lidocaine-the first amide local anesthetic was
introduced with greater potency, more rapid onset and less allergenicity as compared to the
previously introduced esters.
Pain control in dentistry presents one of the greatest challenges. Pain leads to increased stress,
release of endogenous catecholamines and unexpected cardiovascular responses. Before
anesthetization, dentists should evaluate the medical history of each patient and document
data on the systemic and psychological status of the patients in order to determine whether
the patient is able to tolerate the treatment with no risk from the systemic and psychological
points of views. Before the injection of the local anesthetic, the dentist should recognize the
potential risks. However, most adverse reactions to local anesthetics are not related to the drug
itself, but to the injection of the drug. The injection of the local anesthesia is the most reported
cause for fear and discomfort of dental patients. Vasodepressor syncope and hyperventilation
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4 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2
syndrome are the most common reactions. Others include tonic-clonic spasm, bronchospasm
and angina pectoris. Continual research in the field of pain control is still being done in the
quest for novel techniques and safer drugs. [1-4].
2. Anatomy
Management of pain in dentistry requires knowledge about the fifth cranial nerve anatomy-
the trigeminal nerve. It is the largest of the cranial nerves and has three major divisions:
ophthalmic, maxillary and mandibular.
The trigeminal nerve is the major sensory nerve of the face containing both motor fibers for
masticatory muscles and sensory fibers. This nerve exits the brain through the area between
the pons and the middle cerebellar peduncles.
The ophthalmic branch runs through the lateral wall of the cavernous sinus and, through the
superior orbital fissure, enters the orbit, branching again to provide sensation of the lacrimal
apparatus, cornea, iris, forehead, ethmoid and frontal sinuses and the nose. The ophthalmic
nerve –V1- is the smallest of the three divisions, dividing in to three main branches: the
nasociliary, frontal and lacrimal nerves (Figure 1).
The maxillary branch is the second branch of the trigeminal nerve – V2 – passes horizontally
forward, through the lateral wall of the cavernous sinus, exiting the cranium through the
rotundum foramen which is located in the greater wing of the sphenoid bone. Once outside
the cranium, this nerve crosses between the pterygoid plates of the sphenoid bone and the
palatine bone. As the maxillary nerve crosses the pterygopalatine fossa, it gives off branches
to the posterior–superior alveolar nerve, the sphenopalatine ganglion and the zygomatic
region. Branches of this nerve continue through the inferior orbital fissure and infraorbital
foramen, providing sensation of the maxillary sinuses, upper jaw, sides of the nose and the
cheek (Figure 2). [5, 6]
The branches of the maxillary nerve are given off in four regions:
1. Cranium
2. Pterygopalatine fossa
3. Infraorbital canal
4. Face
The branch entering the cranium –the middle meningeal nerve– travels with the middle
meningeal artery to provide sensory innervation of the dura mater.
Several branches are given off in the pterygopalatine fossa namely the zygomatic nerve, the
pterygopalatine nerve and the posterior superior alveolar nerve.
The greater palatine nerve descends through the pterygopalatine canal and through the
greater palatine canal emerges on the hard palate, coursing anteriorly between the osseous
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Overview of Local Anesthesia Techniques 5

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hard palate and the mucoperiosteum supplying sensory innervation to the bone and palatal
soft tissues as far anterior as the first premolar.
The lesser palatine nerve travels along with the posterior palatine nerve emerging from the
lesser palatine foramen.
The posterior superior alveolar nerve (PSA) branches from the main trunk of the maxillary
division into the pterygopalatine fossa just before the maxillary division enters the infraorbital
canal.
The maxillary division (V2) gives off two significant branches namely the anterior superior
(ASA) and middle superior (MSA) alveolar nerves.
The ASA nerve – given off from the infraorbital nerve – descends within the anterior wall of
the maxillary sinus, providing pulpal innervation of the central and lateral incisors, canine and
the sensory innervation of periodontal tissues, buccal bone and the mucous membrane of the
gums.
The MSA nerve provides sensory innervation of maxillary premolars and, perhaps, the
mesiobuccal root of the first molar, periodontal tissues, buccal soft tissues and the bone and
gums in the premolar region.
Branches of the face: through the infraorbital foramen, the infraorbital nerve emerges into the
face dividing into its terminal branches: the inferior palpebral, external nasal and superior
labial.
The mandibular branch (V3) is considered a motor-sensory nerve innervating masticatory

muscles, lower jaw and teeth, parotid and sublingual gland, two third of the tongue and the
ear canal and exits the skull through the ovale foramen. The mandibular division: The
mandibular division – the largest branch of the trigeminal nerve – descends between the medial
ramus and the medial pterygoid muscle, entering the mandible through the mandibular
foramen (Figure 2.).
The inferior alveolar nerve has the largest diameter of 2.4±0.4 mm at the lingula.
The anterior division of the V3 branch provides sensory innervation of the cheek, mucous
membrane in the buccal of the mandibular molars and motor innervation of the masticatory
muscles.
The buccal nerve, passing through the two heads of the lateral pterygoid, reaches the external
surface of the lateral pterygoid muscle, continuing in an anterolateral direction.
The auriculotemporal nerve passes through the upper part of the parotid gland crossing the
posterior portion of the zygomatic arch.
The lingual nerve travels downward and medial to the lateral pterygoid muscle, lying
between the ramus and the medial pterygoid muscle in the pterygomandibular space as it
descends. The sensory tract of the anterior two-third of the tongue, the mucous membrane of
the mouth floor and mandibular lingual gingiva is provided by the lingual nerve.
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Figure 1. The superficial branches of the trigeminal nerve
Figure 2. Branches of the trigeminal nerve

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http://dx.doi.org/10.5772/59214
The mylohyoid nerve branches off the inferior alveolar nerve just before the entrance of the
inferior alveolar nerve into the mandibular canal. This is a mixed nerve providing sensory
innervation of the mandibular incisors, and portions of mandibular molars in some. It also
provides the motor innervation of the anterior belly of the digastrics and the mylohyoid
muscle.
At the mental foramen, the inferior alveolar nerve branches into its terminal branches-- the
incisive and the mental nerves:
The incisive nerve, remaining within the mandibular canal, forms a nerve plexus innervating
the pulpal tissues of the mandibular first premolar, canine and incisors via the dental branches.
The mental nerve innervates the skin of the chin and the mucous membrane of the lower lip.
[1-6]
3. Mandibular anesthesia
There is a great variety of techniques for anesthetizing different regions of the mandible, the
most common and useful ones are described in this section.
3.1. Inferior alveolar nerve block
The inferior alveolar nerve block (IANB) is one of the most important and commonly used
techniques in dentistry. Unfortunately it is also the most frustrating with the highest percent‐
age of failure even when properly administrated [1].The IANB anesthetizes the IAN (a branch
of mandibular division of the trigeminal), incisive nerve, mental nerve and commonly (but not
always) the lingual nerve of the injected side. This block effects the sensation of all the teeth
on one side of mandible, the bone from the inferior portion of ramus to the midline, the lingual
soft tissue and periosteum of the mandible, buccal soft tissues anterior to the mental foramen
and anterior two thirds of the tongue and floor of the oral cavity [2].
In one technique, the patient is positioned supine (recommended) or semi-supine. The thumb
of the free hand is placed on the coronoid notch retracting the soft tissues. The insertion point
of the needle is about 6 to 10 mm above the occlusal plane and at the 3/4 of the anterior posterior
distance from the coronoid notch to the pterygomandibular raphe (visual in the oral cavity).
The syringe is advanced from across the lower premolar teeth of the opposite side. A long
dental needle is used; the bone must be touched while advancing about 25mm of the 35 mm
needle into the tissue. After contacting bone the needle is withdrawn slightly, aspiration
performed and if negative in two directions 1.5 to 1.8 ml of solution is deposited over a
minimum of 60 seconds (Figure 3).. [1]
Two problems occur very commonly with this technique [7]:

1. Contacting the bone too soon: to solve this problem the needle is withdrawn halfway, still
remaining in the soft tissue, then the barrel of the syringe is swung over the mandibular
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Figure 3. The Inferior Alveolar Nerve Block
teeth of the side being anesthetized, then the needle is advanced about 2.5 mm and the
solution is deposited. This is a modification of IANB (the indirect technique) [8].
2. The bone is not contacted after 30 mm of needle insertion: the needle should be withdrawn
halfway back then the barrel of the syringe is swung over the molar teeth of the opposite
side being anesthetized, and then advanced to touch the bone and then continued as
described. When the bone is not touched the solution should not be deposited because the
needle could be in the parotid gland near the facial nerve and an injection there could lead
to transient paralysis of the facial nerve [1].
One of the most common causes of failure of IANB is depositing the solution too low (below
the mandibular foramen) in this case it can be corrected by re-injecting at a higher site,
approximately 5 to 10 mm above the previous site.
Mylohyoid nerve is the most common nerve which provides mandible teeth with accessory
sensory innervation (most commonly the mesial portion of mandibular first molar). A
supplemental injection at the apical region of the tooth in question on the lingual side will
solve the problem [9].
Incomplete anesthesia of the central and lateral incisors is due to overlapping fibers of the
contralateral inferior alveolar nerve. In this case a supplemental injection with infiltration
technique or PDL injection should be done [1].
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Olsen reported that in children the mandibular foramen is situated at a level lower than the
occlusal plane [10]. Therefore in pediatric patients the injection must be made slightly lower
and more posteriorly than for an adult patient.
3.2. Vazirani-Akinosi (closed mouth) mandibular block
Dr. Joseph Akinosi described a close-mouth approach in 1977 [11]. This technique became a
successful alternative for inferior alveolar and Gow-Gates mandibular nerve blocks. In 1960 a
very similar technique was described by Vazirani, there for the term “Vazirani-Akinosi” is
used for the approach. It is also known as “Close-mouth mandibular nerve block” and
“Tuberosity approach”. Although this technique can be used whenever mandibular anesthesia
is desired, its primary indication is in situations where the patient has a limited mouth opening
range such as patients with trismus or when spasm of the masticatory muscles on one side of
the mandible occur due to several unsuccessful attempt to anesthetize it with IANB, the
Vazirani-Akinosi anesthesia approach provides successful anesthesia and a motor blockade
(of V3 division of trigeminal nerve) to relieve trismus if it is produced secondary to muscle
spasm.
In 1992, Wolfe described a modification of the Vazirani-Akinosi technique, in which the needle
is bent at a 45 degree angle to adapt better with the lingual aspect of the ramus. But due to the
increase risk of needle breakage this technique cannot be recommended [12]. If the Vazirani-
Akinosi technique administered successfully anesthesia of inferior alveolar, incisive, mental,
buccal, lingual and mylohyoid nerves is obtained.
For administration of this technique a 25 or 27 gage needle is used. The patient should be
positioned supine or semisupine. The index finger or thumb is placed on the coronoid notch
reflecting the tissue on the medial side of the ramus laterally. The patient is asked to occlude
gently with cheeks and muscles of masticatory relaxed. The syringe is held parallel to the
maxillary occlusal plane, with the needle at the mucogingival junction of maxillary third molar
(or second molar). The bevel of the needle should be held toward the bone. The needle is
inserted to the soft tissue overlying the medial border of the mandible ramus at the point
described, and is advanced 25mm (for an average-sized adult) posteriorly and slightly
laterally. After negative aspiration in two planes the anesthesia solution can be deposited.
Motor nerve paralysis is the first sign to occur so a patient with trismus will notice increased
ability to open the jaw. After 1 to 1.5 minute anesthesia of the lip and tongue is noted, and the
dental procedure usually can start within 5 minutes.
It is shown in studies that the Vazirani-Akinosi technique has the same success rate of
conventional IANB. But with fewer complications and a lower aspiration rate (<10%) [1].
3.3. Gow-Gates mandibular nerve block
In 1973, George Albert Edwards Gow-Gates described a new approach to mandibular

anesthesia which he had experience with and reported a success rate of 99% [13]. In this
technique the anesthesia solution is deposited on the medial side of the condylar neck just
below the insertion of the lateral pterygoid muscles and truly anesthetizes the entire distribu‐
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tion of V3, including the inferior alveolar, lingual, mylohyoid, mental, incisive, auriculotem‐
poral and buccal nerves (in 75% of patients). The Gow-gates technique has a higher success
rate and a lower incidence of positive aspiration in comparison to IANB.
In this technique the patient is positioned supine or semisupine and is asked to open his mouth
widely, then the syringe, fitted with a long needle, is introduced into the mouth through the
corner of the mouth on the opposite side. Insertion point is distal to the second molar and in
a height of the mesiopalatal cusp of the second molar. The needle is inserted into the tissue
and aligned with the plane extending from the corner of the mouth on the opposite side to the
intertragus notch on the side of injection, then advanced about 25mm (two third of the needle)
until the bone is touched. Then it is withdrawn about 1mm and after negative aspiration in
two directions about 1.8 ml of the solution is deposited. If the bone is not contacted, either the
patient has partially closed his mouth or the needle is deflected medially (most common cause).
In this situation ask the patient to hold his mouth completely open and after withdrawing the
needle half way realign the needle anteriorly by swinging the barrel of the syringe somewhat
more distally and then advance the needle to contact the bone and continue the process of
anesthesia [1, 9](Figure 4).
Due to greater diameter of the mandibular nerve it may require a larger volume of the
anesthesia solution, so if the depth of the anesthesia is inadequate after the first injection
deposit up to 1.8 ml in the second injection [9].
Figure 4. The Gow-Gates technique

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3.4. Buccal nerve block
The buccal nerve provides sensory innervation to the buccal gingiva, mucosa and part of the
cheek in mandibular molar region. This nerve is consequently not anesthetized during IANB,
so if required this nerve most be separately anesthetized. Because the buccal nerve lies
immediately beneath the mucous membrane it can be anesthetized easily by depositing about
0.5ml of solution at the coronoid notch (the area distal and buccal to the last molar in the arch).
And this nerve block has a success rate of approximately 100% [9].
3.5. Mental and incisive nerve block
The mental nerve and incisive nerve are the terminal branches of the inferior alveolar nerve
and provide sensory innervation to the buccal soft tissues lying anterior to the foramen and
the soft tissues of the lower lip and chin and those teeth located anterior to the foramen
(premolar, canine and incisors) on the injection side. To administer this technique the mental
foramen should be located with finger palpation near the apex of the second premolar. The
bone immediately around the foramen is rougher to the touch and the patient might feel some
soreness when you press your finger against the mental nerve. The needle bevel should be
directed toward the bone and the mucosa is penetrated near the mucobuccal fold and the
needle is advanced until it reaches the mental foramen, then about 0.6 ml of solution (one third
of a cartridge) is deposited. After injection the tissue should be massaged to facilitate entry of
the solution into the mental foramen. In the early literature it was emphasized to enter the
foramen for a successful nerve block but now it has been shown that this action is completely
unnecessary and only increases the risk of damaging the nerve or vessels of the area. Bilateral
mental block is very useful when procedures are to be done on anterior or premolar teeth on
both sides. [1]
4. Maxillary anesthesia techniques
Different regional blocks and infiltration injections can be used for anesthetizing the maxilla.
Some are described herein.
4.1. Supraperiosteal injection (infiltration)
This is the most common technique used for obtaining pulpal anesthesia and is more com‐
monly known as local infiltration. In this technique the patient is asked to partially open his
mouth and the syringe is held parallel to the long axis of the tooth. The needle is inserted in
the mucobuccal fold above the apex of the tooth and advanced until it touches the bone then
withdrawn a little and the solution is deposited at a rate of 30 s/ml (Figure 5). If the solution
is deposited while the needle touches the bone the solution is injected below the periosteum
which is more painful and may cause post injection discomfort.
This is a very easy technique and has a high success rate but when several teeth require
anesthesia or there is an infection or acute inflammation in the area of the injection regional
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Figure 5. The infiltration technique
nerve blocks are preferred. In pediatric patients infiltration technique can also be used for
anesthetizing mandibular primary teeth and in several studies it has been shown that in these
patients infiltration technique has a comparable effectiveness to mandibular nerve block for
dental procedures [14].
4.2. Maxillary nerve block
The Maxillary (v2) nerve block is an effective method for achieving anesthesia of the hemi‐
maxilla. With a single injection you can anesthetize all maxillary teeth of one side, buccal
periodontium and bone overlying these teeth, soft tissue and bone of hard palate and part of
the soft palate, skin of the lower eyelid, side of nose, cheek and upper lip. This nerve can be
blocked through several approaches:
4.3. High-Tuberosity approach
The patient is positioned supine or semisupine and the patient’s mouth partially open, the
mandible is pulled toward the side of the injection and the soft tissues are retracted with the
index finger. Then injection is done into the mucobuccal fold distal to the second molar at an
angle of 45 degrees; next the needle is advanced posteriorly, superiorly and medially about
30mm and the solution is deposited [9].
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4.4. Greater foramen approach
In this approach we attend to insert the needle to the pterygopalatine fissure through the
greater palatine foramen and affect the maxillary nerve as it passes through the fossa. We ask
the patient to hold his mouth wide open. Palpate the greater palatine foramen medial to the
distal aspect of the second molar. Insert the needle at an angle of 45 degree superiorly and
distally to the foramen. After advancement about 30mm we deposit the anesthesia solution.
This technique is painful and may be dangerous is rarely needed if ever and thus, is not
recommended.
4.5. Posterior superior alveolar nerve block
By blocking the posterior superior alveolar (PSA) nerve the molar teeth of maxilla, the
associated bone and buccal gingiva will be anesthetized. It is shown that only in 28% of patients
the middle superior alveolar nerve provides the mesiobuccal root of the first molar with
sensory innervation, in this situation an extra injection (usually infiltration) is necessary to
anesthetize the accessory innervations.
To block the PSA, we partially open the patient’s mouth and pull the mandible to the side of
injection. A short needle is used to prevent distal insertion of the needle which can produce a
temporary (10 to 14 days) hematoma. The needle is inserted into the mucobuccal fold over the
second molar and advanced about 16mm upwards, inwards and backwards. Then, the
anesthesia solution is slowly deposited (Figure 6). [1]
Figure 6. The PSA nerve block

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In pediatric patients with primary or early mixed dentition, the thick bone of zygomatic process
lies over the buccal roots of the second primary and first permanent molars, attenuating the
effectiveness of infiltration injection in this region. So in this situations a PSA nerve block may
be used instead [15].
4.6. Middle superior alveolar nerve block
As mentioned before the MSA exist only in 28% of people and provides sensory innervation
to maxillary premolars and mesiobuccal root of the first molar. The MSA block is performed
by delivering a buccal infiltration at the apex of the second premolar tooth.
4.7. Anterior superior alveolar nerve block
The Anterior Superior Alveolar nerve (ASA) supplies the maxillary incisors and canine teeth
on one side and the soft and hard tissue adjacent to it. On the other hand the infraorbital nerve
provides sensory innervation to the mucosa and skin surface of one half of the upper lip and
part of the skin on lateral aspect of the nose; but because these two nerves can be anesthetized
with one approach, the technique is either known as “ASA block” or “Infraorbital nerve block”.
To perform this technique we locate the infraorbital foramen; to do so the infraorbital notch is
palpated with the index finger then moved downward from the notch, the bone immediately
inferior to the notch is convex, which is the roof of the infraorbital foramen, as we continue
inferiorly a concavity is felt, this is the infraorbital foramen. When we press against it the
patient senses a mild soreness. After the foramen is located we retract the lip and cheek of the
patient, a syringe with a long needle is inserted into the mucobuccal fold at the apex of the first
premolar. The syringe is held parallel to the long axis of the tooth and is advanced till it reaches
near the foramen. The average depth of insertion into the tissue is 16mm (half of the length of
a long needle) for an adult of average height. When the needle is in the target area, slowly
deposit 0.9 to 1.2ml of the solution. You would be able to “feel” the anesthesia solution as it is
deposited beneath the finger on the foramen. Maintain firm pressure with your finger over the
injection site for 1 or 2 more minutes to increase the diffusion of the solution into the infraorbital
foramen. For decreasing the pain on insertion of the needle and tearing of the periosteum insert
the needle with an angled position (away from the bone) and solution is deposit while the
needle is advanced through soft tissue [1].It is in no way necessary to enter the foramen.
4.8. Greater palatine nerve block
It is possible to anesthetize palatine tissue by palatal infiltration technique at any place needed
but by performing a greater palatine nerve block the posterior portion of the hard palate and
the overlying soft tissue anteriorly as far as the first premolar on one side will be anesthetized.
The foramen creates a depression in the palate usually distal to the maxillary second molar,
which can be located by palpating the area. Deposition of 0.5ml of anesthesia solution in the
region of the greater palatine foramen will block the nerve [9].
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A very rare complication is ischemia and necrosis of soft tissue of the injection region and it
only happens when highly concentrated vasoconstrictor solution is used for hemostasis over
a prolonged period [1]. It is in no way necessary to enter the foramen.
4.9. Nasopalatine nerve block
This block anesthetizes the anterior portion of the hard palate (soft and hard tissue) bilaterally
mesial to the first premolars. The technique can be performed by depositing 0.2 to 0.5 ml of
anesthetic solution adjacent to the incisive papilla. Because the soft tissue in this area is dense,
firmly adherent to underlying bone, and quite sensitive the injection in this area is very painful,
so several methods are suggested to decrease the pain. One is anesthetizing the dental papilla
between centrals labially and inserting the needle through it to the palatal side near the
foramen and depositing a little solution to partially anesthetize the soft tissue overlying the
nasopalatine nerve before the main injection [1].
4.10. Anterior middle superior alveolar nerve block
This is a relatively new technique, first demonstrated by Friedman and Hochman during
development of a computer-controlled local anesthetic delivery (C-CLAD) system [16, 17]. This
technique relies on the slow delivery and penetration of anesthetic solution through the porous
cortical bone and the nutrient canals.
About 1.4 to 1.8ml of solution (one cartridge) should be deposited very slowly (0.5ml per
minute) into the tissue halfway between the palatal midline and the premolar palatal gingival
margin. This method is best performed with a C-CLAD. This method blocks the ASA and MSA
so it anesthetizes the palate and the teeth anterior to the first molar and adjacent buccal attached
gingiva. In studies the AMSA block is shown as effective as multiple maxillary infiltrations [18].
4.11. Palatal anterior superior alveolar nerve block
This method like the AMSA block relies on slow delivery of anesthetic solution via a C-CLAD
system and was defined by Friedman and Hochman in the mid1990s [8, 17, 19]. In this approach
1.4 to 1.8ml of solution is deposited in the incisive canal at a rate of 0.5 ml per minute. This
block anesthetize the pulp of the incisors and canine bilaterally, facial periodontal tissue
associated with these same teeth and anterior hard palate. You should keep in mind that also
the injection with a C-CLAD system is not painful but it will take about 3 or 4 minutes which
some patients may be reluctant to tolerate.
5. Supplemental anesthesia techniques
These techniques include intraosseous, intrapulpal, intraseptal and intraligamentary methods.

1. Intraosseous technique: This is done through a special tool such as X-TIP. The advantages
of this method are rapid onset (less than 30 seconds), mild side effects, without the
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numbness of the lips and tongue and an atraumatic technique. Contraindications for this
method are infection and severe inflammation at the injection area. In this technique, first,
a point is recorded distal to the teeth in 2 mm apical to confluence of two lines consisting
of a horizontal line from the gingival margin and a vertical line from the interdental
papillae. The perforation of the soft tissue and bone is done at this point and the anesthetic
drug is injected into the cancellous bone. In this method, depending on the number of
teeth ¼ to 1 cartridge is used for the anesthesia. Vasoconstrictors should not be used except
where required. The duration of pulpal anesthesia in this technique will be from 15 to 30
minutes [1].Sixon's study in 2008 revealed the effectiveness of this technique as a primary
technique. For a total of 181 children and adults, 225 intraosseous injections were done
with 4% articaine. The success of this technique was reported to be 95% for primary teeth
and 87.9% for permanent teeth and it was shown that the use of this technique could be
an appropriate alternative method to classic infiltration anesthetic techniques in children
and adults [20]. Wood compared intraosseous and infiltration anesthetic techniques for
changes in heart rate and serum concentrations of the drug in 2005. For both techniques
lidocaine 2% with epinephrine 1/100000 was used. Pulse oximetery was used to assess
heart rate and blood samples were taken to check the amount of lidocaine in the serum.
Results showed significant changes in HR for intraosseous compared to the infiltration
technique but in the evaluation of lidocaine in serum, no significant difference was found
between the two methods [21].
2. Intraligamentary technique: Advantages include minimal anesthetic drug requirements,

rapid onset and the lack of tongue and lip numbness. This technique can be used as an
adjunct method after a nerve block. Contraindications include infection and primary teeth
(due to possible damage to permanent teeth). In this technique, a 27 gauge short needle
with its long axis parallel to the tooth is inserted at the mesial or distal of the dental root.
If the injection is not possible in the mesial or distal surfaces because of tight proximal
contacts, it should be applied into the buccal and lingual surfaces parallel with the long
axis of the tooth. The infusion rate must be 0.2 ml over 20 seconds. The duration of
anesthesia produced by this method is between 5 to 55 minutes [1]. In a 2005 study on 54
patients in whom IAN block did not provided appropriate anesthesia for treatment, it was
found that PDL injection provided successful anesthesia in 56% of patients (30 patients)
showed this to be a reliable method [22]. A modified technique is recommended for PDL
injection with a needle angle of 30 degrees relative to the longitudinal axis of the tooth
and the entrance point in the mesiobuccal and distobuccal area; which is a time-tested
method (Figure 7) [23].
3. Intraseptal technique: This method is indicated when there is a need for pain control and
hemostasis of soft and hard tissue simultaneously. Infection in the injection area is a
contraindication for this technique. The benefits are similar to the previous techniques.
The short duration of pulpal anesthesia and the requirement of the numerous tissue
punctures are in the context of its disadvantages. In this technique, a short 27-gauge needle
is inserted into the center of the interdental papilla. The entrance point is 2 mm below the
tip of the papilla and the direction of the needle will be towards the apex of the tooth. The
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Figure 7. Intraligamentary (PDL) technique
angle of the needle in the frontal plane must be 45 degrees relative to the long axis of the
tooth. Then 0.2 to 0.4 ml is injected [1] (Figure 8). This technique can be used for anesthesia
in the posterior mandible with dense bone and is comparable to the inferior alveolar nerve
block injection [24].
Figure 8. Intraseptal technique
4. Intrapulpal technique: In the absence of adequate anesthesia methods, this method can
be used for the endodontic treatment of teeth. The benefits consist of fast onset, mild side
effects and the lack of lip and tongue numbness. A major disadvantage is that it requires
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exposure of the pulp which limits the ability to use this method only in endodontic therapy
[1] or in the course of removal of impacted teeth.
5. Mandibular infiltration technique: This has a high success rate in children with primary
teeth but its success is reduced when children grow and the teeth change from primary
to mixed dentition and mandibular cortical thickness increases. Studies have shown that
this technique is more successfully with articaine 4% rather than lidocaine 2% but the
mechanism is yet unknown. One theory suggests that there is a thiophene loop in articaine
that provides greater penetration compared to lidocaine, which has a benzene loop [25].
6. Topical anesthesia: The use of topical anesthesia in dentistry or the treatment of
laceration is very useful especially in children. The skin needs a larger amount of drugs
for topical anesthesia because of less blood supply than mucosa. Due to the poor
solubility in water and thus reducing the systemic absorption, benzocaine is the drug
of choice for use on mucosal surfaces. Benzocaine Ointment (20%) is used for this
purpose. The onset time is 2 to 3 minutes and the duration of anesthesia is 15 minutes.
Lidocaine 5% is another common drug in this category with a similar onset and
duration of anesthesia to benzocaine. Tetracaine is the strongest surface anesthetic drug
that has be presented in a cold spray type in combination with 14% Benzocaine.
Tetracaine is also used for endoscopic procedures and gag control [1, 2]. Topical
anesthesia will not cause a completely painless injection and that depends more on the
needle gauge and duration of the injection. Topical anesthesia will be helpful for
periodontal examinations and very conservative treatments [27].
6. New local anesthetics
1. LMX: This consists of liposomal capsules containing lidocaine. Liposomes increase

lidocaine absorption in a controlled pattern and prevent its systemic toxicity. This drug
should be given 30 minutes before surgical intervention on the area in the amount of 1 to
2 mg, sufficient for an area of skin measuring 10 square centimeters [2]. In a study in 2002,
liposomal capsules of ropivacaine were compared to EMLA for topical anesthesia of the
palatal mucosa during needle entrance into the tissues in which EMLA was significantly
more successful than encapsulated ropivacaine [28].Studies have shown that other
anesthetic drugs such as bupivacaine provide a greater duration of anesthesia into the
liposomal formulation as compared to the normal [29].
2. EMLA: This cream is used widely for topical anesthesia to treat laceration and lumbar
punctures (Figure 9). This medication contains lidocaine 2.5% and prilocaine 2.5% that
penetrate well into tissues due to its micron-sized droplets. Its onset time of action
depends on blood supply for the area. On the face it starts to work within 15 minutes. Its
maximum depth of anesthesia is 5 mm and can be achieved within 120 minutes. So if more
depth is needed we should use the usual anesthetic injection techniques. The amount of
1 to 2 mg of this drug is sufficient for an area of 10 square centimeters of skin and should
be placed on the area. At least 1 hour before starting the treatment process. Use of this
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medication on the mucosa due to its systemic absorption has not yet been approved [2].
Studies have reported that the analgesic effect of EMLA for periodontal probing and
scaling is more than 5% prilocaine ointment. The use of 4 g of EMLA for the creation of
analgesia is recommended for the removal of arch bars [30]. The study of Hassio in 1990
showed no difference between 10% lidocaine spray and EMLA for topical anesthesia of
the gums. The level of anesthesia at 13-14 minutes measured by EMLA-apparatus was
equal in both. The sensitivity of the gums returns to normal within 30 minutes. No toxic
reactions were observed but it is said that the absorption of EMLA is faster than lidocaine
spray [31].
Figure 9. EMLA
3. LET: This drug is a combination of lidocaine 4%, epinephrine 0.1% and tetracaine 5%
which is available in two types including methylcellulose gel or an aqueous solution.
Often used to repair lacerations in children and because of the presence of epinephrine;
this drug should not be used in extremities such as fingers, ears or the nose. LET should
be given on the area 20 minutes before the start of the treatment and its duration is 40
minutes [2].
4. Microparticulate formulations: In this formulation, to increase the duration of anesthesia

and reduce the side effects, various drugs and combinations are added to the local
anesthetic drugs. For example, the addition of dexamethasone to lipid - protein - sugar
particles containing bupivacaine caused the doubling of the nerve block time. These
techniques can be used for chronic facial pain or to facilitate physiotherapy in muscle
dysfunction [2].
5. TAC: TAC is the combination of cocaine 4-11 %, epinephrine 0.025-0.05 % and tetracaine
0.25-0.5 % which begins to work in 10 to 15 minutes and has a duration of 15 to 25 minutes.
It can be used to treat children lacerations but has complications such as hypertension,
seizures and systemic toxicity [32].
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6. Drug Combination: The combination of local anesthetic drugs with systemic analgesic
drugs such as morphine can reduce the amount of pain during and after the surgery [33].
In general, the combination of opioid with anesthetic drugs reduces the need for analgesics
after surgery and increases the duration of anesthesia but has side effects such as nausea
and vomiting. The combination of alpha-2 adrenergic agonists such as clonidine, espe‐
cially with medium-acting anesthetic medications, increases the potential of these drugs.
The drug side effects include bradycardia, hypotension and dryness of the mouth, which
of course are caused by doses greater than 2 micrograms per kilogram. Ketamine,
midazolam and magnesium can increase the power of anesthetic drugs but they must also
be considered for their neurotoxic properties. Symptoms such as hallucination and
sedation occur following the use of these drugs [34].
7. New techniques
1. Electronic dental anesthesia (EDA): This technique is based on the TENS (transcutaneous
electronic nerve stimulation) and the electronic waves are used to disrupt neural pain
transmission to the brain. Research on this technique continues for use in the dental field
[1].
2. Needle-free injection: The injection system is based on a piston-pressure system and

several systems are introduced such as PED-O-JET, SYRIJET and MED-E-JET. These
techniques are widely used for daily injections of insulin in diabetics. In studies, these
systems showed less pain compared to conventional injections with a needle gauge of 25
(Figure 10).[1]
Figure 10. SYRIJET needle-free injection.
1. Computer controlled injection: In this technique, computer controls the speed and
injection pressure. C-CLADS (computer controlled local anesthetic delivery system) has
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less pain and discomfort for patients than conventional syringe injections, but requires
greater facilities, more space and higher costs [1].
2. Ionthophoresis: This is a new technique for the transdermal administration of lidocaine.
In this way, the two external electrodes on the skin are used to make the transition of
ionized lidocaine from the stratum corneum layer to the dermis layer to block the nerve
ends. Drug penetration rate in this technique is higher than the passive diffusion. The 0.6
to 1 mL of lidocaine 2% with 0 to 4 mA electrical current is used during 10 minutes which
causes 5 to 7 mm of drug penetration to the tissue and provides anesthesia [2].
3. Thermal: Ice can be used to create a temporary anesthesia for injection or treat small
lacerations. For this purpose, the ice should remain on the skin for more than 10 seconds.
Ethyl chloride spray as an alternative method can be used for 1-2 seconds, but the duration
of anesthesia will be less than caused by ice. These techniques with the saline containing
benzyl alcohol are used in hair transplantation [1].
4. STA system device: This is an auxiliary system for injection especially made for PDL
injections where the dynamic pressure sensory system improves the quality and reduces
the side effects of injections. Low-pressure dynamic injection in this technique prevents
tissue damage and pain during the injection. In addition, the injected anesthetic drug
leakage is detected and prevents creation of an unpleasant taste in the patient’s mouth.
However, this technique requires the computer system tools [1].
5. Intranasal local anesthesia: In the past, the use of nasal mucosa was conventional due to
the high blood supply and ability to achieve the systemic effects of drugs. Nowadays for
the nasal mucosa and even upper teeth numbness, anesthetic drugs (especially tetracaine)
are used on the nasal mucosa. Studies have shown that the use of intranasal tetracaine
with a vasoconstrictor such as oxymetazoline can provide tooth anesthesia for the first
molar on one side to the first molar on the other side and dental procedures can be
performed for the teeth, without need to inject anesthetic drugs [1].
6. Phentolamine mesylate (Oraverse): The injectable form of phentolamine (alpha adrener‐
gic receptor antagonist) can be used to terminate drug-induced local anesthesia when it
is not required. Especially in high risk populations, where children and the elderly can
inadvertently damage the tissues inside the mouth. Soft tissue numbness causes problems
with normal functions such as talking, laughing, eating and drinking and can sometimes
cause tissue damage. To prevent this situation, a 1.7 mL dental cartridge containing 0.4
mg phentolamine mesylate is used. In this way, the approximate time for the return of
normal sensation will be about half. For example, the normal sensation of the tongue will
return within 60 minutes with phentolamine mesylate and 125 minutes without it [1].
7. Electrospun drug-eluting suture: Contains absorbable sutures with PLGA chemical
structures that are combined with bupivacaine. The sutures can slowly release the drug
to the surgical site within 12 days and provide appropriate analgesia. Higher concentra‐
tions of the anesthetic drug cause a decrease in the suture tensile strength. The suture
tissue reaction is comparable to regular PLGA sutures without the combination of
anesthetic drugs [35].
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8. Intraoral lidocaine patch (dentipatch): This patch contains 10-20% lidocaine which is
placed on dry mucosa for 15 minutes and provides suitable anesthesia for the mandible
and maxilla [36].
9. Jet–injection: In this technique, a small amount of anesthetic drug driven into the
submucosa without a needle. The air pressure is used for the infiltration of the drug into
the mucosa through tiny pores. This method is particularly useful for topical anesthesia
for palatal injection [36].
10. Vibrajet: It is a device that provides high frequency vibrations in the dental injection
syringe which causes a relative decrease in pain during the injection [37].
11. Accupal: This is a tool to create pressure and vibration at the injection site. These men‐
tioned irritate the larger nerve fibers and cause the lack of sensitivity during the penetra‐
tion of the needle [37].
12. TENS (transcutaneous electronic nerve stimulation): The result of this method in patient
comfort and it provides less pain during the injection. This has been demonstrated
especially for IAN nerve block techniques, while topical anesthesia does not cause
significant changes to reduce pain during the injection. This technique stimulates the
nervous system and it starts before injecting and the pulse rate increases to make a good
shake to the patient. The needle is inserted at an area between the electrodes of TENS
while generated impulses are continuing at the same level. After withdrawing the
injection and removing the needle, pulses are slowly reduced and stopped (Figure 11). [38]
Figure 11. Transcutaneous electronic nerve stimulation

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8. Complications
The complications of the injection of local anesthetic drugs can be divided into two parts
namely systemic and local complications, explained below.
8.1. Local complications
1. Pain during injection: The main reason for this is high-speed injection which can be
avoided by injecting each cartridge slowly within a minute. The temperature of the drug
also causes pain. The ideal temperature for injection is room temperature. The use of sharp
needles, topical anesthesia before injecting and regulating the pH of the drug at 7.4 can
help to reduce pain during injection [1].
2. Trismus: Its causes include damage to muscles and blood vessels at the infratemporal
fossa, damage of the pterygoid muscle, hemorrhage caused by injection and massive
volumes of anesthetic drugs. The use of sterile needles, refraining from repeated injections
in one area and the use of the minimum effective dose can prevent it. In the case of trismus,
it’s recommended to use a warm wet towel and physiotherapy for opening the mouth,
with the use of anti-inflammatory drugs, analgesics and muscle relaxant drugs such as
diazepam. It is important that the patients with continued trismus be referred to a
maxillofacial surgeon [1, 2].
3. Hematoma: This occurs mostly due to the damage of mental vessels or pterygoid venous
plexus. Injections for blocking the inferior alveolar nerve and PSA can cause a large
hematoma. The knowledge of the area’s anatomy, changes in injection techniques based
on patient-specific anatomy and the reduction of frequent needle penetration into the
tissues can be helpful in preventing hematoma. Injection for the PSA block is the most
common type of anesthetic technique leading to a hematoma. If the hematoma occurs, it
is recommended to apply direct pressure on the area, analgesic, anti-inflammatory drugs
and placement of ice on the swelling [1]. A study by Bajkin conducted in 2010 showed
that there is little risk of hemorrhage and hematoma even in patients taking oral antico‐
agulant if the correct injection technique is used. Undoubtedly PDL and intraseptal
techniques reduce the risk of hematoma more than routine IAN block techniques.
Vasoconstrictors and thin needles may help the clinician prevent it [39].
4. Infection: This is a very rare complication with contaminated injection needles as the most
common cause. The use of sterile needles, disposable cartridges and application of topical
antiseptics can be effective in preventing it. Infections have symptoms such as pain and
dysfunction. When it occurs, the prescription of antibiotics (penicillin V 500 mg every 6 h
for 7-10 days), analgesics, heat, drainage and physiotherapy are recommended for
treatment [1, 2].
5. Breakage of injection needles: Excessive force during injection, bent needles and
unfamiliarity with anatomy are the causes of this rare event. The thin needles (30 gauge)
break more often than thicker needles. In case of an accident the patient should be
referred immediately to a maxillofacial surgeon. The routes of preventing this in‐
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clude not using a 30 gauge needle for IAN block injection, not bending the needles¸
preventing full penetration of the needle into the tissues and precision during injection
for young patients or children that can make sudden moves resulting in needle
breakage [1].When the needle breakage occurs during the inferior alveolar nerve block
injection, it can often be found in the pterygomandibular space, but can migrate to
adjacent vital structures and cause damage to them (Figure 12). An unusual case of
broken needle displacement during the IAN block injection into the external audito‐
ry canal is reported for a 25-year-old woman [40].
Figure 12. Broken needle shown in the panoramic radiograph
6. Long-term sensory changes: This can be due to direct damage to nerves and the contam‐
ination of local anesthetic drugs with alcohol that has a neurolytic effect. The most
common sensory change is paresthesia. Direct damage is the most common cause of long-
term sensory changes, which happens through three mechanisms. Firstly, injury to the
nerve fibers. Secondly, the destruction of small vessels in epineurium and the creation of
interneural hemorrhage. Finally, the destruction of connective tissue and creation of
edema sets in. The dose and concentration of the local anesthetic drugs are contributing
factors in this process. According to studies, high concentration drugs such as 4% articaine
and prilocaine can cause long-term sensory changes more than other drugs. During
injection, the lingual nerve is affected more than other nerves by direct damage. Sensory
changes usually resolve within 8 weeks during which the patient should be informed and
re-injection of the drug in the affected area should be avoided [2].
7. Facial nerve paralysis: Temporary damage to the facial nerve can occur as a result of the
spread of local anesthetic drugs to the parotid capsule. Great penetration of the needle in
the Akinosi-Vazirani technique or the inappropriate posterior direction of the needle in
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the IAN block injection can cause this complication. Prevention is the best cure. When it
occurs, inform the patient of the incident, removal of eye lenses and eye protection should
be carried out. It must be explained that nerve function will return to normal within a few
hours [2].
8. Soft tissue damage: After injection, children often bite their lips and cheeks, followed by
numbness in these areas (Figure 13). Avoidance of anesthetics with long-term effects,
placement of cotton rolls between the teeth and lips, informing the patient to not use warm
materials and not bite the oral tissues are effective ways of preventing soft tissue damage.
If this happens we need to check for the appropriate use of antibiotics, analgesics and
overlying creams on the injury site [1]. In cases of soft tissue injury following numbness,
correct diagnosis is very important. Sometimes misdiagnosis causes incorrect treatment
such as hospitalization, unnecessary surgical interventions and administration of sys‐
temic antibiotics due to improperly suspected bacterial infections. Effective communica‐
tion between dentists and other medical staffs can help prevent these events [41].
Figure 13. After injection, children often bite their lips and cheeks, because of numbness in these areas.
9. Burning during the injection: Burning during injection is a relatively common condition
due to low pH and acidity of the local anesthetic with vasoconstrictors, rapid drug
injection and contamination of anesthetic drugs with alcohol or sterilizing solutions. To
prevent it, the pH of anesthetic drugs should reach 7.4 by buffering the solution before
injection. The reduction of injection speed and the maintenance of drugs at room temper‐
ature, away from alcohol or sterilizing solution are the other preventing factors. Burning
during the injection is transient and does not require specific care [1].
10. Tissue sloughing: This occurs due to prolonged use of topical anesthesia drugs or
ischemia caused by prolonged use of vasoconstrictor drugs on palatal tissue, of which
sterile abscess and epithelial desquamation are symptoms. For prevention, topical
anesthetic drugs should only be used for one to two minutes and the use of high concen‐
tration vasoconstrictor solutions should be limited. If it occurs, it is not necessary to do
anything specific except for pain relief. This condition will resolve spontaneously within
7 to 10 days [1, 2].
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11. Intraoral lesion occurrences after injection: Recurrent aphthous stomatitis and herpetic
lesions originate from this type of lesion that can occur two days after the injection due to
the trauma of the needle at the injection site. Treatment will be palliative and the lesions
will resolve spontaneously within 7 to 10 days [1].
12. Eye complications: Eye complications can occur following the injection of anesthetic
drugs in the maxilla and mandible. A permanent loss of vision is reported following a
prilocaine injection for tooth extraction in a 73-year-old man prior to surgery for the mitral
valve. Visual injury following the injection of anesthetic in dentistry is extremely rare and
its mechanism is unknown. A possible etiology is retinal and choroid artery occlusion
following the intra-arterial injection which strongly emphasizes the need for aspiration
prior to the injection [42]. The next case is a report of paralysis of the right lateral rectus
muscle and blurred vision after IAN block and infiltration injections were done in the
right maxilla to extract the number 8 tooth in the right mandible and maxilla in a 22-year-
old woman who had been normal in terms of systemic health. In this patient, blurred
vision and diplopia resolved 6 hours after the injection. The mechanism of this condition
is deep anesthetic injections in the retromaxilla, drug diffusion through the greater
palatine channel and the lack of the bony barrier between the orbit and this area [43]. In
general, the most common ocular complications due to anesthetic injection include:
diplopia, mydriasis, eyelids ptosis and abduction disorder and damaged eye. These
complications can occur several minutes after the injection and can resolve spontaneously
without causing permanent injury and a known mechanism for them is anesthetic drug
diffusion to the orbital area [44].
13. Rare complications: There are reports of osteonecrosis following the intraosseous
injection probably due to the heat of bone drilling done to make a perforation hole for the
injection (Figure 14). In addition, systemic disease, such as diabetes and HIV can also have
an effect in creating this phenomenon [45].
Figure 14. Osteonecrosis following the intraosseous injection

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8.2. Systemic complications
1. Overdose: Due to a low dose of local anesthetic drugs in dentistry, its prevalence is low.
Early symptoms include muscle twitching, shivering, tremor and tonic-clonic seizures.
The next symptom that occurs with increased blood toxicity doses is sedation. Respiratory
depression and lethargy and ultimately cardiovascular dysfunction will lead to arrhyth‐
mias and bradycardia. Some prognostic factors such as very high and very low ages
(because of a lower metabolic rate and increase in the half-life of the drug), patient weight,
medications (antidepressant, H2 blocker, anti-dysrhythmia drugs), gender (due to the
impairment of renal function the risk of overdose increases during pregnancy) and,
genetics (genetic deficiency in serum cholinesterase enzyme) should warn us about the
risk of overdose. High drug concentration (> 2%), the absence of vasoconstrictors, high-
speed injection and the vascularity of the injection area can increase the risk of overdose.
Aspiration in at least two planes before the injection, slow injection, dosage adjustment
and review of the patient's age, sex, weight, diseases and medications can prevent or
reduce the risk of overdose. If the symptoms of overdose occur, the necessary measures
are taken including PABCD protocol (position – airway – breathing – circulation –
definitive cure). Definitive cures include oxygen prescription, vital signs monitoring,
application of anti-seizure medications such as midazolam and stopping the dental
procedure. The overdose of vasoconstrictors (such as epinephrine) can result in a rapid
increase in blood pressure (primarily in systolic pressure). Tachycardia and cardiac
dysrhythmia which will have symptoms such as tremor, anxiety, dizziness, weakness,
fatigue and difficulty in breathing may be seen. Treatment will include PABCD protocol,
prescription of oxygen (except in hyperventilation) and monitoring of vital signs
[2].Unfortunately, a large percentage of dentists do not have enough information about
how to determine and calculate the dose of anesthetic drugs (87%) and about 53% of them
do not aspirate when injecting [46].
2. Allergy: Because of the presence of Para Amino Benzoic Acid (PABA), this occurs more
for ester anesthetic drugs. Allergy to an amide local anesthetic drug does not prevent the
use of other types of amid anesthetic drugs because the cross-sensitivity to these drugs is
not seen. If there is a sensitive reaction to both types of local anesthetic drugs, diphen‐
hydramine solution (0.5 – 1 %) should be used for anesthesia. Allergic reactions include
dermatitis, respiratory symptoms (respiratory distress, dyspnea, cyanosis, tachypnea)
and generalized anaphylaxis that is a life-threatening condition. Symptoms of anaphylaxis
include skin reactions, gastrointestinal smooth muscle spasm (muscle cramps), respira‐
tory distress and cardiovascular collapse. In case of allergies, the PABCD protocol should
be implemented. Definitive cure includes prescription of oxygen (5-6 liters per minute),
intramuscularly epinephrine in the vastus lateralis with a dose of 0.3 mg for patients
weighing more than 30 kg and 0.15 mg for patients weighing less than 30 kg, histamine
blocker drugs (50 mg Diphenhydramine or 10 mg Chlorpheniramine), Corticosteroids
(100 mg Hydrocortisone) and the cricothyrotomy if needed [2].
3. Methemoglobinemia: It occurs due to the oxidation of the iron atoms in hemoglobin by

local anesthetic drugs such as prilocaine that causes a defect in the transportation of
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oxygen and leads to cyanotic conditions in patients 1 to 3 hours after the injection of
anesthesia. The symptoms of cyanosis are created when levels of methemoglobin reach
10 to 20 percent. Increase of methemoglobin levels causes various symptoms such as
dyspnea and tachycardia. Children, with methemoglobin reductase and G6PD enzyme
deficiency are at a higher risk than other people to methemoglobinemia. The treatment of
methemoglobinemia is the intravenous injection of 1-2 mg/kg methylene blue [1].
4. Malignant Hyperthermia: MH is determined by the increase in body temperature, muscle

stiffness and increased oxygen consumption. The role of anesthetic drugs in the creation
of MH is still controversial. This condition is more common in children than adults [2].
5. Drug interactions: There are no absolute contraindications to the use of medicinal drugs
together with local anesthesia and vasoconstrictors but sometimes there is a need to reduce
or adjust the dose of drugs. The chieftains of these drugs are the blood pressure lowering
medications. For example, epinephrine in combination with beta-blocker drugs can
greatly increase the systolic blood pressure and calcium channel blockers can cause
hyperkalemia related to epinephrine. Also beta-blockers reduce hepatic blood flow and
decrease the metabolism of anesthetic drugs leading to their increased toxicity [1, 2].
6. Hemodynamic alterations: Following the injection of anesthetic drugs in the presence or

absence of vasoconstrictors, diastolic blood pressure increases slightly. In the presence of
vasoconstrictors, systolic blood pressure increases more than anesthetic drugs without
them. Blood glucose increases by administering anesthetic drugs containing vasocon‐
strictors [47]. However, changes in blood pressure in the presence of an anesthetic were
not significant and do not jeopardize the patient's hemodynamics but studies have shown
that if you do not inject anesthetic drugs hypertension will be noticeable during dental
treatment [48].
Author details
Mohammad Ali Ghavimi*, Yosef Kananizadeh, Saied Hajizadeh and Arezoo Ghoreishizadeh
*Address all correspondence to: m_ghavimi@yahoo.com
Faculty of Dentistry, Tabriz University of Medical Sciences, Tabriz, Iran
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and maxillofacial tissues. Pain. 2005;115(3):348-54. Epub 2005/05/07.
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Chapter 2
Crestal Anesthesia for Dentoalveolar Surgery
Koroush Taheri Talesh, Shiva Solahaye Kahnamouii,

Mohammad Hosein Kalantar, Motamedi,
Shahram Mehrzad and Javad Yazdani
http://dx.doi.org/10.5772/59162
1. Introduction
Predictable anesthesia is an essential requirement for both the patient and the dentist. The
patient’s opinion about the dental treatment is closely related to the local anesthesia (LA)
experience and the proper use of LA techniques and pain management which are indispen‐
sable for successful dental treatment. In modern dentistry, creating favorable local anesthesia
is an important factor in patient satisfaction and relaxation, the general view of the most
successful dentist is one who can do without pain and anxiety for patients. Local anesthesia is
a technique that is indispensable for dental professionals. Preventing pain during dental
treatment is the ultimate goal of all dentists who are working in their profession. Sometimes
problems can prevent them from achieving this goal. These problems include: lack of anes‐
thesia in patients with possible aberrations, inner fears, infections etc. There are many causes
for the occurrence of these problems, including: biological diversity in response to medications,
anatomical differences between patients and considerable fear and anxiety associated with the
injection of local anesthesia. Although this problem may arise in any part of the oral cavity, it
most often occurs in the mandibular second molars. In the absence of complete anesthesia,
performing dental treatment cannot be done and a significant number of cases of medical
emergencies have arisen during dental treatment without LA. Although pain control is
accomplished successfully in most cases, some anesthesia techniques like mandibular block
are accompanied by drawbacks including difficulty in achieving anesthesia because of
anatomic variations, deep and invasive needle penetration, paresthesia, trismus, paralysis,
transportation of oral microbial flora to anatomic spaces, delayed onset of anesthesia, hema‐
toma formation, high incidence of positive aspiration, undesired soft and/or hard tissue
anesthesia with possible patient-induced injury, and difficulty in hemostasis in those with
bleeding disorders. [1]
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The inferior alveolar nerve block (IANB) is the most commonly used injection technique for
achieving local anesthesia for mandibular restorative and surgical procedures. However, the
IANB does not always result in successful pulpal anesthesia. Failure rates of 7 to 75% have
been reported in experimental studies.
Supplementary anesthetic injection methods have evolved to circumvent the above disadvan‐
tages. These include intrapulpal, intraosseous, intraseptal and intraligamentary injections.
Giffin introduced crestal anesthesia (CA) as a new variation of intraosseous anesthesia, which
he claimed was tested for different dental procedures ranging from simple restorations to
extractions. The technique relies on alveolar crestal perforations formed by canals of Zucker-
kandl and Hirschfeld, which provide gingiva with innervation and circulation. Since then
some have commented on the technique and approved it. However, to the best of our knowl‐
edge, no systematically designed case-controlled study has been done to evaluate its benefits
and disadvantages. This chapter assesses our experience with this technique in the mandible.
Mandible anatomy the mandible, the largest and strongest bone of the face, encases the lower
teeth. It consists of a curved, horizontal portion, the body, and two perpendicular portions,
the rami, which unite with the ends of the body nearly at right angles.
2. Mandibular canal
In human anatomy, the mandibular canal is a canal within the mandible that contains the
inferior alveolar nerve, inferior alveolar artery, and inferior alveolar vein. It runs obliquely
downwards and forwards in the ramus, and then horizontally forward in the body, under the
alveoli and communicates with them by small openings. On arriving at the premolar teeth, it
exits via the mental foramen; a small branch known as the mandibular incisive nerve continues
to the incisor teeth (Figure 1).
Figure 1. On arriving at the premolar teeth, the IAN exits via the mental foramen; a small branch known as the incisive
nerve continues to the incisor teeth through the bone.
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Crestal Anesthesia for Dentoalveolar Surgery 35

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The lamina dura is the part of the alveolar bone that lines the socket; it is a thin layer of dense
cortical bone called the lamina dura made of immature bone that lies adjacent to the perio‐
dontal ligament; lamina dura surrounds the tooth socket and provides the attachment surface
which Sharpey's fibers of the periodontal ligament perforate. On an x-ray the lamina dura
appears as a radiopaque line surrounding the tooth root. An intact lamina dura is seen as a
sign of healthy periodontium. The lamina dura, along with the periodontal ligament, plays an
important role in bone remodeling and thus in orthodontic tooth movement. The bone that
underlies the lamina dura is cancellous bone. Under the lamina dura is the less dense cancel‐
lous bone. Trabeculii are tiny spicules of bone crisscrossing the cancellous bone that make it
look spongy. These trabeculii separate the cancellous bone into tiny compartments which
contain the blood producing marrow.
The alveolar process is the thickened ridge of bone that contains the tooth sockets in the maxilla
and the mandible. It is also referred to as the alveolar bone. The mineral content of the alveolar
bone is mostly hydroxyapatite, which is also found in enamel as the main inorganic substance.
The buccinator muscle attaches to the alveolar processes of both the maxilla and mandible.
The periodontal ligament (PDL) is a group of specialized connective tissue fibers that
essentially attach a tooth to the alveolar bone within which it sits.[1] These fibers help the tooth
withstand the substantial natural compressive forces which occur during chewing. It consists
of cells, and extracellular compartments of fibers. The cells are fibroblast, epithelial, undiffer‐
entiated mesenchymal, bone and cementum cells. The extracellular compartment consists of
collagen fiber bundles embedded in ground substance. The PDL substance has been estimated
to be 70% water and is thought to have a significant effect on the tooth's ability to withstand
stress loads. The PDL is a part of the periodontium that provides for the attachment of teeth
to the surrounding alveolar bone by way of the cementum. The PDL appears as the dark space
(0.4 to 1.5 mm on radiographs), or radiolucent area between the radiopaque lamina dura of
the alveolar bone proper and the radiopaque cementum.
In modern dentistry, providing an efficient and localized anesthesia is a must. The reality is
that without anesthesia, one cannot perform safe treatment. In some occasions the anesthetiz‐
ing techniques are accompanied by some drawbacks especially in mandibular block anesthesia
such as: difficulty in achieving anesthesia (due to anatomic variations); deep and invasive
needle penetration, paresthesia, trismus, paralysis, transportation of oral microbial flora to
anatomic spaces, delayed onset of anesthesia, hematoma formation, high incidence of positive
aspiration, undesired soft and/or hard tissue anesthesia with possible patient induced injury
and difficulty in hemostasis in patients with bleeding disorders.(3-20)
Supplementary anesthetic injection methods have evolved to circumvent the abovemen‐

tioned disadvantages. These include intrapulpal, intraosseous, intraseptal and intraligamen‐
tary injections. Giffin introduced a new variation of intraosseous anesthesia -Crestal
Anesthesia (CA) - which he claimed was tested on more than 6000 teeth for different dental
procedures ranging from simple restorations to extractions. The technique relies on alveolar
crestal perforations formed by foramina of Zuckerkandl and Hirschfield (17), which provide
gingiva with innervation and circulation (Figure 2).
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Figure 2. Alveoli of mandibular teeth. Note that the foramina of the nutrient canals are greater both in number and
size in the interdental bone (arrow) comparing to marginal bone (*)
Since, then some have commented on the technique and approved it. (9) We also assessed this
technique on 69 systemically and mentally healthy individuals between 18 and 47 years
randomly selected from patients referring to the department of oral and maxillofacial surgery
in Tabriz during 2003-2005. We did a split-mouth case-control clinical trial.
Crestal anesthesia technique: A regular dental anesthetic syringe and a standard short 27
gauge needle are used. Then an interdental gingival papilla is selected adjacent to the tooth or
area to be anesthetized. A topical anesthetic agent (in this study benzocaine) is applied with a
cotton-tipped applicator and the syringe is positioned so that as the papilla is penetrated,
needle bevel and orifice are positioned subperiosteally adjacent to bone and crestal nutrient
canals (Figure 3).
Then, using significant pressure the anesthetic agent is injected. This procedure should last at
least 20 sec. usually 1/8 of a standard anesthetic cartridge suffices per papilla. One or both of
the papilla (in case of inadequate numbness) can be used for the procedure. In this study, we
used both papillae to get adequate anesthesia required for extraction. A classic direct Inferior
Alveolar Nerve Block (IANB) plus long buccal nerve block was performed on the contralateral
side for purpose of comparison. All of the extractions were completed in less than 10 minutes.
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Figure 3. CA technique. Note the pooling of the injectate in subperiosteal area (P). B = alveolar bone, PA =interdental
papilla
All had 2 bilateral posterior teeth (premolars, first and second molars) to be extracted. All
patients were asked to rate the injection pain based on a scale of 0-5, where 0 represented no
pain, 1 mild pain, 2 moderate pain, 3 moderate to severe pain, 4 severe and 5 intolerable pain.
The contralateral canine was used as the unanesthetized control to ensure that the pulp tester
was operating properly and that the subject was responding appropriately during the
experiment. At the beginning of each appointment and before any anesthetic, the experimental
tooth and the control canine were tested 3 times using a pulp tester (Gentle-Pulse, Parkell,
Farmingdale, NY, USA) to record baseline vitality. The criterion for pulpal anesthesia was an
absence of response by the patient to the maximum output (10). To record the changes
(increase) of blood pressure an automatic digital blood pressure monitor (Omron HEM-711AC,
Omron Healthcare Inc, Bonnockbum, Il, USA) was used. The blood pressure was recorded 5
sec prior to the penetration of syringe's needle to record the baseline blood pressure. Then we
recorded the pressure immediately after the injection was initiated terminated and immedi‐
ately before its termination. Again an average of 2 recordings was used to compare the
difference of blood pressure in the 2 techniques. In order to compare, the administered volume
of the anesthetic solution, anesthetic cartridges were stamped with milliliter marks and the
used volume was recorded. CT scan of the lower jaw after the CA injection (using the men‐
tioned combination of anesthetic solution and radiopaque agent previously tested on rabbits)
to show the solution's penetration; the diffusion of the anesthetic solution can be seen in Figure
4 a-e; note the opaque area in the injection site that is a result of the instant diffusion of the
injected contrast medium (anesthetic agent + opaque media).
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Figure 4. a-e: Penetration of radiopaque contrast media in cancellous bone shows penetration after crestal injection on
axial CT scan.
Our study showed there was a statistically significant difference (p<0.001) in the onset of
anesthesia between CA (7.00+0.71 sec) and IANB (3.30+0.67 min). A statistically significant
difference was also present (p<0.05) between the duration of anesthesia in CA and IANB which
lasted 23.10+2.13 min and 32.10+2.02 min respectively. Thus, the anesthesia was virtually
instantaneous for CA and more lasting in IANB. The anesthetic success rates are presented in
Table 1.
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Table 1. Percentage (No.) of successful anesthesia gained by Crestal Anesthesia (CA) and Inferior Alveolar Nerve
Block (IANB) techniques
There were no significant differences in heart rate increase between CA (0.58+0.32 beat min')
and IANB (0.97+0.00 beat min') (p> 0.05). Blood pressure increased 0.00+0.07 mmHg in CA and
0.97+0.00 mmHg in IANB. There was no statistically no difference between them (p>0.05). Only
about a 5th of an anesthetic cartridge (0.40+0.07 mL) was used in CA. On the other hand, IANB
needed about five times more anesthetic solution (1.99±0.06 mL) for initiating the anesthesia.
Most of the pain ratings were in the moderate to severe and severe categories for IANB
(3.44+0.22) and only in the moderate to severe category for CA (1.45+0.18) and there was a
statistically significant difference between them (p<0.001).
The majority of patients receiving CA appreciated not having discomfort and incapacitation
often experienced with IANB anesthesia.
One patient with IANB anesthesia developed dry socket she was not a smoker and no other
reasonable rationale was found for this occurrence. By the end of three month follow up we
found no problems that could be attributed to CA.
3. Conclusion
Although, the CA method or other similar methods of injection such as the intraseptal method
(utilizing the alveolar bone nutritional canals) are traditionally considered as supplementary
injections, they are successfully used by numerous clinicians as a primary route of anesthetic
administration and high success rates of anesthesia and satisfaction both by patients and
dentists have been obtained.
The benefits of conventional Intraosseous Injections (I0I) are clearly known. With the advances
in this area and introduction of new instruments and techniques patients and dentists benefit
from profound anesthesia without unnecessary lip and tongue anesthesia. Unfortunately
above facts have not made IOI as popular as the infiltration and block techniques.
Unsuccessful injections in the premolar region may be due to dense cortical bone of mental
foramen that acts like a dam and reduces the diffusion rate of anesthetic solution. Also reduced
diameter and fewer nutrient canals compared to posterior region may play a role. Reported
primary intraligamentary anesthesia success rates of 74-92% were <99% observed in CA. (10)
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It seems that the high success rate of CA is due to fast (or even immediate) diffusion of
anesthetic agent through the very porous region of the tooth socket.
Longer duration of anesthesia in IANB compared to CA was an expected finding. CA produced

duration of anesthesia similar to those of reported intraligamentary injection (2).
Another advantage of CA is its 0% of positive aspiration. The above facts might explain the
reason for the statistically lesser readings of blood pressure and the heart (pulse) rate. As with
intraosseous types of injections, the CA allows bilateral treatment of mandibular areas without
complete mandibular numbness or lack of tongue control.
CA injections penetrate the uncomplicated tissue structures aseptically that probably account
for mild post injection discomfort (gingival soreness). The presence of anatomical anomalies
such as tori at the proposed site of injection would preclude the dentist from using the CA
effectively.
Crestal anesthesia is an efficient, fast, and reliable technique in posterior mandibular dental
restorative procedures and may be considered as a reliable and safe primary injection method
in posterior mandibular teeth for exodontias or restorative dental procedures.
Author details
Koroush Taheri Talesh1, Shiva Solahaye Kahnamouii1*, Mohammad Hosein Kalantar,

Motamedi2, Shahram Mehrzad3 and Javad Yazdani1
*Address all correspondence to: shiva.kahnamouii@gmail.com
1 Tabriz University of Medical Sciences, Tabriz, Iran
2 Trauma Research Center, Baqiyatallah University of Medical Sciences and Azad Universi‐
ty of Medical Sciences, Tehran, Iran
3 Private Practice, Country
References
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[2] Dower, J.S. Jr. and Z.M. Barniv, 2004. Periodontal ligament injection: Review and rec‐
ommended technique. Gen. Dent, 52 (6): 537-542.
[3] J. Weaver, 1987. An evaluation of electric pulp tester as a measure of analgesia in hu‐
man vital teeth. J. Endod., 13: 233-238.
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[4] Fish, L., D. McIntire and L. Johnson, 1 989. Temporary paralysis of cranial nerves III,
IV and VI after a Gow-Gates injection. JADA., 119: 127-30.
[5] Giffin, K.M., 1 994. Providing intraosseous anesthesia with minimal invasion. JADA,
125: 1119-11121.
[6] Goebel, W., 1 983. Multiple techniques of mandibular analgesia. Gen. Dent, 31:
216-220.
[7] Gow-Gates, G., 1973. Mandibular conduction anesthesia: A new technique using ex‐
traoral landmarks. Oral. Surg. Oral. Med. Oral. Pathol., 36: 321-328.
[8] Kafalias, M., G. Gow-Gates and G. Saliba, 1 987. The Gow-Gates technique for man‐
dibular block anesthesia: A discussion and a mathematical analysis. Anesth. Prog.,
34: 1 42-1 49.
[9] Kama, J.C., 1994. Intraosseous pressure anesthesia. JADA, 125 (11): 1420-1421.
[10] Kaufman, E., L. LeResche, E. Sommers, S. Dworkin and E. Truelove, 1 984. Intraliga‐
mentary anesthesia: A double-blind comparative study. JADA, 108: 175-178.
[11] Khedari, A., 1982. Alternative to mandibular block injections through intraligamental
anesthesia. Quintessence Int., 2: 231-237.
[12] Kleber, C.H., 2003. Intraosseous anesthesia: Implications, instrumentation and tech‐
niques. JADA,134 (4): 487-491.
[13] Malamed, S., 1981. The Gow-Gates mandibular block. Oral. Surg. Oral. Med. Oral.
Pathol., 51: 463-467.
[14] Malamed, S., 1982. The Periodontal Ligament (PDL) injection: An 0alternative to infe‐
rior alveolar nerve block. Oral. Surg. Oral. Med. Oral. Pathol., 53: 117-1721.
[15] Malamed, S., 2005. Hand Book of Local Anesthesia.5th Edn. Mosby, St. Louis.
[16] Reams, G. and J. Tinkle, 1989. Supplemental anesthetic techniques. J. Ore. Dent. As‐
soc., 58: 34-39.
[17] Schroeder, H. and R. Page, 1990. The normal periodontium. In: Shluger, S., R. Youde‐
lis, R. Page, R. Johnson (Eds.). Periodontal diseases. Philadelphia: Lea and Febiger,
pp: 31-77.
[18] Walton, R., B. Abbott, 1 981. Periodontal ligament injection: A Clinical Evaluation.
JADA, 103: 571-575.
[19] Watson, J. and G. Gow-Gates, 1992. Incidence of positive aspiration in Gow-Gates

mandibular block. Anesth. Pain Control Dent, 1: 73-76.
[20] Watson, J., 1973. Some anatomic aspects of Gow-Gates technique for mandibular an‐
esthesia. Oral. Surg. Oral Med. Oral. Pathol, 36: 328-330.
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Chapter 3
Modified Jorgensen and Hayden Approach to Intraoral

Mandibular Anesthesia
Flaviana Soares Rocha, Rodrigo Paschoal Carneiro,

Aparecido Eurípedes Honório Magalhães,
Darceny Zanetta-Barbosa,
Lair Mambrini Furtado and
Marcelo Caetano Parreira da Silva
http://dx.doi.org/10.5772/59163
1. Introduction
There is a wide gap between the success rates of maxillary nerve block anesthesia and inferior
alveolar nerve (IAN) block. Clinically acceptable anesthesia in the maxilla rarely represents a
problem, except in cases of anatomical abnormality or pathological conditions. [1] For
maxillary surgical procedures, in the vast majority of cases infiltration anesthesia is all that is
required because the cortical plate of the alveolus of the upper jaw is almost always thin and
porous enough to make infiltration anesthesia effective.
Procedures on the lower jaw will most often require nerve block anesthesia of the inferior
alveolar, lingual, and buccal nerves. The IAN block is the most commonly used block in
dentistry, having widespread applications in all fields of dentistry. Unfortunately, anesthetic
block of the IAN has high failure rates, varying between 15% and 35%. [1,2] The high failure
rate is frequently attributed to differences in the morphology of the mandibular ramus and
also the position of the mandibular foramen, however inadequate technique is the most
common cause for failure. [3,4] Specifically, improper mouth opening allows the IAN to stay
relaxed preventing the close approximation of the nerve with the medial wall of the ramus.
Incorrect anterior, posterior or inferior placement of the needle also leads to failure. Because
the target for the conventional IAN block is very near the neurovascular bundle, this technique
also has a high frequency of positive aspiration, and intravascular injection is possible. [5]
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Achieving excellence in pain control is an intrinsic, yet challenging, goal of dentistry. Tradi‐
tionally, the inferior alveolar nerve block (IANB), also known as the “standard mandibular
nerve block” or the “Halsted block,” has been used to provide anesthesia in mandibular teeth.
This technique, however, has a success rate of only 80 to 85 percent, with reports of even lower
rates. Investigators have described other techniques as alternatives to the traditional approach,
of which the Gow-Gates mandibular nerve block and Akinosi-Vazirani closed-mouth man‐
dibular nerve block techniques have proven to be reliable but each of which have merits and
draw backs [5].
2. Standard Inferior Alveolar Nerve Block (SIANB)
There are many reasons why the success rate of SIANB is low. One is that the dentist can make
mistakes during the technique. These problems are easily resolved by reviewing the anatom‐
ical landmarks and the steps to perform the technique involved. Another important reason is
the presence of inflamed or infected tissue. Infection areas are acidic, which can influence the
beginning of anesthesia. When infection occurs, it is necessary to administer an injection into
a deeper location away from infection to avoid this problem. A third reason is that a patient’s
anxiety often can cause local anesthetic failure. [6] This problem can be solved by the discussion
with his fear of injections patient and, if necessary, considering the use of minimal sedation
such as that provided by nitrous oxide. Intravascular injection may be another reason for
failure because the local anesthetic can be taken away from the site of action. This problem can
be avoided by careful aspiration before any injection [7].
Anatomical variability and accessory innervation can also be a problem in providing successful
mandibular anesthesia. Once the needle has penetrated the oral mucosa, the dentist is
essentially proceeding in a blind mode and assuming that the patient has the same anatomy
learned in the dental school. All patients anatomy, however, are not the same and this anatomic
variability can lead to failure of SIANB. [8]
Accessory innervation occurs when the main inferior alveolar nerve trunk is not the only
source of innervation to the pulp. This accessory innervation may arise from various sources
such as a distinct branch from alveolar nerve [8], mylohyoid nerve, as well as the buccal, lingual
or auriculotemporal nerves. This situation can be diagnosed when the patient has signs of a
successful mandibular nerve block such as a dormant lip, but the tooth is still sensitive when
stimulated with a drill [8,9].
Although some researchers report that the success rates for alternative blocks are higher than
those reported for SIANB [8,10], others reported comparable rates [11,12]. However, research‐
ers of the latest study reported that the best rate for SIANB was probably due to the experience
of dentists who administer the anesthetic blocks. [12]
The main objective of each block of the mandibular nerve is the inferior alveolar nerve
anesthesia, which innervates the pulps of the lower teeth, as well as the buccal periodontium
anterior to the mental foramen. This is achieved by depositing the anesthetic within pterygo‐
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Modified Jorgensen and Hayden Approach to Intraoral Mandibular Anesthesia 45

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mandibular space. This anatomic space encloses the inferior alveolar nerve and the lingual
nerve. The pterygomandibular space also contains the inferior alveolar artery and vein and
sphenomandibular ligament. This space is limited laterally by the mandibular ramus, medially
and inferiorly by the medial pterygoid muscle, superiorly by the lateral pterygoid muscle,pos‐
teriorly by the parotid gland and anteriorly by the buccinator muscle [10,11].
The Gow-Gates and Akinosi-Vazirani methods are indicated when there is anatomical
variation or accessory innervation. The Akinosi-Vazirani method is also indicated when the
patient has limited mouth opening or whose tongue persistently obstructs the view of the soft-
tissue landmarks used in the IANB. These three techniques have similarities, and each has
advantages and disadvantages [11].
3. Gow-Gates mandibular nerve block
Gow-Gates initially described what became known as the “Gow-Gates mandibular nerve
block” in 1973. The aim of the technique is to place the needle tip and administer the local
anesthetic at the neck of the condyle. This is in proximity to the mandibular branch of the
trigeminal nerve after it exits the ovale foramen. Before looking inside the patient’s mouth it
is necessary to establish the extra-oral reference points. An imaginary line is drawn from the
intertragus notch (the point immediately inferior to the tragus of the ear) to the corner of the
mouth. Then we align the syringe parallel to this plane during insertion.. Inside the mouth,
we have to find the bony landmark by palpating the external oblique ridge of the anterior
surface of the ramus in the coronoid notch. The temporal muscle attaches onto the coronoid
process, and it is important to feel this muscle when inserting the needle. After palpating the
landmarks, we must keep the syringe at the correct angle, as determined previously, with the
needle tip aiming for the neck of the condyle. The barrel of the syringe usually is over the
contralateral mandibular canine or premolars [12,13].
The intraoral insertion point is lateral and superior when compared with that of the SIANB.
This point is on the lateral margin of the pterygotemporal depression and just medial to the
attachment of the temporal muscle. The upper boundary of the insertion point is the maxillary
occlusal plane. Usually, the needle lies just below the mesiopalatal cusp of the maxillary second
molar, which can be a reliable landmark [13].
Just before the needle insertion, we ask the patient to open his mouth as widely as possible.
The wide opening is critical to the success of this technique. Once the needle is inserted, is
moved forward slowly until it contacts bone (the condyle neck). This contact should occur at
a depth of 25 millimeters. If bone is not contacted, we should not apply the injection, but instead
redirect the needle until we feel the neck of the condyle. Once contact is made, we remove the
needle 1mm and administer a full cartridge of local anesthetic after a negative aspiration. We
should not administer less than a full cartridge [12,13].
The final position of the needle tip is just anterior to the neck of the condyle, inferior to the
lateral pterygoid muscle, lateral to the medial pterygoid muscle and medial to the ramus. The
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nerves anesthetized by Gow-Gates technique include the inferior alveolar and its branches
(incisors and mental), lingual, mylohyoid, auriculotemporal and buccal (about 75 percent of
the time). Anesthesia of the mylohyoid and auriculotemporal nerves resolve the concern with
accessory innervation, as would be the uppermost position of the anesthetic administration.
The gow-gates technique resulted in a rate of about 2% positive suction compared with 10 to
15% SIANB. [1] This rate may be lower because the inferior alveolar vein and artery are further
away than the target site are to SIANB [9, 10,12,13].
After the injection is administered, we should ask patients to keep their mouths open for at
least 20 seconds, if possible, to keep the inferior alveolar nerve closer to the site of injection
and improve onset of anesthesia. The onset of anesthesia is usually five to 10 minutes, which
is longer than that for the SIANB (usually three to five minutes) [13].
4. Akinosi-Vazirani closed-mouth mandibular nerve block
Two dentists independently described the closed mouth mandibular nerve block as an
alternative to the IANB. In 1977, Akinosi [14] brought this method to the attention of educators,
but they soon realized that this technique had been published by Vazirani in 1960. [15] This is
indicated particularly if the patient has trismus or the dentist has difficulty seeing the intraoral
landmarks used for the SIANB.
What makes this technique unique is that the patient's mouth is closed. The aim is to place the
needle tip between the ramus and the medial pterygoid muscle. Since the mouth is closed,
seeing the intraoral landmarks can be difficult. A curve at approximately 15° to 30° angle
toward the ramus can help minimize the chance of the needle being inserted into the medial
pterygoid muscle [15].
Inside the mouth, the bone reference is essentially the same as it is for the SIANB and Gow-
Gates methods. We palpate the external oblique ridge of the anterior surface of the ramus and
then move the thumb superiorly to palpate the coronoid. The temporal muscle attaches here,
and the needle should not enter this sensitive structure. Thus, in a lateral plane, the insertion
point is medial to the coronoid process and lateral to the maxillary tuberosity. In superoinferior
plane, this insertion point is at the height of the mucogingival junction of the upper teeth, with
the tissue retracted laterally, the dentist should insert the needle in a posterior direction [14, 15].
The syringe should be at the level of the mucogingival junction of the upper molars, parallel
to maxillary occlusal plane and as close to the maxillary mucosa as possible without touching
it. We move the syringe such that the needle moves laterally and posteriorly. Once the needle
is inserted 25 mm (for an average adult patient) to stop the advancement of the syringe and
administer one full cartridge after a negative aspiration [10,15].
The purpose of using the Akinosi-Vazirani technique is to fill the pterygomandibular space
with local anesthetic, bathing the inferior alveolar, lingual and mylohyoid nerves with
anesthetic solution. Using Akinosi-Vazirani technique should result in no bony references
being hit. The nerves anesthetized by the Akinosi- Vazirani technique include the inferior
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alveolar and its branches (incisive and mental), lingual, mylohyoid and buccal (approximately
75 percent of the time). A separate buccal nerve block is not needed because successful
anesthesia of the buccal nerve is common when this technique is used. The begining of
anesthesia is intermediate (five to seven minutes) compared with that of the SIANB and the
Gow-Gates technique [10,14,15].
5. Modified Jorgensen & Hayden technique
To achieve mandibular anesthesia, many dentists use an injection technique targeting the
mandibular sulcus, similarly described by Jorgensen and Hayden in 1967. [16] This injection
remains a proven method for the delivery of local anesthetic safely with minimal discomfort
to the patient. However, there are disadvantages associated with standard inferior alveolar
nerve block, usually associated with the identification of anatomical landmarks [14,16].
Therefore, we propose a modified Jorgensen - Hayden technique to achieve mandibular
anesthesia.
6. Anatomical aspects for modified Jorgensen - Hayden technique
A thorough knowledge of the anatomy of the pterygomandibular space is essential for the
successful administration of the inferior alveolar nerve block. Anesthetic solutions deposited
low in the pterygomandibular space will not diffuse up to where the inferior mandibular nerve
enters the mandibular canal. In addition to the neural aspects of the pterygomandibular space,
there are vascular pathways, fibrous tissue elements, muscular structures, and glandular tissue
that need to be considered to improve the predictability, effectiveness, and safety of block
anesthesia. Greater understanding of the nature and extent of variation in intraoral landmarks
and underlying structures should lead to improved success rates, and provide safer and more
effective IAN anesthesia.
Pterygomandibular space: The pterygomandibular space is a small fascial-lined cleft contain‐
ing mostly loose connective tissue. [17] It is bounded medially and inferiorly by the medial
pterygoid muscle and laterally by the medial surface of the mandibular ramus. Posteriorly,
the parotid gland curves medially around the posterior border of the mandibular ramus to
form a posterior boundary of the space, whereas anteriorly, the buccinator and superior
constrictor muscles come together to form a fibrous junction, the pterygomandibular raphe.
Important structures are positioned in this space: the inferior alveolar nerve (IAN), the inferior
alveolar artery (IAA), inferior alveolar vein (IAV), lingual nerve (LN), mylohyoid nerve and
the sphenomandibular ligament.
Pterygomandibular raphe: The pterygomandibular raphe (pterygomandibular ligament) is a
ligamentous band of the buccopharyngeal fascia, attached superiorly to medial pterygoid
plate, and inferiorly to the posterior end of the mylohyoid line of the mandible (Figure 1). It is
formed by the junction of the buccinators muscle and pharynx superior constrictor muscle. [16]
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Figure 1. Pterygomandibular raphe location.
Coronoid fossa/notch: The coronoid fossa/notch is the region of greatest concavity of the
anterior border of the ramus of the mandible (Figure 2). [1]
Figure 2. Coronoid fossa location.
Temporal crest: The temporal crest is an extension of the coronoid process, which ends in the
retromolar area. [18] An extremely important technical aspect is that on the temporal crest the
deep temporal muscle tendon is inserted (Figure 3).
Sphenomandibular ligament: The sphenomandibular ligament is a flat, thin band which is
attached superiorly to the spine of the sphenoid bone, and, becoming broader as it descends,
is fixed to the lingula of the mandibular foramen. [19] The sphenomandibular ligament has a
very important influence on the diffusion of anesthetic solution injected into the area.
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Figure 3. Temporal crest location.
Mandibular foramen: In the center of the medial ramus of the jaw there is a large hole, the
foramen of the mandible, which continues inside with the mandibular canal. Serve as a passage
way to IAN, IAA and IAV (Figure 4). [18]
Figure 4. Mandibular foramen location.
Mandibular lingula and mandibular groove: The margin of the mandibular foramen is
irregular; presented in front of a prominent ridge, topped by a sharp spine, the mandibular
lingula, which gives attachment to sphenomandibular ligament; at its lower and back part
there is a notch from which the mylohyoid groove runs obliquely downward and forward,
and allocates the vessels and mylohyoid nerve (Figure 5). [19]
Occlusal plane: In 1972 Jorgensen and Hayden [16] reported that if we could trace a line
parallel to the occlusal plane, passing through the center of the coronoid fossa, we could reach
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Figure 5. Mandibular lingula position.
a point immediately above the mandibular foramen. According to the literature, a needle
inserted 5 mm above the occlusal plane and parallel to it would lie above the lingula in 64%
of mandibles and below it in 36%. A needle placed 11 mm above the occlusal plane would be
above the lingula in 96% of mandibles. [20]
Contralateral premolars: The premolars on the opposite side of injection are used to help direct
the syringe (Figure 6).
Figure 6. Position of the syringe in relation to the opposite premolar teeth.
7. Modified Jorgensen & Hayden technique
Patient positioning and maintenance of aseptic conditions are prerequisites to avoid compli‐
cations with local anesthesia. The technique is performed with a long needle gauge (25 mm).
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We use the index finger to palpate the point of greatest depression of the Coronoid fossa/notch.
This will give us a notion of the height of the puncture. We then move the index finger
posteriorly, maintaining the cheek and the deep temporal muscle tendon retraction while
feeling the temporal crest (Figure 7).
Figure 7. Palpation on the coronoid fossa, delimitating the area of puncture.
This modification is proposed to ensure better delimitation and also narrow the area of
puncture, facilitating IAN block. We maintain this position during the technique. The needle
is inserted medially to the temporal crest, and laterally to the pterygomandibular raphe. The
height of the puncture is center of the fingernail, which corresponds to the center of the
Coronoid fossa/notch (Figure 8).
Figure 8. Palpation on the temporal crest.
The syringe is positioned parallel to the occlusal plane and directed between the premolars of
the opposite side. The needle is inserted until hitting the bone (Figure 9).
Figure 9. Needle insertion until hitting the bone.
This area is immediately over the mandibular lingula and near the mandibular foramen. The
next step is to pull back 1mm to avoid intravascular injection. Then we aspirate and slowly
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inject almost all of the anesthetic solution. We then withdraw the needle halfway and inject
the remainder of the anesthetic solution to block the lingual nerve. The buccal nerve must be
anesthetized separately.
8. Discussion
Anatomical knowledge of pterygomandibular region is very important when we want to

perform a successfully IAN block. The correct palpation of the coronoid fossa gives us the
appropriate height of the puncture and along with other anatomical references, permits the
delimitation of a compartment located between the mandible and sphenomandibular liga‐
ment. If we respect the anatomic points, the anesthetic solution will be deposited at a point
immediately above the mandibular lingula. The proposed modification of Jorgensen - Hayden
Technique facilitates the correct puncture. Also, the restriction in the horizontal plane avoids
both excessive and insufficient introduction of the needle - a common cause of failures. Another
important aspect of this modified technique is the anesthetic block of the inferior alveolar nerve
and also the lingual nerve in a single injection.
9. Summary
The anesthesia of the inferior alveolar nerve is a basic procedure in clinical practice and
Dentistry. In order to enhance their practice, every contribution is welcome, allowing achieving
a higher success rate in implementation. This chapter draws attention to anatomical guidelines
that are easily found in all patients, making it a safer and successful procedure.
Author details
Flaviana Soares Rocha*, Rodrigo Paschoal Carneiro, Aparecido Eurípedes Honório Magalhães,
Darceny Zanetta-Barbosa, Lair Mambrini Furtado and Marcelo Caetano Parreira da Silva
*Address all correspondence to: flavianasoares.rocha@gmail.com
Department of Oral and Maxillofacial Surgery and Implantology – School of Dentistry -

Federal University of Uberlândia, Brazil
References
[1] Malamed SF. Handbook of local anesthesia.Elsevier Editora Ltda. Rio de Janeiro,
2013; 428p.
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[2] Gautam A, Madan GA, Sonal G, Sonal G. Failure of inferior alveolar nerve block: ex‐
ploring the alternatives. J. Am. Dent. Assoc. 2002; 843-846.
[3] Madan GA, Madan SG, Madan AD. Failure of inferior alveolar nerve block: explor‐
ing the alternatives. J Am Dent Assoc. 2002 Jul;133(7):843-6.
[4] Perin CP, Suzuki AMM, Fernandes A, Westphalen FH, Schussel JL. Importância das
variações anatômicas dos canais mandibulares e suas implicações clínicas. J Bras Clin
Odont Int. 2004; 8 (44): 144-6.
[5] Johnson TM1, Badovinac R, Shaefer J. Teaching alternatives to the standard inferior
alveolar nerve block in dental education: outcomes in clinical practice. J Dent Educ.
2007 Sep;71(9):1145-52.
[6] Kaufman E, Weinstein P, Milgrom P. Difficulties in achieving local anesthesia. JADA

1984;108(2):205-208.
[7] Palti DG, Almeida CM, Rodrigues Ade C, Andreo JC, Lima JE. Anesthetic technique
for inferior alveolar nerve block: a new approach. J Appl Oral Sci. 2011 Jan-Feb;19(1):
11-5
[8] Afsar A, Haas DA, Rossouw PE, Wood RE. Radiographic localization of mandibular
anesthesia landmarks. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86(2):
234-241.
[9] Blanton PL, Jeske AH; ADA Council on Scientific Affairs; ADA Division of Science.
The key to profound local anesthesia: neuroanatomy. JADA 2003;134(6):753-760.
[10] Malamed SF. The Gow-Gates mandibular block: evaluation after 4,275 cases. Oral
Surg Oral Med Oral Pathol 1981;51(5):463-467.
[11] Aggarwal V, Singla M, Kabi D. Comparative evaluation of anesthetic efficacy of

Gow-Gates mandibular conduction anesthesia, Vazirani-Akinosi technique, buccal-
plus-lingual infiltrations, and conventional inferior alveolar nerve anesthesia in pa‐
tients with irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2010;109(2):303-308.
[12] Robertson WD. Clinical evaluation of mandibular conduction anesthesia. Gen Dent
1979;27(5):49-51.
[13] Montagnese TA, Reader A, Melfi R. A comparative study of the Gow-Gates techni‐
que and a standard technique for mandibular anesthesia. J Endod 1984;10(4):158-163.
[14] Gow-Gates GA. Mandibular conduction anesthesia: a new technique using extraoral
landmarks. Oral Surg Oral Med Oral Pathol 1973;36(3):321-328.
[15] Akinosi JO. A new approach to the mandibular nerve block. Br J Oral Surg
1977;15(1):83-87.
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[16] Vazirani SJ. Closed mouth mandibular nerve block: a new technique. Dent Dig
1960;66:10-13.
[17] Jorgensen NB, Hayden JJr. Local and Sedation Anesthesia in dentistry. 2 Ed. Lea &
Febierg Ed. Philadelphia. 1972: 163p.
[18] Berns JN, Sadove NS. Mandibular block injection: a method of study using an inject‐
ed radiopaque material. J Am Dent Assoc, 1962 Dec; 65: 735-745.
[19] Madeira MC. Anatomia da Face, 7a ed., São Paulo: Sarvier, 2010.
[20] Sicher H, ed. Sicher and DuBrul`s oral amatomy. 5th ed. St. Louis; Ishyaku Euro
America; 1998; 273-280.
[21] Ogle OE, Mahjoubi G. Local anesthesia: agents, techniques, and complications. Dent
Clin North Am. 2012 Jan;56(1):133-48.
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Chapter 4
Novel Modifications in Administration of Local

Anesthetics for Dentoalveolar Surgery
Esshagh Lassemi, Fina Navi,

Mohammad Hosein Kalantar Motamedi,
Seyed Mehdi Jafari, Kourosh Taheri Talesh,
Kamal Qaranizade and Reza Lasemi
http://dx.doi.org/10.5772/59235
1. Introduction
The importance of pain management during dental procedures cannot be over-emphasized,

but without proper anesthesia, the treatment plan may not be feasible or may result in potential
harm to some of the patients. Anesthetic injections should be as painless as possible, especially
in the palate which is the most sensitive area of the oral cavity for injection [1].
The conventional nasopalatine nerve block is commonly used to obtain anesthesia in the
anterior portion of the palate. The painful nature of this approach, however, has led investi‐
gators to seek alternative methods to obtain an anesthesia. Labial infiltration of the maxillary
central incisors can be considered an effective anesthetic substitute for procedures of the
anterior palate. This chapter presents the anesthetic effect of a modified labial infiltration
method for anesthetizing the nasopalatine nerve. The authors have reported this method of
labial infiltration to be an effective alternative to the painful conventional nasopalatine nerve
block to obtain efficient anesthesia of the anterior palate (p <0.001).
1.1. Modified labial infiltration method to obviate nasopalatine nerve block or lessen pain
of injection
1.1.1. Clinical anatomy

Anesthesia of the nasopalatine nerve is a mandatory prerequisite to perform surgical proce‐
dures on the soft and hard tissues of the anterior palate and for extraction of upper anterior
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teeth [1].The nasopalatine nerve passes through the Incisive fossa which is posteroinferior to
anterior nasal spine and finally enters the oral cavity via the incisive foramen and innervates
the anterior palate, maxillary central incisors and nasal floor (Figure 1). [1-3]
Figure 1. Diagram of the nasopalatine and surrounding nerves
Labial tissues are anaesthetized by labial infiltration. Obtaining anesthesia for the relevant
palatal soft tissue is however, not possible this way and necessitates direct injection of an
anesthetic agent in the palatal area (incisive papilla). Palatal soft tissues, especially in the
vicinity of the hard palate, are tightly attached to the underlying bone. Injection in this area is
thus, painful when the conventional method for injecting the anesthetic agent directly into or
aside the incisive papilla is used [4].Therefore removal of maxillary teeth without a palatal
injection is desirable.
1.2. Technique
In this technique two injections at two sites should be done.

1. Anesthesia of the maxillary hard and soft tissue of the labial area is obtained by injection
of 1 cc of local anesthetic agent in the labial vestibule, with the syringe parallel to the long
axis of the lateral incisor tooth and the needle bevel toward the bone. This is a nerve block
because local anesthetic is deposited close to the main nerve trunk [2] (Figures 2, 3 and
4).With this injection the canine, lateral incisor, central incisors, hard and soft tissue of the
alveolar area to the midline are anesthetized.
2. After 2-3 minutes and relative anesthesia of the labial area, infiltration of about 0.6 ml of
the remaining solution is administered via a needle inserted superior to the apices of
central incisors in the vicinity of the superior border of the base of the anterior nasal spine
near the nasal floor at a 45 degree angle to the long axis of the central incisor, to obtain
anesthesia in the anterior palate (Figure 5).
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Figure 2. Diagram of the nasopalatine and surrounding nerves (from Gray’s Anatomy, 37th Ed.).
Figure 3. Nerve block (from Malamed 2013, 5th ed.)
Five to six minutes following the second injection, the extension and efficiency of anesthesia
in the anterior palate is assessed by an explorer or periosteal elevator and if pain-free the
nasopalatine nerve need not be injected from the palate and there is no need for another
injection for extraction or dentoalveolar surgery. In the case of mild pain, severe pain, moderate
pain or no anesthesia, a complementary injection in the palate is needed. The authors assessed
this via a clinical trial that included 60 patients referring for the extraction of maxillary incisors
and canine. They showed complete anesthesia of the anterior area of the palate in 76.7% of
patients using this method; 23.3% needed a conventional nasopalatine nerve block to comple‐
ment the effect of anesthesia prior to treatment. In controls we used the conventional technique.
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Figure 4. The anesthesia of the maxillary hard and soft tissue of the labial area is obtained by injection of 1 cc of local
anesthetic agent, with the syringe parallel to the long axis of the tooth. Orient the needle bevel toward the bone.
Figure 5. Needle inserted superior to the apices of central incisors in the vicinity of the superior border of the base of
the anterior nasal spine near the nasal floor at a 45 degree angle to the long axis of the central incisor, to obtain anes‐
thesia in the anterior palate.
The level of anesthesia obtained by our method in the anterior palate is satisfactory. The labial
infiltration method resulted in total anesthesia in the majority of the cases. Failures may be the
result of anatomic and physiologic variations. An eight minute wait or longer may be more
effective than five minutes following the second injection. The amount of pain experienced by
the patients during the injection in the labial infiltration approach is less than the conventional
approach in most cases. [5]
2. Modified mental incisive nerve block technique
2.1. Overview
• The mental-incisive nerve block can be used where lower premolars and anterior teeth
require treatment. In this chapter we present our method of mental-incisive nerve block for
extraction of the lower premolars and anterior teeth or dentoalveolar surgery.
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• The authors reported a 95% success rate with the modified injection distal to the second
lower premolar, while the success rate was 72.5% when the injection was done traditionally
between lower premolars.
• This modified mental-incisive nerve block with injection done distal to the second premolar
is more successful than between premolars
2.2. Background
The Inferior Alveolar Nerve Block (IANB) is the most important injection technique in
dentistry. Unfortunately it also proves to be the most frustrating; with the highest percentage
of clinical failure [6]. Potocnik and Bajrovic reported that even when a proper technique is
employed, clinical studies show that IANB fails in approximately 30% to 45% of cases [7]. When
dental treatment involved procedures on mandibular premolars and anterior teeth the incisive
nerve block can be administered with greater success [6]. However, the injection technique for
mental-incisive nerve block (MINB) may also influence the success rate.
2.3. Clinical anatomy
The target is the mental foramen located on external surface of the body of the mandible below
the first and second premolars where the IAN divides into terminal (incisive and mental)
branches. The incisive branch continues forward in a bony canal or in a plexiform arrangement,
giving off branches to the first premolar, canine and incisor teeth, and the associated labial
gingiva. The lower central incisor teeth receive a bilateral innervation, fibers probably cross
the midline within the periosteum to re-enter the bone via numerous canals in the labial cortical
plate. The mental nerve passes upward, backward and outward to emerge from the mandible
via the mental foramen between and just below the apices of the premolar teeth [8].
Figure 6. In 24% of individuals the mental foramen is located distal to the root of the second premolar; in 20 to 25%,
between the premolars roots, in 50% at the site of the second premolar root and in 1% to 2% anterior to the first premo‐
lar or mesial to the first molar.
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However, the location of mental foramen varies in different people [8-13]; in 24% of individuals
the mental foramen is located distal to the root of the second premolar; in 20 to 25%, between
the premolars roots, in 50% at the area of the second premolar root and in 1% to 2% anterior
to the first premolar or mesial to the first molar (Figure 6). [13] This variability in location may
cause problems in obtaining anesthesia [8, 10, 13-15].
2.4. Technique
There are different methods for MINB; the authors compared 2 mental–incisive nerve block
techniques for the extraction of lower premolars and anterior teeth bilaterally. One method
was to inject between the first and second premolar so that the needle passed between the two
premolars vertically. In the other method, the injection was performed distal to the second
premolar.
This randomized double blind, split-mouth clinical study was done; in the case group, the
needle penetrated the depth of the vestibule distal to the second premolar using a 27 gauge
needle. Entry was from behind the patient at the ten O’ clock and the opposite side at the 2 O’
clock position. The needle entered the soft tissue about 5-8 mm supraperiosteal, with mouth
half-open and lip and buccal tissues retracted. When standing behind the patient, the ana‐
tomical landmarks were the second premolar and buccal vestibule (Figure 7).
Figure 7. The injection administered distal to the second premolar. The syringe should be from posterior to anterior,
from above to below and from lateral to medial while standing behind the patient.
In the control group an injection was done in the depth of buccal mucosa between two
premolars at a depth of 5-6 mm using a 27 gauge needle with the mouth half open standing
behind the patient (Figure 8). [16]
In both groups the local anesthetic solution was lidocaine 2% (1 cc) with epinephrine (1/80000).
It is not necessary for the needle to enter the mental foramen. Data was statistically analyzed
using the chi-square test. All patients had a lingual injection (0.5 cc) which was administered
5 mm distal to the tooth in the floor of the mouth.
The MINB with needle entrance distal to the second premolar from behind had a 95% success
rate and MINB with needle entrance between premolars had a 72.5% success rate respectively
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Figure 8. The injection administered in the depth of buccal mucosa between two premolars at a depth of 5-6 mm using
a 27 gauge short needle with the mouth half open while standing behind the patient.
(p<0.01). Thus, if the mental nerve block injection is administered with the needle entrance
between premolars, the chance of failure is greater (R.R=5.5).
2.5. Discussion
The MINB can be an alternative to the IANB when dental procedures requiring pulpal
anesthesia on mandibular teeth anterior to the mental foramen (e.g. canine to canine or
premolar to premolar) are treated. According to the result, we found that MINB with needle
penetration distal to second premolar was more effective (95%) than injection between two
premolars (72.5%). Al Yasser and Al Nwoku [15] showed that the mental foramen location on
both sides of the mandible in 80% of cases is symmetrical and in 46.2% of cases the mental
foramen is located between the longitudinal axes of the two premolars. Moiseiwitch [10]
reported that anterior-posterior positions of mental foramens in most cases are symmetrical.
In most studies on mental foramens in different cases, researchers reported that most mental
foramens are in line with second premolars [11, 14]. What most scientists agree with is the
presence of mental foramen in range of the long axis of the second premolar [10-12] with about
50% of cases at the level of the root of second premolar, between the two premolars in about
20% to 25% and posterior to the second premolar in about 24%, and in approximately 1% to
2% it lies as forward as the first premolar or as far back as the first molar [13]. This may be why
the technique in which the needle penetrates mucosa distal to second premolar may yield the
success rate of MINB higher. According to the results, the success rate of anesthesia adminis‐
tered distal to second premolar was 95% and with needle penetration between premolar was
72.5% [6, 9]. According to Malamed the correct position of the dentist is in front of the patient
so that the syringe may be placed into the mouth below the patients line of sight and the thumb
or index finger in the mucobuccal fold against the body of the mandible in the first molar area
and moved slowly anteriorly until feeling the bone become irregular and somewhat concave
[6] while in our technique there is no need to palpate the area and produce discomfort for
patients. Mucosal penetration done from the distal of the second premolar hides the needle
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from the line of sight of the patient. When standing in front of the patient it is easier for the
patient to see the needle whereas when standing behind the patient it is unlikely for him or
her to visualize the needle. [17]
2.6. Conclusion
Mental-incisive nerve block injection distal to the second premolar from behind the patient
was more successful than between premolars from the front.
3. Modified direct inferior alveolar nerve block technique
3.1. Overview
This modified direct technique is easier and more practical than the conventional technique
described by Malamed in the handbook of local anesthesia [18]; also it is easier to learn and
teach dental students. We have used this technique in practice for many years with a high
success rate (up to 98%).
3.2. Technique
a. A 27 gauge short or long needle is recommended.
b. The mouth should be open wide.
c. Placement of the syringe barrel at the first molar of the opposite side.
d. Needle penetration occurs at the point one centimeter above the occlusal plane of the
mandibular molar and parallel to it just at the lateral border of pterygomandibular raphe.
In this situation, the needle touches the medial aspect of the ramus at about a 90 angle.
When entering the pterygomandibular space injury to the medial pterygoid muscle
should be avoided. The pterygomandibular fold may serve as a landmark for the anterior
border of the muscle. The needle pierces the mucous membrane lateral to the pterygo‐
mandibular fold and injury to the medial pterygoid muscle is avoided easily [18-21]
e. While slowly advancing, the needle contacts bone; then we withdraw the needle about 1
mm to prevent subperiosteal injection. If aspiration is negative, we slowly deposit 1.5 ml
of anesthetic within 60 seconds; the remaining solution is deposited for lingual nerve
anesthesia while withdrawing the needle. The average depth of needle penetration to
bony contact depends on soft tissue thickness of the area on the medial aspect of the ramus.
This will be approximately 8-10 mm or less, it is not necessary to advance the needle in
the posterior direction at all or you will be far from the exact injection site. In this technique
using the thumb or finger is not necessary, a dental mirror or Minnesota retractor can be
used; however there is really no need to use these instruments. With this technique the
inferior alveolar and lingual nerves are anesthetized. The long buccal nerve should be
anesthetized separately for molar extraction (Figure 9).
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http://dx.doi.org/10.5772/59235
Figure 9. The modified direct technique.
4. Conclusion
With regard to the high success rate of the technique and because of simplicity and easy
learning curve by dental students it can be placed into the academic curriculum.
Author details
Esshagh Lassemi1, Fina Navi1*, Mohammad Hosein Kalantar Motamedi1,2, Seyed Mehdi Jafari1,
Kourosh Taheri Talesh1,3, Kamal Qaranizade1 and Reza Lasemi4
*Address all correspondence to: fina_navi@yahoo.com
1 Department of Oral and Maxillofacial Surgery, Dental School, Azad Islamic University of
Medical Sciences, Tehran, Iran
2 Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
3 Department of Oral and Maxillofacial Surgery,Dental School, Tabriz University of Medical

Sciences, Tabriz, Iran
4 Medical University of Vienna, Austria
References
[1] Uckan S, Dayangac E, Araz K. Is permanent maxillary tooth removal without palatal
injection possible? Oral Surg Oral Med Oral Pathol Oral RadiolEndod2006; 102: 733-735.
www.dentalbooks.co
[2] Malamed (2013) Local Anesthesia. (5thed), Elsevier Mosby Publications, USA, and
Chap13:190-191
[3] Meechan J G, Day P F, McMillan A S. Local anesthesia in the palate: a comparison of

techniques and solutions. AnesthProg2000; 47: 139-142.
[4] Meechan J G, Howlett P C, Smith B D. Factors influencing the discomfort of intraoral

needle penetration. AnesthProg2005; 52: 91-94.
[5] Lassemi E, Motamedi M. H. K., Jafari S. M, TaleshK. T., Navi F. Anesthetic efficacy of
alabial infiltration method on the nasopalatine nerve.Br Dent J. 2008 Nov 22;
205(10):E21. doi: 10.1038/sj.bdj.2008.872.
[6] Malamed S (2004) Hand book of local anesthesia (5thedn), Mosby Publications, Mis‐
souri, USA 14: 228-252.
[7] Potocnik I, Bajrovic F (1999) Failure of inferior alveolar nerve block. Endod Dent
Traumatol 15: 247-251.
[8] Williams D, Bannister L, Berry M (2008) Gray’s Anatomy(39thedn) Churchill Living‐

stone Publications 33: 601.
[9] Joyce A, Donnely J (1992) Evaluation of effectiveness and comfort of incisive nerve
anesthesia inside or outside the mental foramen. J Endod 18: 409-411.
[10] Moiseiwitsch JR (1998) Position of the mental foramen in North American white pop‐
ulation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 85: 457-460.
[11] Green R (1987) The Position of the mental foramen: A comparison between the
southern Chinese and other ethnic and racial groups. Oral Surg Oral Med Oral Path‐
ol 63: 287-290.
[12] Phillips JL, Weller RN, Kulid JC (1992) The mental foramen: Part 3, size and position
on panoramic Radiographs, J Endod 18: 383-386.
[13] Henry Hollinshead. Anatomy For Surgeons: The Head and Neck. (3rd ed) Harper &
Row, Publishers Philadelphia 1: 358.
[14] Wesley E Shankland (1994) The position of the Mental Foramen in Asian Indians. J
Oral Implantology 20: 118-122.
[15] Al Jasser NM, Al Nwoku (1998) Radiographic study of the mental foramen in a se‐
lected Saudi population. Dento maxillofacial Radiology 27: 341-343.
[16] Sicher H (1970) Oral Anatomy. (5thedn), Mosby Publications, USA, chap 1: 44-48.
[17] Lassemi E, Kalantar Motamedi MH, Alemi Z (2013) Anesthetic Efficacy Assessment
of Two Mental Nerve Block Techniques for Tooth Extraction. Anaplastology S6: 003.
doi: 10.4172/2161-1173.S6-003
[18] Malamed (2013) Local Anesthesia. (5thedn), Elsevier Mosby Publications, Chap14: 228
www.dentalbooks.co

http://dx.doi.org/10.5772/59235
[19] Gray`s Anatomy (2008).(39thed), Elsevier Ltd,USA,Chap 32:574
[20] Gray `s Anatomy (1989). (37thedn), Churchill Livingstone Publications, UK, Chap
7:1101
[21] DuBrul and Sicher, Oral anatomy (1970). (5thedn), Mosby company, USA, Chap
10:416-417
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Chapter 5
Orthodontic Considerations in Surgical Interventions for

Impacted Teeth
Massoud Seifi and

Mohammad Hosein Kalantar Motamedi
http://dx.doi.org/10.5772/59143
1. Introduction
Parallax is the effect whereby the position of a tooth or similar structure appears to differ when
viewed from different positions of the X-ray tube.[1] This method (Image/Tube Shift Method,
Buccal Object Rule or Clark’s Rule) has been the technique of choice to localize impacted teeth
anterior to the molars in both jaws using Vertical or Horizontal Tube Shift (VTS /HTS).[2] With
the continued technologic advances, the role of Cone Beam Computed Tomography (CBCT)
is changing in orthodontic workup and should be viewed as complementary to plain X-rays
or 2D X-rays in effective diagnosis, especially in impaction cases as a 3D evaluation. Effective
dose of radiation measured in micro-Sievert (µSv)) is decreased from full field of view (FOV)
to both jaws (13 cm) and single jaws (6 cm), from large-volume to small-volume and from high
resolution (HR) to conventional.[3] Therefore, as the effective dose is of foremost concern, it
can be decreased by appropriate selection of exposure parameters, FOV and resolution (only
for impacted tooth/teeth) to be comparable from a “dose” perspective with several periapical
and occlusal radiographs (parallax). However, the results of dosimetry on a specific CBCT
scanner may not be transferable to another CBCT scanner and every image involving ionizing
radiation, including CBCT, must be justified and optimized.
The treatment (including decision makings) of impacted teeth can be categorized into five
steps:
1. Cost-Benefit Analysis/ Cost-Effectiveness Analysis
2. Space preparation/Barrier removal
3. Selection of the method for eruption (Closed vs. Open)

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4. Selection of the appropriate (effective) biomechanical approach

a. Anchorage preparation (Direct vs. Indirect)
b. Force application
5. Alignment/ Leveling Torque/Angulation (ALTA) corrections
2. Cost-Benefit Analysis (CBA)/ Cost-Effectiveness Analysis (CEA)
Cost-benefit analysis (CBA) or Cost-effectiveness analysis (CEA) requires quantifiable input

data; both methods are accounting techniques that have been applied to medical decision-
making. Using Standard CEA, benefits are expressed either directly or indirectly in terms of
“quality of life” improvement, and costs are expressed in monetary values and in morbidity
and mortality. Using CBA, benefits and costs are all converted into monetary equivalents.[4]
The CBA is also defined as a systematic process for calculating and comparing benefits and
costs of a project or decision i.e. exposure of impacted tooth and ALTA correction versus
alternative treatment modalities. Results must be treated with caution, making it difficult to
make robust claims about the comparative cost-effectiveness of either treatment plan.
Systemic conditions or metabolic disturbances may be related to multiple impacted teeth. To
achieve optimum results, an interdisciplinary teamwork is needed between the orthodontist,
oral surgeon, prosthodontist and possibly some other specialties. The patient shown in Figure
1 an active social person, had several impactions in both jaws but was seeking a swift procedure
to get his anterior teeth. The facial profile, esthetic smile, and time spent for each appointment
in a nonprofit dental center were also among his concerns. It seems that the selected option for
the patient had more benefit gain in comparison to cost (time, pain, inconveniences, and risks
and...etc.).
In the first step clinicians should make a decision from the CBA/CEA perspective to select the
best option appropriate for the individual looking for treatment of the impacted tooth/teeth.
2.1. Early intervention for impaction prevention
Space deficiency has been mentioned as the first etiologic factor for a palatal impaction. Many
other contributing factors are associated with a palatal impaction such as over-retention of the
primary canines, abnormal position of the tooth bud, disturbances in tooth eruption, localized
pathologic lesions, abnormal sequence of eruption, missing lateral incisors or abnormal form
of the lateral incisor roots (e.g. dilacerations), presence of an alveolar cleft, supernumerary
tooth, and idiopathic factors.[5]
Crowding, thick soft tissue, supernumerary tooth/teeth, and tipped tooth/teeth situations are
considered as barriers to eruption. During the regular orthodontic examination of a patient
(Figure 2) an impaction was discovered on panoramic radiography suspected to be an
abnormal position of the tooth bud but proximity of developing root of tooth 14 and crown of
#13 (FDI Two-Digit Notation- ISO 3950) in addition to their abnormal route are the major
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In first step clinicians should make a decision from CBA/CEA perspective to select the best option appropriate for the individual
looking for treatment of the impacted tooth/teeth. Orthodontic Considerations
As mentioned earlier, cost is notinonly
Surgical
moneyInterventions for of
and other aspects Impacted
the cost Teeth 71
including the time, disturbances, risks, and… should be taken into account. http://dx.doi.org/10.5772/59143
Figure 1. Cost versus benefit appraisal for the above patient was considered according to the duration of the treatment
Figure 1. Cost versus benefit appraisal for the above patient were considered according to the duration of the treatment versus
versus time needed
time needed to receivetoanterior
receive anterior
implants andimplants
reliability and
of thisreliability of thisimpacted
option. Multiple option.teeth
Multiple impacted
were extracted andteeth were extracted
after placement
andof after placement
allografts-based of graft
bone allograft-based bone
substitute, four graft
dental substitute,
implant four dental
were inserted. Patient implants were
continued his inserted.
treatment The patient
and implant continued
were used
hisastreatment andextruding
anchorage for the implants wereimpacted
mandibular used asteeth.
anchorage for extruding mandibular impacted teeth.
concerns. It was postulated that rapid developing root with differentiating cells of the dental
papilla plus vascular pressure toward malposed erupting crown of tooth 13 had caused both
Early intervention for impaction prevention
teeth
Spaceto deviate
deficiency hasfrom their normal
been mentioned route.
as the first After
etiologic extraction
factor of the upper
for palatal impaction. right
Many other first primary
contributing molar,
factors are
the pressure
associated was relieved.
with palatal impaction suchByasusing a banded
over-retention expander
of the primary canines,and extraction
abnormal position ofit
theseems that
tooth bud, more space
disturbances
in tooth eruption, localized pathologic lesions, abnormal sequence of eruption, missing lateral incisors or abnormal form of the
was provided
lateral incisor roots for
(e.g. erupting
dilacerations),teeth
presenceand
of an the impacted
alveolar caninetooth,
cleft, supernumerary is getting more
and idiopathic vertical relative to
factors.(5)
the initial
Crowding, radiograph.
Thick soft tissue, Supernumerary tooth/teeth, and tipped tooth/teeth situations are considered as barriers to eruption.
During the regular orthodontic examination (patient K.E.-Figure 2) an impaction condition was discovered in panoramic
radiograph suspected to abnormal position of the tooth bud but proximity of developing root of tooth 14 and crown of #13 (FDI
Two-Digit Notation- ISO 3950) in addition to their abnormal route are the major concerns. It was postulated that rapid
2.2. Difficulty
developing root withindex as a tool
differentiating cells offor expression
dental of the
papilla plus vascular “Cost”
pressure toward malposed erupting crown of tooth 13 had
The canine is the second most commonly impacted tooth (after the third molar), with the rate
of maxillary canine impaction ranging from approximately 1% to 3% [6] and incidence of
approximately 20% in orthodontic clinics. Should you ALTA correction of tooth at the expense
of extra time and money or extract the impacted tooth, saving time and orthodontic payments
for the patient but perhaps at the expense of esthetics and long-term function.
When treating impacted teeth, duration of treatment or chairtime, success rate or risks, and
complcations (root resorption of impacted or adjacent teeth, ankylosis,..) can be converted to
to initial radiograph.
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α1 Angle α2 Angle
Figure Figure
2. Impacted caninecanine
2. Impacted has angulated towards
has angulated the horizontal
towards (Top-right)
the horizontal and made
(Top-right) and madethe management
the management moremore challenging
challeng‐and
difficult.
ingImpacted tooth Impacted
and difficult. 13 has tipped
toothtoward
13 has atipped
bettertoward
verticalaposition (Bottom
better vertical left to (bottom
position bottom right)
left to in other right)
bottom wordsinAlpha
other(α)
angle iswords
decreased
Alphaafter banded
(α) angle expander installed
is decreased and expander
after banded tooth 54 (D) was extracted
installed and tooth(α541>α 2).was
(D) (Bottom right(αis1>α
extracted the
2).
only picture 9
month after intervention)
a single score that would be compared to the benefits. However, sensitivity and specificity of
these scores or methods are uncertain and questionable. Many variables have role in determi‐
nation of difficulty for impaction cases including age (over 25 requires longer time), distance
Difficulty index as a tool for expression of the “Cost”
of impacted tooth from occlusal plane, mesiodistal location of the crown, angulation of the
The canine is the second most commonly impacted tooth (after the third molar), with the rate of maxillary canine impaction
rangingtooth, transverse relationship
from approximately 1% to 3% (6) of the
and crown of
incidence to approximately
the midline,20% location of the impacted
in orthodontic toothyou
clinics. Should cusp/
ALTA
incisal
correction tipatand
of tooth its relationship
the expense toand
of extra time themoney
adjacent teeththe(lateral
or extract impactedincisor in canine
tooth, saving impaction
time and orthodonticcases),
payments
for the patient but perhaps at the expense of esthetics and long-term function.
apex position, and transposition with adjacent teeth (lateral incisor and first premolar in canine
When treating impacted teeth, duration of treatment or chairtime, success rate or risks, and complcations (root resorption of
impactedimpaction
or adjacentcases).[7] Angular
teeth, ankylosis,..) canmeasurements
be converted to aon lateral
single scorecephalometry are Omega
that would be compared to the(ω) angleHowever,
benefits. and
Delta (δ) angle and linear measurement is d2 (Distance to Occlisal Plane) (Figure 3). Angular
measurements in panoramic views are the canine inclination (C.I.) to midline or Alpha (α)
angle and its inclination to the lateral incisor (or first premolar) or Beta (β) angle (Figure 4-
second row). Mesiodistal position of the canine cusp tip in relation to adjacent lateral and
central incisors on panoramic radiographs is called “Zone” and numbers 1 to 5 are assigned
to its position as it gets closer to the midline (Figure 4-third row).[6] Inclination of the canine
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Orthodontic Considerations in Surgical Interventions for Impacted Teeth 73

sensitivity and specificity of these scores or methods are uncertain and questionable. Many http://dx.doi.org/10.5772/59143
variables have role in determination
of difficulty for impaction cases including age (over 25 requires longer time), distance of impacted tooth from occlusal plane,
mesiodistal location of the crown, angulation of the tooth, transverse relationship of the crown to the midline, location of the
in the tooth
impacted horizontal
cusp/incisalplane
tip andor the degree
its relationship to theofadjacent
mesial teethorientation ofcanine
(lateral incisor in the impaction
canine cases),
is analyzed by
apex position,
and transposition with adjacent teeth (lateral incisor and first premolar in canine impaction cases).(7) Angular measurements on
measuring the Gamma (γ) angle between projection of long axis of the canine and
lateral cephalometry are Omega (ω) angle and Delta (δ) angle and linear measurement is d2 (Distance to Occlisal Plane) (Figure
the midline
of the maxilla
3). Angular in axial
measurements CBCT slice
in panoramic views ofare maxilla
the canine (Figure
inclination 4-bottom left)
(C.I.) to midline or Alpha (α) angle and its inclination to
the lateral incisor (or first premolar) or Beta (β) angle (Figure 4- second row). Mesiodistal position of the canine cusp tip in
In quantitative
relation terms,
to adjacent lateral andthe larger
central theonrelative
incisors panoramicrisk, the more
radiographs likely
is called theand
“Zone” association
numbers 1 tois5 causal. When
are assigned to its
position as it gets closer to the midline (Figure 4-third row).(6) Inclination of the canine in the horizontal plane or the degree of
studying causative
mesial orientation factors,
of the canine it is by
is analyzed very important
measuring the Gamma to (γ)
analyze the strength
angle between projection ofof the
long association
axis in
of the canine and
addition
the midline oftothethe significance.
maxilla in axial CBCTMore slice ofadvanvce
maxilla (Figure canine
4-bottomdevelopment,
left) a more medial position of
In quantitative terms, the larger the relative risk, the more likely the association is causal. When studying causative factors, it is
the
very canice
importantcusp, considering
to analyze the strength ofthe the zones
association[1-5], and mesial
in addition inclination
to the significance. Moreof the canine
advanvce to midlinea
canine development,
exceeding 25° (αofangle)
more medial position the canicearecusp,
powerful
considering factors.[8]
the zones (1-5), and mesial inclination of the canine to midline exceeding
25° (α angle) are powerful factors.(8)
δ (Delta) Angle
Nasal Floor
Distance to occlusal plane
ω (Omega)Angle
Figure 3. Angular measurements or inclinations of the canine in the sagittal plane are Omega (ω) angle and Delta (δ) angle (path
Figure 3. Angular measurements or inclinations of the canine in the sagittal plane are Omega (ω) angle and Delta (δ)
of eruption) and linear measurement is d2 (Distance to Occlisal Plane).
angle (path of eruption) and linear measurement is d2 (Distance to Occlisal Plane).
Regression analysis indicated that horizontal position, age of patient, vertical height and
Regression analysis indicated that horizontal position, age of patient, vertical height and bucco-palatal position, in descending
bucco-palatal
order of importance,position, in descending
are the factors which determineorder of importance,
the difficulty are the factors which determine the
of canine alignment.(9)
difficulty of and
Sector location canine alignment.[9]
angulation of the unerupted tooth have been analyzed previously as predictors of canine eruption after
deciduous extraction. Additionally, sector location has been studied as an indicator of eventual impaction, resulting in good
predictive success (Figure 5).(10) Different indices provide useful treatment planning aid for the management of impacted
Sector location and angulation of the unerupted tooth have been analyzed previously as
predictors of canine eruption after deciduous extraction. Additionally, sector location has been
studied as an indicator of eventual impaction, resulting in good predictive success (Figure 5).
[10] Different indices provide useful treatment planning aid for the management of impacted
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maxillary canines like treatment difficulty index (TDI) [9] and 3D cone beam CT based
classification system for canine impactions (the KPG index).[11]
maxillary canines like treatment difficulty index (TDI) (9) and 3D cone beam CT based classification system for canine
impactions (the KPG index).(11)
β Angle
α Angle
Zones
54321
γ (Gamma)Angle
Figure 4. Angular measurements in panoramic views are the canine inclination to midline or Alpha (α) angle and its inclination to
Figure 4. Angular
the lateral incisor measurements
or Beta (β) anglein(second
panoramic views are position
row). Mesiodistal the canine inclination
of the canine cusptotip
midline or Alpha
in relation (α) lateral
to adjacent angle and
and its
inclination to the lateral
central incisors incisorradiographs
on panoramic or Beta (β)is angle
called (second row).row).
“Zone” (third Mesiodistal
Inclinationposition of theincanine
of the canine cusp tip
the horizontal in relation
plane or the to
adjacent lateral and central incisors on panoramic radiographs is called “Zone” (third row). Inclination of the canine in
the horizontal plane or the degree of mesial orientation of the canine is analyzed by measuring the Gamma (γ) angle
between projection of long axis of the canine and the midline of the maxilla (bottom left).
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degree of mesial orientation of the canine is analyzed by measuring

Orthodontic the Gamma in
Considerations (γ)Surgical
angle between projection
Interventions of long axis
for Impacted of the 75
Teeth
canine and the midline of the maxilla (bottom left). http://dx.doi.org/10.5772/59143
Figure 5. Sector I represents area distal to line tangent to distal heights of contour of lateral incisor crown and root.
Figure 5. II
Sector Sector I represents
is mesial to sectorarea distal
I, but to line
distal tangentof
to bisector tolateral
distal heights
incisor’soflong
contour
axis.of lateralIIIincisor
Sector crown
is mesial and root.
to sector Sector
II, but II is
distal
mesial to sector
to mesial I, butofdistal
heights to bisector
contour of lateral
of lateral incisorincisor’s longroot.
crown and axis.Sector
SectorIVIIIincludes
is mesialalltoareas
sectormesial
II, buttodistal to III
sector mesial heights
(3 red line- of
contour of lateral
Top right). The incisor crown and
most superior pointroot. Sector
of the IV includes
condyle all areas
was selected as amesial
landmark;to sector III (3 redline
a bicondylar line- Top
was right).
then drawnTheand
most
superior point
used as of the condyle
a constructed was selected
horizontal as a landmark,
reference a bicondylar line
line. The measurement waswas thenofdrawn
taken and used
the mesial angleas formed
a constructed horizontal
by using the
reference line. The
constructed measurement
horizontal and thewaslongtaken
axisofof the
the mesial angletooth
unerupted formed
(Topbyright).
using the constructed horizontal and the long axis of
the unerupted tooth (Top right).
3. Space preparation/Barrier removal

2‐ Space preparation/Barrier removal
Space is needed (space available) for bringing teeth (teeth materials) into the dental arch. Many
Space is needed (space
mechanisms available)
exist for bringing
for creating theteeth (teeth materials)
adequate space into the dentalStripping
including arch. Many mechanisms
mesial or exist
distalforenamel
creating the
adequate space including Stripping mesial or distal enamel of the teeth (proximal) with condition of existing Bolton discrepancies
of the
between teeth
upper and (proximal)
lower dentition,with condition
Extraction of existing
of premolars, Bolton
incisors with discrepancies
condition between
of Bolton ratio upper
considerations, and
or decayed
lower
teeth, dentition,
Derotation Extraction
or Uprighting of the of premolars,
posterior incisors
teeth after with
extractions condition
or in the missingof Bolton
teeth ratioProclination
conditions, considerations,
of anterior
teeth, Distalization of the posterior teeth, Orthopedic (Maxilla) or Orthodontic Expansion of dental arches.
or decayed teeth, Derotation or Uprighting of the posterior teeth after extractions or in the
missing teeth conditions, proclination of anterior teeth, distalization of the posterior teeth,
Orthopedic (Maxilla) or Orthodontic Expansion of dental arches.
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Constricted arches, dental irregularities, proclinations of teeth relative to jaw bases or patient
profile, deep bites and open bites with tight contacts between the teeth should be considered
as space deficiency or crowding. Reproximation or proximal stripping produces up to 3.5 mm
of space and 1 mm of expansion in the posterior part of maxilla is capable to produce 0.7 mm
increase in arch perimeter that can be used for crowding resolution.
Upper dental arch expansion and lower dental arch uprighting (from lingual side to buccal
side) produce space for bringing the impacted teeth to the dental arch. After full bonding of
the arches, by incremental increase in wire diameter plus changes in cross sections (from round
to rectangular) and material (from NiTi to Stainless Steel); dental arches begin to get adapted
to final wire shape and size from its lingually collapsed cases to the consequent expanded arch.
Maxillary expansion can be skeletal or orthopedic if it is conducted in appropriate time i.e.
before fusion of palatal suture. For maxillary expansion, banded expander (with Hyrax screw
and acrylic free palate), banded+bonded (occlusal acrylic coverage) expander, and banded
+palatal acrylic (Haas type) expander can be used for both dental and skeletal expansions.
In addition to space regaining in dental arches, physical barriers as supernumerary teeth,
odontomas, or other pathologic lesions that inhibits tooth eruption; should be removed. Apart
from hard tissue lesions, soft tissue fibrotic hyperplasia or thick fibrotic gingiva can prevent
regular tooth eruption and they can be treated surgically or by laser beam.
4. Selection of the method for eruption of impacted tooth (Closed versus

Open)
Method of exposure is very important to be practical for the surgeon, to be useful for appli‐
cation of biomechanical forces for the orthodontist, and to be beneficial for the patient. Benefits
for the patient consist of several immediate and future outcomes; including periodontal health,
esthetics, and stability of treatment. Facio-lingual and vertical position of the impacted teeth
are very important in determining an appropriate approach for exposure. Buccally/Labially
impacted teeth can be accessed after apically positioned flap or closed eruption technique.
Excisional uncovering or gingivectomy necessitates special conditions including superficial
position of tooth (vertically and facio-lingually), and adequate width of keratinized gingiva.
An example of inappropriate surgical approach for uncovering the impacted central is
conducting the procedure apical to the mucogingival junction and removing the keratinized
gingiva (Figure 6).
Apically positioned flap (Open) or closed eruption technique is an aid for maintenance of the
biologic width. The biological width is comprised of epithelial attachment and connective
tissue attachment (both dimensions added) coronal to the crest of the alveolar bone. It should
be planned to preserve an adequate apico-coronal height of keratinized gingiva (2-3 mm),
especially in the presence of thin gingival biotype (transparency of the periodontal probe
through gingival margin). In some cases impacted teeth are superficial and coronal or near
mucogingival junction, in these circumstances, an apically positioned flap or open approach
including superficial position of tooth (vertically and facio-lingually), and adequate width of keratinized gingiva. An example of
inappropriate surgical approach for uncovering the www.dentalbooks.co
impacted central is conducting the procedure apical to mucogingival junction
and removing the keratinized gingiva. (Figure 6)

http://dx.doi.org/10.5772/59143
Figure 6. An inappropriate order to expose the impacted left central incisor. Incorrect technique is independent of tools i.e. laser
Figure
beam or6.scalpel;
An inappropriate wayoftoattached
a required width expose gingiva
the impacted left for
(necessary central incisor.health)
periodontal Incorrect technique
has been is independent
removed of tools
to create a buttonhole
i.e. laser(Left-clinical)
window beam or scalpel;
as anaunaccepted
required width of attached
procedure gingiva
with a bonded (necessary
attachment. Onfor
theperiodontal health)
first right slice has been
of CBCT, removed to
an odontoma-like
create a buttonhole
malformations window
is obvious but has(Left)
been as an unaccepted
neglected during theprocedure with a bonded
surgical intervention attachment. On the first right slice of
(red arrow).
CBCT, an odontoma-like malformation is obvious but has been neglected during the surgical intervention (red arrow).
is indicated but the author suggests minimum apical repositioning of the flap equal to the
amount neededflap
Apically positioned for(Open)
bonding of an
or closed orthodontic
eruption technique isbracket
an aid forin proper position
maintenance for width.
of the biologic avoiding future
The biological
width is comprised of epithelial attachment and connective tissue attachment (both dimensions added) coronal to the crest of the
apical migration of the gingival margin. Uneven gingival contours can be corrected by cosmetic
periodontal plastic surgery (laser, scalpel, or radiosurgery) if adequate soft tissue exist.
Uncontrolled tipping toward labial/buccal can produce gingival/bone recession plus a long
clinical crown that should be avoided.
When impacted teeth need a facial (labial or buccal) approach, and the position of tooth is
deep, closed eruption is an option. In the aforementioned situation, an apically positioned flap
will not be stable and rebound of soft tissue may occur in addition to unwanted exposed parts
of the bone that should be covered by a flap (Figure 7).
During tooth exposure, care should be given to protect root surface, for example; by avoiding
the usage of sharp or rotary instrument if possible because bone and the unerupted tooth are
color matched and any damage to the root leads to periodontal ligament breakdown, increased
risk of ankylosis, and increased risk for future bone and gingival recession (deleterious effects
to periodontal health and esthetics). Thin layers of bone can be removed by periosteal elevator
or similar instruments e.g. curette to reach the coronal part of the tooth (Figure 7).
Soft tissue covering the hard palate is called masticatory mucosa and it consists of keratinized
stratified squamous epithelium. Since the palate is covered with keratinized mucosa or
attached gingiva, problems with alveolar mucosa are not part of this operational area. If the
bulge of an impacted canine is obvious from the palatal aspect, the cuspid tooth should be
located superficially and accessible after soft tissue removal plus removal of covering bone.
The patient shown in Figure 8, had no canine bulge on the left side on facial aspect (top row-
left and center slides) but it was seen on the palatal aspect clinically (top row-right slide) and
also in CBCT (bottom- left and center). Uncovering the tooth and bonding through a small
window can be hectic using a scalpel a palatal flap may help in achievement an isolated and
dry environment for the bonding and open or close eruption technique. Again sufficient bone
removal is recommended without damage to the tooth root because PDL is the interface for
tooth movement and the enamel of the crown has no potential for participating in bone
remodeling and consequent tooth movement. Absolute anchorage was used for eruption of
instrument if possible because bone and unerupted tooth are color matched and any damage to root leads to periodontal ligament
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breakdown, increased risk of ankylosis, and increased risk for future bone and gingival recession (deleterious effects to
periodontal health and esthetics). Thin layers of bone can be removed by periosteal elevator or similar instruments e.g. curette to
reach coronal part of tooth (Figure 7).
Figure 7. Upper right central incisor is positioned horizontally. An apically positioned flap is not indicated in the
present
Figure 7. situation and
Upper right a closed
central eruption
incisor surgical
is positioned approach Apically
horizontally. may be positioned
used. Thinflap
overlying bone can
is not indicated in be
the removed with a
present situation
periosteal elevator instead of rotary instrument (burs) and bonding performed in an isolated dry environment (top
and
row). After
ordered closedwound healing,
eruption tooth
surgical 11 canThin
approach. be pulled towards
overlying the dental
bone can arch by
be removed withmeans of absolute
periosteal elevator anchorage
instead of (mini-
rotary
screws) or(burs)
instrument after and
bonding upper
bonding dental in
performed arch (continuous
isolated wire). In (top
dry environment this row).
case, After
an orthodontic attachment
wound healing, tooth 11wascanbonded
be pulledin
toward dentalfossa
the lingual arch of
by tooth
means11of and
absolute anchorage
ligature (Mini-screws)
wire was placed outorofafter
thebonding
flap forupper dental archextrusive
biomechanical (continuous wire).
forces In the
(bottom
present condition, orthodontic attachment was bonded in lingual fossa of tooth 11 and ligature wire was placed out of flap for
row).
biomechanical extrusive forces (Bottom row).
tooth #23 by means of Seifi Twin Screws (STS) for protecting other teeth from early unwanted
orthodontic forces (Figure 8).

Soft tissue covering hard palate is called masticatory mucosa and it consists of keratinized stratified squamous epithelium. Since
palate
has is
notcovered
potentialwith keratinized mucosa
for participating in bone or attached and
remodeling gingiva, problems
consequent toothwith alveolar Absolute
movement. mucosa are not applied
anchorage to this
was used for part of
eruption
operational area.byIfmeans
of tooth #23 the bulge of impacted
of Seifi canine
Twin Screws is obvious
(STS) from palatal
for protecting aspect,
other teeth fromcuspid tooth should
early unwanted be located
orthodontic superficial
forces (Figureand8).
accessible after soft tissue removal plus precautious removal of covering bone. Patient G.H. (Figure 8), had not canine bulge of
left side on facial aspect (top row-left and middle slides) but it was seen on the palatal aspect clinically (top row-right slide) and
also in CBCT (bottom- left and middle). Uncovering the tooth and bonding through a small window can be hectic (control of
vascular bleeding, plasma fluid exudation, and even next week granulation tissue bleeding) and a palatal flap may help in
achievement an isolated and dry environment for the bonding and open or close eruption technique. Again sufficient bone
removal is recommended without damage to the tooth root because PDL is interface for tooth movement and enamel of crown
Figure
Figure8.8.Patient
Patientwith
G.H.an impacted
with toothtooth
an impacted #23 #23,
underwent
underwenta surgical uncovering
a surgical uncoveringofofapalatal
palatalleft
leftcanine
canine (mirror
(mirror image
image after
after surgery-bottom
surgery-bottom right).
right). An absolute
An absolute anchorage
anchorage by combination
by combination of two of two miniscrews
miniscrew and a cantilever
and a cantilever helical loophelical
(Seifi loop
Twin
(Seifi Twin Screws/STS)
screws/STS) was
was used for usederuption
forced for forced eruption of
or extrusion orimpacted
extrusioncanine
of impacted canine without
without exerting unwantedexerting unwanted
orthodontic force toor‐the
thodontic
adjacent force to the adjacent
teeth. Miniscrews were teeth.
coveredMiniscrews were
by composites for covered by composites
better performance forand
of spring better performance
sustained stability. of springs and
sustained stability.
4‐ Selection of the appropriate (efficient) biomechanical approach
After selection of proper approach to reach the impacted tooth, an appropriate biomechanical approach should be selected. A
proper biomechanic system is capable of protecting periodontium and avoiding any unwanted tooth movement or root damage of
the adjacent teeth.
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http://dx.doi.org/10.5772/59143
5. Selection of the appropriate (effective) biomechanical approach
After selection of the proper approach to reach the impacted tooth, an appropriate biome‐
chanical approach should be selected. A proper biomechanical system is capable of protecting
periodontium and avoiding any unwanted tooth movement or root damage of the adjacent
teeth.
a. Anchorage preparation (Direct vs. Indirect)
In contrast to dental implants, orthodontic miniscrews are loaded immediately, and most
authors suggest the use of light forces early on.[12] Only a few studies, mostly on animals,
have dealt with the investigation of tissue reaction to immediate loading of miniscrew
implants. Miniscrew implants can be immediate loaded (there is no need for a waiting period
for osseointegration, in contrast to orthodontic implants), reducing the total treatment time.
There is no need for complicated clinical and laboratory procedures (i.e., fabrication of acrylic
splints by taking imprints with additional implant copying systems to accurately transfer the
implant position to cast models) to facilitate safe and precise implant insertion.[13]
casesDirect
(Group anchorage screws are
B), posterior protraction useful
is almost when
equal prognosis
to anterior of and
retraction, theineruption (impacted
minimum anchorage tooth)
cases (GroupisC),
questionable.
posterior protraction is If thethan
more impacted
75% of thetooth is ankylosed,
extraction site. by applying force from a continuous arch,
Indirect anchorage miniscrew stabilizes dental units, which in turn serve as the anchor units, and opens absolute anchor
the dental arch could be deflected towards the ankylosed tooth (sometimes creating open
possibilities that can be even more flexible than direct-anchor setups. Indirect-anchor setups will entail an implant, or TAD,
bites); but, an absolute
placed in a non-dental anchorage
location, which could
is then used be a valuable
to stabilize tool tothem
teeth, rendering determine
as indirectthe sensitive
absolute stage
anchors, of
on which
tooth eruption
orthodontic without
force is placed. endangering
Locations the adjacent
for indirect anchors anchored
include retromolar, teeth
buccal (Figure
vestibule, and8). Direct anchorage
midpalatal (Figure 11). As
they are not destined for restoration or any functional use after serving as anchor units, all indirect-anchor devices are explanted
cantime
at some be used forcompletion
after the anterior retraction in protrusion
of orthodontics. Consequently, cases or non-extraction
all indirect-anchor devices, betreatment of theimplants
they endosseous Class or
III malocclusions
mini-screws, (retraction
must be considered TADs.(14)of lower anterior sextant) and cases who have midline shift toward
previous extraction sites (Figure 9).
Figure 9. Patient M.T. had Class III open bite with midline deviation toward left side, a prvious extraction site. A miniscrew was
Figure
inserted 9. Patient with
in retromolar area Class III open
of right bitemidline
side for with midline deviation
correction towards the
and meanwhile left side,ofa prvious
retraction anterior extraction site. Aclass
teeth to correct min‐III
iscrew was
relationship inserted in theofright
and establishment properretromolar area
overjet and for midline correction ; meanwhile retraction of anterior teeth to cor‐
overbite.
rect class III relationship and establishment of proper overjet and overbite was done.
Protraction of the upper dentition is possible by using miniscrews in anterior or palatal parts.
Better results in protraction of the upper dentition can be expected by using miniscrews in
combination with miniplates. In some situations transpalatal arch (TPA) is used for eruption
of impacted teeth as a direct anchorage unit; resistance to displacement depends on the number
of teeth and the root surface area (Figure 10).
Figure 10. Transpalatal arch (TPA) has served as indirect anchorage (contributing role of root surface area of upper first molars)
in addition to a full size rectangulet wire that resist against reactive forces produced by traction force on the impacted upper right
canine.
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cases (Group B), posterior protraction is almost equal to anterior retraction, and in minimum anchorage cases (Group C),
80 A Textbook
posteriorFigure of Advanced
protraction is more
9. Patient Oral
than
M.T. had 75%and
Class ofMaxillofacial
III bite with Surgery
the extraction
open Volumetoward
site. deviation
midline 2 left side, a prvious extraction site. A miniscrew was
Indirect inserted
anchorage miniscrew
in retromolar areastabilizes dental
of right side units, which
for midline in and
correction turnmeanwhile
serve as retraction
the anchor units, and
of anterior teethopens absolute
to correct anchor
class III
possibilities that can
relationship andbe even moreofflexible
establishment than direct-anchor
proper overjet and overbite. setups. Indirect-anchor setups will entail an implant, or TAD,
placed in a non-dental location, which is then used to stabilize teeth, rendering them as indirect absolute anchors, on which
orthodontic force is placed. Locations for indirect anchors include retromolar, buccal vestibule, and midpalatal (Figure 11). As
they are not destined for restoration or any functional use after serving as anchor units, all indirect-anchor devices are explanted
at some time after the completion of orthodontics. Consequently, all indirect-anchor devices, be they endosseous implants or
mini-screws, must be considered TADs.(14)
Figure 10. Transpalatal arch (TPA) has served as indirect anchorage (contributing role of root surface area of upper first molars)
Figure 10. Transpalatal
in addition arch (TPA)
to a full size rectangulet hasthat
wire served as indirect
resist against anchorage
reactive (contributing
forces produced role
by traction of on
force root
thesurface
impactedarea of right
upper upper
first molars) in addition to a full size rectangulet wire that resists reactive forces produced by traction force on the im‐
canine.
pacted upper right canine.
Following force application, some mobility or movement of teeth will be noticeable and on X-
ray examination, disappearance of the lamina dura plus widening of PDL will be evident; these
are sequel of force dispersion in the dental anchorage units. In maximum anchorage cases
Figure 9. Patient M.T. had Class III open bite with midline deviation toward left side, a prvious extraction site. A miniscrew was
(Group
inserted A), mesial
in retromolar area ofmovement
right side for of posterior
midline teeth
correction and(protraction) should
meanwhile retraction be lessteeth
of anterior than to 25%
correctofclass
the III
extraction site, in moderate anchorage cases (Group B), posterior protraction is almost equal
relationship and establishment of proper overjet and overbite.
to anterior retraction, and in minimum anchorage cases (Group C), posterior protraction is
more than 75% of the extraction site.
Indirect anchorage miniscrew stabilizes dental units, which in turn serve as the anchor units,
and opens absolute anchor possibilities that can be even more flexible than direct-anchor
setups. Indirect-anchor setups will entail an implant, or TAD, placed in a non-dental location,
which is then used to stabilize teeth, rendering them as indirect absolute anchors, on which
orthodontic force is placed. Locations for indirect anchors include retromolar, buccal vestibule,
and midpalatal areas (Figure 11). As they are not destined for restoration or any functional use
after serving as anchor units, all indirect-anchor devices are explanted at some time after the
Figurecompletion
10. Transpalatal ofarch
orthodontics. Consequently,
(TPA) has served all indirect-anchor
as indirect anchorage (contributing role ofdevices, bearea
root surface they endosseous
of upper first molars)
implants or mini-screws, must be considered TADs.[14]
in addition to a full size rectangulet wire that resist against reactive forces produced by traction force on the impacted upper right
canine.
Figure 11. Miniscrews as an indirect anchorage resist against vertical pull of elastics for open bite closure. In the
present condition eruption of lower anterior teeth has a major role for establishment of proper overbite. Vertical move‐
ment of the maxillary dentition is controlled by ligating both upper canines to miniscrews as indirect anchorage.
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http://dx.doi.org/10.5772/59143
b. Force application
After anchorage preparation, a pivotal phase of treatment begins i.e. force application for
eruption of the impacted tooth into the dental arch. Any root damage to the impacted tooth is
not acceptable e.g. ligating ligature wire around the cervical part of the tooth may destroy PDL
and have a deleterious effect on periodontal health of the future leveled/aligned tooth. In
addition, the author does not prefer enamel drilling for canine traction (EDCT) over accessory
Figure 11. Miniscrews as an indirect anchorage resist against vertical pull of elastics for open bite closure. In the present
bonding for canine traction (ABCT) i.e. bonding orthodontic attachment for loading because
condition eruption of lower anterior teeth has a major role for establishment of proper overbite. Vertical movement of the
of its inherent
maxillary dentition characteristics
is controlled in enamel
by ligating both destruction.
upper canines A clean,
to miniscrews etched
as indirect surface of enamel is a
anchorage.
prerequisite for successful bonding but before force application, a recheck of bonded attach‐
b‐ment by manual traction is a prerequisite for wound closure.
Force application
Description of tooth movement for an impacted tooth is intricate and difficult. Only 3-
dimensional
After anchorage analysis
preparation, that contains
a pivotal information
phase of treatment beginson i.e.both
force rotation
applicationand for translation of the tooth
erupting the impacted tooth to the
dental arch. Any root damage to the impacted tooth is not accepted e.g. ligating ligature wire around the cervical part of the tooth
movement
may destroy PDL and has potential
have deleteriousto evaluate and explain
effect on periodontal healththeofnature of the exact movement.
future leveled/aligned However,
tooth. In addition, author do not
coordinate
prefer enamel systems
drilling aretraction
for canine used in orthodontics
(EDCT) for better
over accessory bondingunderstanding
for canine traction of clinicians.
(ABCT) i.e.Application
bonding orthodontic
of force
attachment to the center
for loading because ofof resistance
its inherent of a rigid body
characteristics in can
enamelproduce translation
destruction. A clean,without rotation.
etched surface If
of enamel is
prerequisite for successful bonding but before force application; a recheck of bonded attachment by manual traction is
the vector
prerequisite for wound of closure.
the force is out of the center of resistance (CRes), according to its distance to the
CRes itofcan
Description produce
tooth movement a moment of the force
for an impacted tooth is(Mintricate
F) withand an expression
difficult. Onlyof3-dimensional
rotation for analysis
free-bodies
that contain
or rotation
information on both tendency
rotations andfor teeth. InofFigure
translation the tooth12, a 100 gram
movement, force plus
has potential 1000 g and
to evaluate mmexplain
of moment equals
the nature of the exact
movement. However, coordinate systems are used in orthodontic for better understanding of the clinicians. Application of force
the 100
to the center gram force
of resistance of aapplied
rigid body tocan
theproduce
bracket with 10without
translation mm distance. Bythe
rotation. If addition
vector ofof thecounterbalancing
force is out of the center of
moment
resistance (MC) i.e.toinsertion
(CRes), according its distance oftorectangular archwire
the CRes; it can produce ain the bracket
moment slot(M
of the force and its engagement
F) with an expression oftorotation
for free-bodies or rotation tendency for teeth. In figure 12, 100 gram force plus 1000 g.mm of moment equals the 100 gram force
the walls, the bracket system will act like the system in the green box of Figure 12 (the green
applied to the bracket with 10 mm distance. By addition of counterbalancing moment (MC) i.e. insertion of rectangular archwire
box isslot
in the bracket hypothetical) and depending
and its engagement onbracket
to the walls, the the proportion
system will act of M C/M
like F, a controlled
system in green box of tipping (0<M
figure 12 C/ box is
(green
MF<1),
hypothetical andtranslation
cannot happenor bodily
in clinics)movement
and depending (MCon /Mthe
F =1), and torque
proportion of M (M
C /MF
C /M
; a F >1) can
controlled be produced.
tipping (0<M C/MF<1),
Translation or Bodily movement (MC/MF=1), and Torque (MC/MF>1) can be produced. The relationship between the orthodontic
The relationship between the orthodontic force and counterbalancing moment is also ex‐
force and counterbalancing moment is also expressed in the “moment to force ratio” or M/F ratio. M/F ratio 1 to 7 would produce
pressed
controlled tipping,in ratios
the “moment
of 8 to 10to force ratio”
(according or M/F
to root length)ratio.
produceM/Fbodily
ratio 1movement,
to 7 produce controlled
and ratios greater tipping;
than root length
produceratios of 8 to
root torque 10 (according to root length) produce bodily movement, and ratios greater than
movement.
root length produce root torque movement.
Uncontrolled Controlled tipping

tipping
A B C
Figure 12. Application of force to the bracket without any tools to exert moment (like round wire in bracket or labial bow in
Figure
removable 12. Application
appliances) produceof force
a typetoof
the“Uncontrolled
bracket without any tools
tipping” to exert moment
movement (slide A).(like round
In this wire
type of in bracket or the
movement, labial
center of
rotationbow(redincircle)
removable appliances)
is near the center produce a type of
of resistance “uncontrolled
(blue circle). Thetipping”
similar movement
or equivalent(slide A). system
force In this type of move‐
can be produced by
exertingment,
forcethe(100
center
g) of rotation
plus moment (red(100x10=1000
circle) is near the centertoofthe
g.mm) resistance
center (blue circle). The
of resistance similar
(green or equivalent
box- slide C). Ifforce
100 sys‐
g force is
appliedtem can be produced
to bracket (slide A)byandexerting force (100 g) plus
a counterbalancing moment
moment (MC(100x10=1000
) is producedg bymm) to the center
rectangular of (slide
wire resistance (green
C) but lessbox-
than 1000
g.mm; slide
it canC).
move If 100 g forceofisrotation
the center appliedtotonear
theapical
bracket
area(slide A) anda type
and create a counterbalancing moment (slide
of “Controlled tipping” (MC) isB)produced by
type of movement.
rectangular wire (slide C) but less than 1000 g mm, it can move the center of rotation near to the apical area and create
a type of “controlled tipping” (slide B) type of movement.
The correct M/F ratio should be obtained for bringing the impacted tooth to the dental arch but it is important to maintain the
ratio for a constant center of rotation. By using rectangular loop (R-loop) in a cantilever spring, load-deflection rate will be
decreased i.e. make the spring more flexible (relative to straight wire), and the configuration of the spring leads to a better
maintenance of M/F ratio for a constant center of rotation. Segmented R-loop has long range of action with minimal force
decrease during tooth movement and acceptable control of force magnitude. If the spring is distorted by the patient, cantilever
spring do not fail safely, and it can significantly move the tooth in an unwanted direction (Figure 13).
Treating a clinical case of a maxillary canine in infralabioversion by means of the straight archwire technique used to level the
tooth is a harmful procedure for adjacent teeth. Canine extrusion would occur regardless of the type of bracket, whether
conventional or self-ligating, however, it would be followed by undesired intrusion and moments on the lateral incisor and first
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The correct M/F ratio should be obtained for bringing the impacted tooth into the dental arch
but it is important to maintain the ratio for a constant center of rotation. By using rectangular
loop (R-loop) in a cantilever spring, load-deflection rate will be decreased i.e. make the spring
more flexible (relative to straight wire), and the configuration of the spring leads to a better
maintenance of M/F ratio for a constant center of rotation. Segmented R-loop has long range
action with
but not necessarily minimal force
connected decrease and
to brackets during tooth movement
adjacent tubes. Thisand acceptable control of forceof wires ma
allows a combination
sions and hardness to be used. Rigid and thick archwires can connect groups the
magnitude. If the spring is distorted by the patient, it can significantly move of tooth
teethininto
an anchorage
unwanted direction (Figure 13).
ires are used to exert forces between these units. (15)
A B
traight wire Figure

is used 13. Ain (A) wire
straight to erupt the
is used in (A)bicuspid. WhenWhen
to erupt the bicuspid. the the
wirewireis bent(blue
is bent (blue line)
line) and andinengaged
engaged the in brac
distal, in nextbracket,
yellow the root apexposition,
line tends to go toroot
distal,is
in upright
the next yellow
andlinemoment
position, thedrops
root is upright and moment
off, and in reddrops off, position; roo
line
and in red line position; roots tends to go to the mesial while the crown is depressed. With this configuration, several
while the crown
centersisofdepressed.
rotation exist andWith this
constancy configuration,
of the several
moment to force ratio center
is affected of rotation
(inconsistent exists
force system). and constancy o
Slide B dem‐
onstrates preactivated
s affected (inconsistent force rectangular
system). loop (R-loop)
Slide which provides constantpreactivated
B demonstrates control of M/F ratio. The R-loop is made
rectangular loop (R-loop) w
from 0.018x0.025 inch Stainless Steel or 0.017x0.025 inch Titanium Molybdenum Alloy (TMA).
ol of M/F ratio. R-loop is made from 0.018x0.025 inch Stainless Steel or 0.017x0.025 inch Titanium
Treating a clinical case of a maxillary canine in infralabioversion by means of the straight
archwire technique used to level the tooth is a harmful procedure for adjacent teeth. Canine
extrusion would occur regardless of the type of bracket, whether conventional or self-ligating;
however, it would be followed by undesired intrusion and moment on the lateral incisor and
first premolar (Figure 14). Many authors believe that these side effects can be solved with
intermaxillary rubber bands, arch bends or wire progression. Conversely, with the aid of the
segmented arch technique (SAT) and after preparation of the anchorage unit, only the canine
is extracted by a cantilever or a rectangular loop (Figure 14).
30 gr
Differently from the conventional techniques, which normally use an archwire made of one
single alloy, connecting all brackets and adjacent tubes, the SAT uses arch segments connected
to each other, but not necessarily connected to brackets and adjacent tubes. This allows a
combination of wires made of different alloys, dimensions and hardness to be used. Rigid and
thick archwires can connect groups of teeth to anchorage units, whereas flexible archwires are
used to exert forces between these units. [15]
30 gr
5 mm
Figure 13. A straight wire is used in (A) to erupt the bicuspid. When the wire is bent (blue line) and engaged in bracket, root apex
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tend to go to distal, in next yellow line position, root is upright and moment drops off, and in red line position; roots tends to go
to the mesial while the crown is depressed. With this configuration, several center of rotation exists and constancy of the moment
to force ratio is affected (inconsistent force system). Slide B demonstrates preactivated rectangular loop (R-loop) which provides
constant control of M/F ratio. R-loop is made from 0.018x0.025 inch Stainless Steel or 0.017x0.025 inch Titanium Molybdenum
http://dx.doi.org/10.5772/59143
Alloy (TMA).
30 gr
30 gr
5 mm
5 mm
4 mm
Figure 14.Figure 14. Top-left)

Top-left) Continuous
Continuous arch (NiTi
arch wire wire (NiTi or CuNiTi)
or CuNiTi) or or straightarchwire
straight archwiretechnique
technique can
can bebeused
usedtotolevel thethe
level im‐ impacted
pacted
canine/high canine/high
buccal buccal canine (infralabioversion
canine (infralabioversion canine);extrusion
canine) but canine but caninewould
extrusion would beby
be followed followed by intrusive
intrusive force andforce positive and
and positive
negative moments on and
firstnegative
premolar moment on the
and lateral first premolar
incisor. A lingualandmoment
lateral incisor. A lingual
is created moment
for upper is created
canine forlead
that will the upper
it to the dental
canine that
arch. Top-right) withwill
thelead it to themechanics
cantilever dental arch.orTop-right)
segmented with thetechnique
arch cantilever (SAT),
mechanics or segmented
a cantilever arch technique
rectangular spring (SAT),
is inserted into
a cantilever
a rectangular rectangular
tube and tied to one spring is inserted
point into aside
on the other rectangular tube “determinate
to produce and tied to one point on the
one-couple other side
system”. to produceSectional
Bottom-left)
cantilever“determinate
spring is usedone-couple system”.
to extrude the Bottom-left) Sectional
impacted canine cantilever
(force spring and
30 grams, is used to extrude
distance the impacted
between canine and caninefirst molar,
(force 30 grams, and distance between canine and first molar, presumably, about 20 mm). Extrusive force on canine (30
presumably, about 20 mm). Extrusive force on canine (30 grams) will produce 30 gram intrusive force on upper first molar plus
grams) will produce 30 gram intrusive force on upper first molar plus 600 g mm moment (M=Fxd=30x20=600) to create
600 g.mm moment (M=Fxd=30x20=600) to create distal root movement (blue arrow). The moment would be created by a couple
distal root movement (blue arrow). The moment may be created by a couple (molar tube, presumably, 4 mm in length)
(molar tube, presumably, 4 mm in length) with 150 grams force (600/4=150g) upward on the mesial end of the tube and 150
with 150 grams force (600/4=150g) upward on the mesial end of the tube and 150 grams downwards on the distal end.
grams downwards on the distal end. Bottom-right) the abovementioned force system from the occlusal view. Consider the
Bottom-right) the abovementioned force system from the occlusal view. Consider the moment created by the rectangu‐
moment created by the
lar archwire rectangular
in molar archwire
tube (torque) andinmoment
molar tube
on the(torque)
canine.and moment
If center on canine.
of resistance If center
of the canine of resistance
tooth is, presuma‐of the canine
tooth is, presumably,
bly, about 5 mmabout 5 mmtolingual
lingual to thebutton
the bonded bonded on button on the
the crown, crown,
a 150 g mma (30x5=150g.mm)
150 g.mm (30x5=150g.mm)
moment rotatesmomentthe tooth rotates the
lingually. At the first molar, if the center of resistance is 5 mm lingual to the tube, a 30 g intrusive force can create 150 g
mm moment to rotate it buccally. If the center of resistance of the impacted canine is, presumably, 10 mm palatal to the
buccal surface of the first molar, activation of spring to tie to the canine, can twist it and create 300 g mm (30x10=300g
mm) moment to rotate the molar crown palatally. The result at the molar is a net 150 g mm (300 g mm palatal – 150 g
mm buccal =150 g mm palatal) palatal crown torque. (Bracket type and existence of continuous archwire of the model
are not related to the biomechanical explanations.)
5.1. Biomechanical alternatives for forced tooth eruption
The orthodontist should avoid mechanics that draw the tooth labially, which could produce
a bony dehiscence and accelerated migration of the labial gingival margin, resulting in labial
recession. A “Ballista” loop is a simple, convenient, unobtrusive method of applying a vertical
vector of force to a labially impacted tooth to erupt the crown into the center of the alveolus.
When the canine crown is displaced mesially and lies over the root of the permanent lateral
The orthodontist should avoid mechanics that draw www.dentalbooks.co
the tooth labially, which could produce a bony dehiscence and accelerated
migration of the labial gingival margin, resulting in labial recession. A “Ballista” loop is a simple, convenient, unobtrusive
method of applying a vertical vector of force to a labially impacted tooth to erupt the crown into the center of the alveolus. When
the canine crown is displaced mesially and lies over the root of the permanent lateral incisor, an apically positioned flap is the
appropriate surgical uncovering technique. Exposure of the crown facilitates attachment of an elastomeric chain directed toward
the center of the edentulous alveolar ridge to gradually guide the canine crown into the dental arch.(16) A “Vertical spring” bent
into 0.14 inch stainless steel wire that faces downward before activation is another alternative. It can be activated by pushing the
vertical legs toward the impacted canine. This kind of round wires have the benefit of increased length and springiness but they
incisor,
need somean kindapically positioned
of anti-rotation bent forflap is the
avoiding appropriate
rotation of round wiresurgical uncovering
inside bracket technique.
slot that neutralizes the Exposure
activity of the
of theAnother
spring. crownalternative
facilitatesis anattachment of anNiTi
“Overlaid Auxiliary elastomeric chain directed
wire” on the rectangular stabilizingtoward theauxiliary
arch. These centerarchof the
wires
are very efficient method to bring an impacted tooth into dental arch. “Cantilever springs” can be used, either soldered to a heavy
edentulous
base arch or fromalveolar ridge
auxiliary tube tofirst
on the gradually
molar. Some guide the
clinician canine
have crown
used headgear tubeinto
plus the dental arch.
an anti-rotation bend on[16]
wire A
and
“Vertical
a helix aroundspring”
main archbent into
wire for 0.14eruption
forced inch stainless
of impactedsteel
teeth. wire that faces downward before activation
is another alternative. It can be activated by pushing the vertical legs toward the impacted
‐Molar uprighting in impacted cases
canine. This kind of round wire has the benefit of increased length and springiness but needs
some kind
Dental arch withofaligned
anti-rotation bent
teeth and heavy mainforarchwire
avoiding rotation
can serve of round
as an anchorage unit towire inside
be used bracket
for uprighting slot second
posterior that
neutralizes the activity of the spring. Another alternative is an “Overlaid Auxiliary
or third molar teeth by a NiTi or sectional Stainless Steel wire incorporating loops e.g. T-loop. Absolute anchorages i.e.
miniscrews or titanium miniplates are other alternatives for distalizing or uprighting impacted molar teeth (Figure 15).
NiTi wire”
on the
Molar rectangular
uprighting stabilizing
is generally arch.
associated with These
extrusion auxiliaryteeth,
of antagonist arch wiresinare
reduction very space,
edentulous efficient to bringinan
bone dehiscence the
impacted tooth into dental arch. “Cantilever springs” can be used, either soldered to a heavy
mesial surface of tipped molars, gingival recession of tipped molars, early contact in centric relation and occlusal interference on
excursion of the mandible. With regard to integrated planning, clinicians must decide whether the tooth subject to uprighting will
base
undergoarch or from
movement for auxiliary
space closure,tube on the
opening firstformolar.
of space Some
prosthetic have used
rehabilitation headgear
or implant tube
placement. plusmovement
Mesial an anti-of
rotation
molars maybend on wire
be rendered andduea helix
difficult aroundalveolar
to the following: main arch wire forresulting
bone resorption forcedfrom eruption ofwhich
tooth loss, impacted teeth.
causes the molar
mesial bone to become too thin; unfavorable root morphology for movement of lower molars; greater mandibular bone density in
relation to the maxilla; and thin buccolingual bone thickness from distal to mesial in the mandibular arch. Using straight wires to
5.2. Molar
upright tipped uprighting in impacted
molars is considered cases
unfeasible, given that, in these cases, there is a strong tendency towards extrusion of molars,
especially due to the short distance between brackets. Additionally, incorporating a T-loop spring into the arch will lead to
extrusion of premolars. A cantilever, extended up to the anterior region, may be used to reduce the effects of extrusion on molars.
A dental have
Researches archproved
witha aligned
moment of teeth and toheavy
1200 gf.mm main for
be appropriate archwire can serve
molar uprighting. asa an
Should anchorage
30-mm unit
cantilever be used,toan
be used offor
activation 40 uprighting
gf is enough forposterior second
molar uprighting, or third
in which case 40molar teeth by
gf corresponds a NiTiforces
to intrusive or sectional Stainless
in the anterior region and
extrusive forces in the region of molar teeth. Mesocephalic or brachycephalic patients are able to eliminate or reduce this effect
Steel wirebyincorporating
of extrusion their own muscularloops
pattern. e.g. T-loop. Absolute anchorages i.e. miniscrews or titanium
(15,17)
miniplates are other alternatives for distalizing or uprighting impacted molar teeth (Figure 15).
Figure 15. T-loops have efficient control on angulation and torque of an inclined tooth (left). An alternative to absolute
anchorage can help in uprighting the tilted impacted second or third molars without endangering other teeth as an‐
chorage units that may be affected with orthodontic force and tooth movement or root resorption.
Molar uprighting is generally associated with extrusion of antagonist teeth, reduction in

edentulous space, bone dehiscence in the mesial surface of tipped molars, gingival recession
of tipped molars, early contact in centric relation and occlusal interference on excursion of the
mandible. With regard to integrated planning, clinicians must decide whether the tooth subject
to uprighting will undergo movement for space closure, opening of space for prosthetic
rehabilitation or implant placement. Mesial movement of molars may be rendered difficult
due to the following: alveolar bone resorption resulting from tooth loss, which causes the molar
mesial bone to become too thin; unfavorable root morphology for movement of lower molars;
greater mandibular bone density in relation to the maxilla; and thin buccolingual bone
thickness from distal to mesial in the mandibular arch. Using straight wires to upright tipped
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http://dx.doi.org/10.5772/59143
molars is considered unfeasible, given that, in these cases, there is a strong tendency towards
extrusion of molars, especially due to the short distance between brackets. Additionally,
incorporating a T-loop spring into the arch will lead to extrusion of premolars. A cantilever,
extended up to the anterior region, may be used to reduce the effects of extrusion on molars.
Researchers have proved a moment of 1200 gf.mm to be appropriate for molar uprighting.
Should a 30-mm cantilever be used, an activation of 40 gf is enough for molar uprighting, in
which case 40 gf corresponds to intrusive forces in the anterior region and extrusive forces in
the region of molar teeth. Mesocephalic or brachycephalic patients are able to eliminate or
reduce this effect of extrusion by their own muscular pattern. [15, 17]
6. Alignment/ Leveling/Torque/Angulation (ALTA) corrections
The root apices are located in the apical portion of the jaws and malposition almost always
develops as the eruption paths of teeth are deflected; for impacted teeth the problem is more
complicated and both apex and crown are usually misplaced. ALTA corrections have been
considered for the time that impacted tooth has been brought near to the dental arch. Light
and continuous force is recommended for the beginning of the treatment i.e. “Alignment”,
through tipping movement for impacted teeth in facio-lingual direction. As a general rule,
heavy wires should be avoided at this stage. A minimum of 0.004 inch clearance is needed for
sliding mechanics, in other words, in 0.018 slot an archwire with 0.014 inch stainless steel can
be accepted for sliding but for severe crowding or malposition situation, more length of wire
in the form of loop or helices should be incorporated. Although resilient wire with rectangular
shape like A-NiTi or CuNiTi (Damon system) could be used, but because they produce
unwanted root movement, possible root resorption, and possible delay in alignment progres‐
sion, rectangular resilient wires are not advisable. Wires should have excellent strength and
springiness, long range of action and low load deflection rate. NiTi wires are springier and
stronger (in small section) than beta-titanium (TMA), for these reasons, A-NiTi and CuNiTi
wires are recommended for initial stages of aligning.
In addition to alignment, impacted teeth should be “Leveled” in occluso-gingival direction.

Leveling can be obtained by absolute intrusion or by relative intrusion and sometimes by
differential elongation or extrusion of teeth. Utility arches e.g. 2x4 appliance, reverse curve for
lower arch, intrusion arch and combination of sectional wires, segmented arches and titanium
miniscrews are used for leveling the dental arch.
After establishment of proper alignment and leveling, two other crown position characteristics
should be achieved i.e. “Torque” and “Angulation”. Torque is in facio-lingual direction and
usually involves root movement and moment (increased M/F ratio) is needed for its correction.
Angulation is related to mesio-distal characteristics of crown positioning and like the amount
of torque degree, is considered in bracket prescription in straight wire appliances (SWA). Wire
bending like what is performed in “Standard Edgewise” for finishing and establishment of
correct torque and angulation, is needed for severe impacted cases for obtaining the proper
ALTA correction and accepted occlusion (according to ABO scores).
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7. Conclusion
Bone-impacted canines of the hard palatal are more likely to respond to surgical exposure and
orthodontic management if angulation to midline is less than 45 degrees on the OPG; there is
no root anomaly found on OPG, periapical (PA), and maxillary occlusal (MO) radiographs;
and overlap of the adjacent lateral incisor root (OALIR) by the canine crown is nonexistent or
less than grade 2 (half the root) on the OPG.[18] Researchers have tried to predict impaction
of a maxillary canine using geometric measurements made on panoramic radiographs.
Diagnosis of an outcome can be performed cross-sectionally, however; for prediction, two
separate prospective data sets should be used. [19]
Deimpaction of the impacted teeth can be accelerated by means of thick soft tissue removal
with laser application. Laser-assisted surgical removal of the fibrous tissue over erupting
premolars (DTE) with appropriate irradiation parameters appears to be a promising adjunct
to orthodontic treatment for bringing them to the aligned and leveled dental arch.[20]
Orthodontic tooth movement and root resorption of impacted teeth can be influenced by laser
[21] and administration of different drugs.[22,23]
Author details
Massoud Seifi1* and Mohammad Hosein Kalantar Motamedi2
*Address all correspondence to: seifimassoud@gmail.com
1 Dentofacial Deformities Research Center, Department of Orthodontics, Shahid Beheshti

University of Medical Sciences, Tehran, Iran
2 Trauma Research Center, Baqiyatallah Medical Sciences University, Tehran, Iran
References
[1] CA C. A Method of ascertaining, the Relative Position of Unerupted Proc R Soc Med
1910;3((Odontol Sect)):87-90.
[2] Jacobs SG. Radiographic localization of unerupted teeth: further findings about the
vertical tube shift method and other localization techniques. American journal of or‐
thodontics and dentofacial orthopedics : official publication of the American Associa‐
tion of Orthodontists, its constituent societies, and the American Board of
Orthodontics. 2000;118(4):439-47.
[3] Roberts JA, Drage NA, Davies J, Thomas DW. Effective dose from cone beam CT ex‐
aminations in dentistry. The British journal of radiology. 2009;82(973):35-40.
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[4] Trobe JD KJ. Cost-benefit analysis in screening. Unexplained visual loss.. Surv Oph‐
thalmol 28(3):189-93.
[5] Bahreman A. Early-age orthodontic Treatment: Quintessence Publishing Co, Inc;

2013.
[6] Stewart JA, Heo G, Glover KE, Williamson PC, Lam EW, Major PW. Factors that re‐
late to treatment duration for patients with palatally impacted maxillary canines.
American journal of orthodontics and dentofacial orthopedics : official publication of
the American Association of Orthodontists, its constituent societies, and the Ameri‐
can Board of Orthodontics. 2001;119(3):216-25.
[7] Zuccati G, Ghobadlu J, Nieri M, Clauser C. Factors associated with the duration of
forced eruption of impacted maxillary canines: a retrospective study. American jour‐
nal of orthodontics and dentofacial orthopedics : official publication of the American
Association of Orthodontists, its constituent societies, and the American Board of Or‐
thodontics. 2006;130(3):349-56.
[8] Ericson S KJ. Resorption of maxillary lateral incisors caused by ectopic eruption of
the canines. A clinical and radiographic analysis of predisposing factors. American
journal of orthodontics and dentofacial orthopedics : official publication of the Amer‐
ican Association of Orthodontists, its constituent societies, and the American Board
of Orthodontics.94(6):503-13.
[9] Pitt S, Hamdan A, Rock P. A treatment difficulty index for unerupted maxillary can‐
ines. European journal of orthodontics. 2006;28(2):141-4.
[10] Warford JH, Grandhi RK, Tira DE. Prediction of maxillary canine impaction using
sectors and angular measurement. American Journal of Orthodontics and Dentofa‐
cial Orthopedics. 2003;124(6):651-5.
[11] Kau CH, Pan P, Gallerano RL, English JD. A novel 3D classification system for canine
impactions--the KPG index. The international journal of medical robotics + computer
assisted surgery : MRCAS. 2009;5(3):291-6.
[12] Melsen B, Verna C. Miniscrew implants: The Aarhus anchorage system. Seminars in
Orthodontics. 2005;11(1):24-31.
[13] Papadopoulos MA, Tarawneh F. The use of miniscrew implants for temporary skele‐
tal anchorage in orthodontics: a comprehensive review. Oral surgery, oral medicine,
oral pathology, oral radiology, and endodontics. 2007;103(5):e6-15.
[14] Celenza F. Implant Interactions with Orthodontics. Journal of Evidence Based Dental
Practice. 2012;12(3):192-201.
[15] Caldas SG, Ribeiro AA, Simplício H, Machado AW. Segmented arch or continuous
arch technique? A rational approach. Dental Press J Orthod. 2014 Mar-Apr;19(2):
126-41.
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[16] Kokich VG. Surgical and orthodontic management of impacted maxillary canines.
Am J Orthod Dentofacial Orthop. 2004 Sep;126(3):278-83.
[17] Romeo DA, Burstone CJ. Tip-back mechanics. Am J Orthod. 1977 Oct;72(4):414-21.
[18] Motamedi MH, Tabatabaie FA, Navi F, Shafeie HA, Fard BK, Hayati Z. Assessment
of radiographic factors affecting surgical exposure and orthodontic alignment of im‐
pacted canines of the palate: a 15-year retrospective study. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2009 Jun;107(6):772-5. doi:10.1016/j.tripleo.2008.12.022.
[19] Sabour S, Vahid Dastjerdi E. Early prediction of maxillary canine impaction from
panoramic radiographs. Am J Orthod Dentofacial Orthop. 2012 Oct;142(4):428; au‐
thor reply 428-9. doi: 10.1016/j.ajodo.2012.08.010.
[20] Seifi M, Vahid-Dastjerdi E, Ameli N, Badiee MR, Younessian F., Amdjadi P. The 808
nm Laser-Assisted Surgery as an Adjunct to Orthodontic Treatment of Delayed
Tooth Eruption: J Lasers Med Sci 2013; 4(2):70-4
[21] Seifi M, Atri F, Yazdani MM. Effects of low-level laser therapy on orthodontic tooth
movement and root resorption after artificial socket preservation. Dent Res J (Isfa‐
han). 2014 Jan;11(1):61-6.
[22] Seifi M, Eslami B, Saffar AS. The effect of prostaglandin E2 and calcium gluconate on
orthodontic tooth movement and root resorption in rats. Eur J Orthod. 2003 Apr;
25(2):199-204.
[23] Seifi M, Badiee MR, Abdolazimi Z, Amdjadi P. Effect of basic fibroblast growth factor
on orthodontic tooth movement in rats. Cell J. 2013 Fall;15(3):230-7. Epub 2013 Aug
24.
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Chapter 6
Surgical Exposure and Orthodontic Alignment of

Impacted Teeth
http://dx.doi.org/10.5772/58956
1. Introduction
Tooth impaction is a condition in which the tooth is embedded in the tissues such that its
eruption is prevented.[1, 2] Management of impactions is usually either by surgical exposure
and forced eruption or surgical extraction; the decision depends upon a multitude of factors
that need to be assessed via clinical and radiographic evaluations of the patient before
formulating the overall treatment plan. The clinical evaluation includes assessment of:
• Patient age
• Oral hygiene and dental caries
• Depth of the impaction
• Displacement of the impaction and associated pathologies
• Esthetics and morphological suitability of the impaction
• Functionality of the impacted tooth
• Length of orthodontic and surgical treatment and costs
• Worthiness of salvaging the impacted tooth
• Treatment options for the impaction
• Feasibility of surgical exposure and orthodontic alignment

These factors are among the issues that are influential in deciding whether to expose or to
extract the impacted tooth. Patient cooperation and compliance are additional determinants
which should be considered before commencing treatment. [3, 4]
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2. Clinical evaluation
2.1. Patient age
The best age for tooth exposure and forced eruption or surgical extraction is in childhood and
adolescence; because as age increases, the impacted tooth often develops ankylosis (fusion to
bone) precluding the possibility to move it into the dental arch orthodontically. The inability
to move the impaction may not be readily diagnosed preoperatively; and may become evident
only when the tooth fails to move after it has been exposed and orthodontic traction has been
applied for several weeks or more. Aside from age, ankylosis may occur following dentoal‐
veolar trauma in childhood or adolescence. Trauma to the primary dentition in childhood can
lead to damage to the dental germ resulting in deformation or displacement. Premature loss
of a primary tooth may also result in delayed or barred eruption of the permanent tooth due
to bone or dense fibrous tissue formation in the normal path of eruption.
2.2. Oral hygiene and dental caries
Tooth exposure, forced eruption and orthodontic therapy of an impaction may not be indicated
if the patient has rampant caries, poor oral hygiene, lacks motivation or is uncooperative. If
the impacted tooth is decayed, it may be an indication for removal of the impaction.
2.3. Depth of the impaction
Impactions that are very deep may not be amenable to exposure and orthodontic therapy.
Sometimes even surgical removal of such teeth is not indicated especially when harm may be
inflicted upon vital structures or teeth in the course of the procedure. Such cases may be left
alone and followed periodically with radiographs every 6-12 months for changes in the follicle
of the impaction. Removal of the crown only (coronectomy) is another option.
2.4. Displacement of the impaction and associated pathologies
Displacement of adjacent teeth and pathological lesions associated with an impacted tooth
may mandate removal of the impaction. However, eruption cysts, dentigerous cysts and
benign lesions (i.e. adenomatoid odontogenic tumor, giant cell lesions, aneurysmal bone cysts
etc.) may be exceptions. In these cases it may be possible to just remove the pathology and
salvage the impacted tooth (discussed later in this chapter). [5-13]
2.5. Esthetics and morphological suitability of the impaction
Esthetics and morphological suitability of the impaction are among the issues that may
influence the decision to expose or to extract the impacted tooth. The canine tooth for example
is very strategic because it is usually visible when the patient smiles; therefore, it merits salvage;
whereas, a deformed, unsightly or nonfunctional canine may not be worth saving unless it can
be restored.
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2.6. Functionality of the impacted tooth
A severely deformed or short-rooted impacted tooth deemed unlikely to be functional is more

likely to require removal rather than surgical exposure and orthodontic alignment.
2.7. Length and costs of orthodontic and surgical treatment
The length of orthodontic and surgical treatment and expenses are additional sideline issues
to be considered and discussed with the patient, parents or guardians before formulating a
treatment plan. The length of orthodontic treatment to guide the impaction into the dental arch
and into occlusion, usually takes 1-3 years (depending on patient age, bone density, the amount
of root formation and dilaceration, depth and angulation of the impaction, available arch space
etc.). Expenses are directly correlated to the aforementioned parameters (the longer it takes to
bring the impaction into position the more it will cost). An estimate should be made prior to
commencing treatment.
2.8. Worthiness of salvaging the impacted tooth
The third molar is commonly impacted because of arch-length tooth-size discrepancy. Wisdom
teeth often require extraction due to of lack of arch space, periodontal pockets, a blocked path
of eruption, malocclusion, caries or pericorontitis. Thus, third molars are rarely surgically
exposed or uprighted; however, up-righting the mandibular third molar may be indicated
when a distal abutment is needed for anchorage of a prosthesis.
Second molars and premolars are less commonly impacted and treatment is dictated by factors
such as occlusion, arch space, caries, strategic value of the tooth and costs. The decision to
salvage or extract is case-specific. Decisions are made after clinical assessment, consultation
and collaboration with the orthodontist.
The permanent incisors are rarely impacted; however, when they are, they often merit salvaging
in both jaws because they are esthetically important and readily seen when the patient smiles.
They also play a major role in the dental midline which is very important esthetically; because
deviation of the dental midline is conspicuous and readily noticed by others.
The permanent canine of the maxilla is the second most commonly impacted tooth. It is the tooth
with the longest root and is important in cuspid-rise type occlusions. The canine is usually
seen when the person smiles. It is thus, esthetically important and merits salvaging whenever
possible.
2.9. Treatment options for the impaction
The treatment options open to a patient with a permanent impacted canine include:
1. Interceptive removal: Interceptive removal of the deciduous canine to enhance eruption of

the permanent canine is done when the root has not formed completely and space is
available for eruption.
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2. No treatment: No treatment, except periodic radiographical evaluation for pathological

changes, is done when there are limitations to surgically expose or extract.
3. Surgical removal: Surgical removal of the impacted canine and prosthetic replacement is
done when there are limitations for salvaging the tooth.
4. Surgical exposure: Surgical exposure of the impacted canine and orthodontic alignment is
done when indicated and deemed feasible. [3, 4]
Data such as age and sex, space for alignment, presence of the primary canine, migration of
the first premolar in the site of the canine, and other aforementioned issues must be assessed
and documented. If the tooth is strategic and should it be desired to save it, then a feasibility
study must also be done to see whether the impacted canine can respond to surgical exposure
and forced eruption or if it has to be surgically removed.
2.10. Feasibility of surgical exposure and orthodontic alignment
Salvaging the bone-impacted canine of the palate usually requires a combination of both
surgical and orthodontic management. To ascertain if exposure and orthodontic treatment is
feasible, first arch space assessment followed by the radiographic evaluation is necessary.
2.11. Arch space assessment
A comprehensive evaluation must be done In order to assess whether or not space is available
in the arch or has to be made available for eruption and alignment of the impacted tooth, or if
the impaction must be removed. Sometimes the primary tooth has not exfoliated and should
be extracted. Arch space and tooth size measurements have to be done. More often than not,
space has to be made orthodontically to accommodate the canine in the dental arch.
2.12. Radiographic evaluation
In addition to clinical assessments, predicting the feasibility to expose and move an impacted
permanent canine from the hard palate into the alveolar arch can be done radiographically.
Radiographic records are used to assess depth of the impaction, root morphology and the
degree of difficulty.
2.13. Radiographic records
Radiographic records (orthopantomogram [OPG], periapical [PA], and maxillary occlusal

[MO]) must be taken, assessed and documented. Preoperative radiographs of each patient
have to be viewed and examined using a light box. Digital images can be viewed on an LCD
monitor. Root anomalies and radiographic measurements are sought prior to treatment.
2.14. Root anomaly
The presence or absence of root anomaly must be recorded when apparent on the OPG,
PA, and MO radiographs. Root angulation or dilaceration must also be assessed from the
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radiographs. Severe dilaceration or bulky roots may render forced eruption and align‐
ment unfeasible.
2.14.1. Radiographic measurements
Several angles and measurements of impacted canine position can be made from the OPG
radiograph namely:
• canine angulation to the midline (CAM),
• ratio of root formation (RRF),
• lateral incisor root overlap (LIRO) and
• degree of vertical impaction (DVI)
The aforementioned measurements may aid in the decision making process.
2.14.2. Canine angulation to the midline (CAM)
A midline is constructed as shown in Fig. 1 and a second line is drawn through the canine root
apex and canine tip to the midline. The angle formed between the 2 lines is the impacted canine
angulation to the midline, and is graded as follows:
• Grade1 (0-15°), Easy
• Grade2 (16-30°), Moderate
• Grade3 (31°+), Difficult
Figure 1. The angulation of the palatally-impacted canine to the midline. The more obtuse the angle the more difficult
it will be to expose and align and the poorer the prognosis.
The more obtuse the angle the more difficult it will be to expose and align the impacted canine
and the poorer the prognosis.
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2.14.3. Ratio of Root formation (RRF)
The canine root formation ratio is graded from 1 to 3 depending upon the amount of root
formed:
• Grade 1 (1/3 formed), Easy
• Grade 2 (2/3formed), Moderate
• Grade 3 (completely formed) Difficult

The more the root has formed the more difficult it will be to expose and align the impacted
canine and the poorer the prognosis.
2.14.4. Lateral incisor root overlap (LIRO)
The position of the canine(s) on the OPG helps predict the feasibility and prognosis for
alignment of the canine by reference to the amount by which its crown overlaps the incisor
roots in both the horizontal and vertical planes. The degree of overlap of the adjacent lateral
incisor root via the crown of the palatally-impacted canine is assessed and graded as follows:
• Grade 1: No horizontal overlap; Easy
• Grade 2: Overlap less than half the root width; Moderate
• Grade 3: Overlap more than half, but less than the whole root width; Difficult
• Grade 4: Complete overlap of root width or more; Very difficult.

The closer the canine is to the midline in the horizontal plane the greater the difficulty and the
poorer the prognosis (Fig. 2).
Figure 2. Grades of overlap of the adjacent lateral incisor root via the crown of the impacted canine in the palate. The
greater the overlap the more difficult the procedure will be.
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2.14.5. Degree of vertical impaction (DVI)

The vertical depth of the canine(s) on the OPG also helps predict the feasibility and prognosis
for alignment of the canine by reference to the amount by which it lies in respect to the apical
third of the lateral incisor root in the vertical plane:
• Grade 1 Easy (canine crown at the coronal segment of the lateral incisor root).
• Grade 2 Moderate (canine crown below the coronal segment of the lateral incisor root but
above half the root).
• Grade 3 Difficult (canine crown below half the root of the lateral incisor root but above the
apex).
• Grade 4 Very difficult (canine crown at the apical segment of the lateral incisor root).
The higher the impaction lies the greater the difficulty and the poorer the prognosis for surgical
and orthodontic treatment (Fig. 3). [5, 6]
Figure 3. Besides the amount of overlap of the adjacent lateral incisor root via the crown of the impacted canine in the
palate, the higher the impaction lies vertically the more difficult the surgical and orthodontic procedure will be.
The influence of increased canine angulation to the midline, the greater lateral tooth overlap
and the deeper the vertical depth means a deep horizontally positioned impaction and thus,
a more difficult canine to expose and align orthodontically. There is an increased probability
that such canines will require removal instead of exposure.14-17 However, although a large
amount of information may be obtained regarding impacted canine position from radiographs,
this was not a major influence on our decision to surgically expose or remove impacted canines.
Our study showed impacted canine angulation and depth correlated with difficulty in
alignment and eruption. Age may be an influencing factor; however, all our cases were
adolescents.
When there is a primary canine remaining in place of the permanent canine impacted in the
palate, the patient does not have much to lose if the impaction is exposed surgically and
orthodontic alignment is attempted. However, if the space is occupied by the permanent first
premolar then extracting the premolar to make space for the palatally bone-impacted perma‐
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nent canine is risky because the canine may be fused and defy forced eruption. Thus, in such
cases it should be attempted to expose and move the impaction before the premolar is
extracted. If the impacted tooth responds favorably to forced eruption then the premolar is
extracted.
3. Surgical exposure techniques
3.1. Exposure technique for a palatally-impacted canine
The surgical technique used to expose a palatally-impacted canine is relatively uncomplicated.

After local anesthesia, a window is made in the palate at the site where the crown of the
impaction is anticipated to be using an electrosurgery knife; the electrosurgery knife is used
to remove the tissue overlying the tooth. Then, the palatal mucoperiosteum is dissected off the
bone and discarded. The bony covering of the tooth is removed with a rose bur and handpiece
under copious saline irrigation. The follicular tissue is scraped off the palatal surface of the
crown and removed. The cavity is enlarged if necessary by further soft tissue and/or bone
removal as required to expose the entire palatal or buccal surface of the impaction (depending
on the orientation of the impaction). The cementoenamel junction is left undisturbed. After
hemostasis, the tooth is dried and after acid etching and resin bonding a bracket is fixed to the
labial or palatal surface of the crown; then the wound is packed using periodontal dressing.
Alternatively, orthodontic brackets may be bonded 3 to 7 days postoperatively by the ortho‐
dontist (instead of intraoperatively). Seven to 10 days postoperatively 50 to 60 g elastic traction
is applied (Fig.4).
Figure 4. A palatally-impacted canine is exposed through a round window and a bracket is attached to the palatal sur‐
face of the crown.
3.2. Exposure technique for a buccally-impacted canine
Buccally-oriented impacted canines are generally easier to treat. The surgical technique used
to expose a buccally-oriented impacted canine after local anesthesia, includes reflection of a
small trapezoid flap at the site where the crown of the impaction is anticipated using a scalpel
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and no.15 blade. The underlying bone is removed using a round bur and handpiece. Then, the
follicle is removed exposing the crown. The flap is then repositioned apically at the CEJ of the
impaction and sutured in the vestibule leaving the crown exposed for bracket bonding. In due
time the tooth erupts (or is forced to erupt) bringing attached gingiva along with it (Fig. 5).
Figure 5. A buccally-impacted canine is exposed through a trapezoid flap sutured apically so that it erupts along with
the attached gingiva; a bracket has been attached and elastic traction has been applied.
Follicular enlargement or cystic change around an impacted canine should be sought and this
factor is taken into consideration when planning treatment for impacted canines. However,
this per se does not mean that the impacted canine must be extracted (discussed later in this
chapter).5,6
3.3. Severely-displaced impacted maxillary canine
Sometimes the impacted canine is displaced in the jaws; this is often due to a pathologic lesion
most commonly a dentigerous cyst (Fig. 6).
Figure 6. Impacted canine displaced high up in the maxilla adjacent to the orbital floor due to a dentigerous cyst.
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In such cases the exposure has to be made through the mucosa. Impediments (cyst, tumor,
teeth, fibrosis etc.) must be removed, sent to the pathologist and the tooth be given time to
descend (Fig.7).
When the tooth is accessible in the vestibule it is then exposed and bonded (Fig. 8). [18]
After 2 years the tooth was finally in the dental arch (Fig. 9).
Figure 7. The tooth has descended after cyst removal.
Figure 8. The tooth has descended 3-4 cm and brought into occlusion.
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Figure 9. The canine tooth has been brought into the dental arch. (Orthodontist: Dr. Jabari)
3.4. Severely-displaced impacted mandibular canine
A cyst may also displace an impaction in the mandible to a great extent. Enucleation of the
cyst without extraction of the impacted tooth may be indicated for children and adolescents if
the involved tooth is strategic. There may be swelling in the vestibular area of the mandibular
canine region. A common cause is a dentigerous cyst. Aspiration of the lesion must be
performed first; in many cases, aspiration reveals a clear yellow fluid in dentigerous cysts.
Next, the entity must be confirmed by a pathologist. In our case, excisional biopsy was
performed under local anesthesia via a submarginal mucoperiosteal trapezoid flap reflected
from the right canine tooth to the left premolar from below the attached gingiva; the cystic
lesion was removed after it was separated from the bone and incised off the tooth surface using
a #15 scalpel. The flap was sewn in the vestibule, which left the crown exposed for bracket
bonding. Orthodontic treatment was started 2 weeks postoperatively. (Figs. 10 and 11).
Figure 10. Orthopantomogram of an impacted canine displaced to the inferior border of the chin by a large dentiger‐
ous cyst of the mandible extending from the right canine to the left first premolar tooth
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Figure 11. Lateral cephalogram obtained at the same time.
The canine was brought into occlusion orthodontically within 4 years (Figs. 12 and 13). [19]
Figure 12. Orthopantomogram 4 years after surgery. The tooth has been brought into occlusion after surgical exposure
and orthodontic guidance; the vitality of all of the teeth has been preserved.
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Figure 13. Lateral cephalogram obtained at the same time. This bone has healed in the chin.
Figure 14. Oral view (Orthodontist Dr. Masoud Seifi).
3.5. Impacted teeth associated with benign tumors
The surgical technique used to expose an impacted tooth associated with a benign tumor is
similar. Aspiration of the lesion is negative for fluid. An excisional biopsy under local anes‐
thesia is done. A trapezoid flap is reflected from the mesial and distal aspects of the involved
tooth. The lesion is completely removed after separating the capsule from the bone and excising
it off the canine tooth surface. Minimal bone removal in the bed of the lesion is done with a
rose bur. Clinically, nothing is left attached to the tooth surface. The wound is irrigated and
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the flap is sutured apically leaving the crown exposed for bracket bonding. Orthodontic
treatment is started 1-2 weeks postoperatively depending on the case (Figs. 15 and 16). [6]
Figure 15. A 13-year-old female with an impacted left mandibular canine tooth and a relatively well-defined radiolu‐
cent lesion (AOT) on the mesial aspect spanning the length of the crown and root. Care was taken not to devitalize the
tooth.
Figure 16. The 3-year postoperative radiograph showing complete bone formation and canine alignment (Orthodont‐
ist: Dr. H.A. Shafeie).
Such cases require periodic follow-up after completion of treatment. Our cases had no
recurrences to date.
4. Conclusion
The decision to expose or remove a bone-impacted permanent tooth is based on clinical and
radiographic information as well as surgical and orthodontic judgment.
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Author details
Trauma Research Center, Baqiyatallah Medical Sciences University and Azad University of
Medical Sciences, Dental College, OMFS department, Tehran, Iran
References
[1] Kasander T. The impacted canine: diagnosis and treatment. J Clin Orthod
1994;5:13-21.
[2] Ericson S, Kurol J. Radiographic assessment of maxillary canine eruption in children

with clinical signs of eruption disturbances. Eur J Orthod 1986;8:133-40.
[3] Ericson S, Kurol J. Early treatment of palatally erupting maxillary canines by extrac‐
tion of primary canines. Eur J Orthod 1988;10:283-95.
[4] Bishara SE. Impacted maxillary canines: a review. Am J Orthod Dentofacial Orthop
1992;101:159-71.
[5] Motamedi MH, Talesh KT. Management of extensive dentigerous cysts. Br Dent J
2005;198:203-6.
[6] Motamedi MH, Shafeie HA, Azizi T. Salvage of an impacted canine associated with
an adenomatoid odontogenic tumor: a case report. Br Dent J 2005;199:89-90.
[7] Motamedi MH, Behroozian A, Azizi T, Nazhvani AD, Motahary P, Lotfi A. Assess‐
ment of 120 Maxillofacial Aneurysmal Bone Cysts: A Nationwide Quest to Under‐
stand This Enigma. J Oral Maxillofac Surg. 2014, joms.2013.12.032. [Epub ahead of
print]
[8] Motamedi MH, Navi F, Eshkevari PS, Jafari SM, Shams MG, Taheri M, Abbas FM,
Motahhari P. Variable presentations of aneurysmal bone cysts of the jaws: 51 cases
treated during a 30-year period. J Oral Maxillofac Surg. 2008 Oct;66(10):2098-103.
[9] Motamedi MH. Destructive aneurysmal bone cyst of the mandibular condyle: report
of a case and review of the literature. J Oral Maxillofac Surg. 2002 Nov;60(11):
1357-61. Review.
[10] Kalantar Motamedi MH. Aneurysmal bone cysts of the jaws: clinicopathological fea‐
tures, radiographic evaluation and treatment analysis of 17 cases. J Craniomaxillofac
Surg. 1998 Feb;26(1):56-62.
[11] Motamedi MH, Stavropoulos MF. Large radiolucent lesion of the mandibular con‐
dyle. J Oral Maxillofac Surg. 1997 Nov;55(11):1300-4.
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[12] Motamedi MH, Yazdi E. Aneurysmal bone cyst of the jaws: analysis of 11 cases. J Or‐
al Maxillofac Surg. 1994 May;52(5):471-5.
[13] Motamedi MH, Khodayari A. Aneurysmal bone cyst mimicking a malignancy. J Oral
Maxillofac Surg. 1993 Jun;51(6):691-5.
[14] Zuccati G, Ghobadlu J, Nieri M, Clauser C. Factors associated with the duration of
forced eruption of impacted maxillary canines: a retrospective study. Am J Orthod
Dentofacial Orthop 2006;130:349-56.
[15] Baccetti T, Crescini A, Nieri M, Rotundo R, Pini Prato GP. Orthodontic treatment of
impacted maxillary canines: an appraisal of prognostic factors. Prog Orthod
2007;8:6-15.
[16] Ferguson JW, Parvizi F. Eruption of palatal canines following surgical exposure: a re‐
view of outcomes in a series of consecutively treated cases. Br J Orthod 1997;24:203-7.
[17] Stivaros N, Mandall NA. Radiographic factors affecting the management of impacted
upper permanent canines. J Orthod 2000;27:169-73.
[18] Motamedi MH, Tabatabaie FA, Navi F, Shafeie HA, Fard BK, Hayati Z. Assessment
of radiographic factors affecting surgical exposure and orthodontic alignment of im‐
pacted canines of the palate: a 15-year retrospective study.Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2009;107:772-5.
[19] Motamedi MH, Seifi M: Is it possible to salvage impacted strategic teeth associated
with extensive dentigerous cysts? JCDA 2005, 71:633-635.
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Chapter 7
Orthodontic Preparation for Orthognathic Surgery
Abdolreza Jamilian, Alireza Darnahal and

Letizia Perillo
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1. Introduction
Orthodontic treatment goals can be divided into five categories: facial esthetics, dental
esthetics, functional occlusion, periodontal health, and stability.[1] Nevertheless, when a
severe skeletal deformity exists in non-growing teen and adult patients with significant skeletal
jaw discrepancy, the goals of treatment are often impossible to achieve by orthodontics alone.
In these circumstances, both orthodontics and surgery are required to correct the dental
malposition and the skeletal disharmony. This corrective jaw surgery, also called orthognathic
surgery, is performed by oral and maxillofacial surgeons to correct a wide range of minor and
major skeletal and dental irregularities, including the misalignment of jaws and teeth, which,
in turn, can improve chewing, speaking and breathing. Orthodontics in conjunction with
orthognathic surgery can do wonders in improving the appearance of the face. Combined
orthodontic and surgical treatment usually requires about 18-24 months to complete. The
treatment may be divided into four stages:
a. Treatment Planning
b. Presurgical Orthodontics
c. Surgical Treatment
d. Post-Surgical Orthodontics
2. Treatment planning
Proffit and Ackerman [2] introduced the concept of envelope of discrepancy to graphically
illustrate four ranges of correction for any characteristics of malocclusion: (A) an amount that
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can be accomplished by orthodontic tooth movement alone; (B) a larger amount that can be
accomplished by orthodontic tooth movement aided by absolute anchorage; (C) an additional
amount that can be achieved by functional or orthopedic treatment to modify growth;[3-5] and
(D) a still larger amount that requires surgery as part of the treatment plan.
People who can potentially benefit from orthognathic surgery include those with jaws that are
positioned incorrectly. Orthognathic surgery is also the treatment of choice in patients who
have not had the benefit of dentofacial orthopedics for growth guidance, or in cases where the
deformity is so severe that orthodontics alone is not enough to correct it. Achieving successful
treatment outcomes in these patients requires implementing an effective treatment plan. It
should be considered that treatment planning is one of the most important stages because once
the treatment is started it is hardly possible to reverse or suspend it. At this stage, the patient
should be verified to have no potential of growth. If the patient is still growing he or she should
be examined annually until growth is complete. Once facial growth cessation is verified the
patient should be referred to a multidisciplinary clinic for joint treatment planning with the
maxillofacial surgeon and orthodontist. In the beginning information about patient’s general
health state and previous diseases is evaluated and if there are no contraindications for surgery
and general anesthesia a thorough examination of the face including evaluation of facial and
dental photographs, cephalometric radiographs, and dental casts should be done. Subse‐
quently, the orthodontist and maxillofacial surgeon should make a joint decision concerning
the treatment approach. One of the aspects for consideration is whether the surgery is required
in the mandible, maxilla or both and whether the jaw is to remain in one piece or to be
segmented.
3. Presurgical orthodontics
Orthodontic preparation for surgery is different from orthodontic correction alone. Achieve‐
ment of optimal facial esthetics requires integrated cooperation of orthodontists and maxillo‐
facial surgeons. Routine preoperative orthodontics involve dental alignment, incisor
decompensation, and arch coordination for the purpose of obtaining maximum intercuspal
interdigitation when the jaws are surgically aligned. In short the aims of presurgical treatment
are to decompensate lower and upper incisors, level and align both arches and relieve the
crowding. In general these corrections will make the malocclusion look worse presurgically,
but it will show the true magnitude of the skeletal problem thus allowing an optimal correction
at surgery.[6] To sum up, the essential steps in orthodontic preparation for orthognathic
surgery are to align the arches individually, achieve compatibility of the arches or arch
segments, and establish the proper anteroposterior and vertical position of the incisors.
3.1. Dental alignment
Dental crowding, spacing, misalignment and rotations of the teeth should be corrected before
orthognathic surgery. The key is to get the teeth in proper position and angulation. In this
phase of the treatment, extractions might be needed to relieve moderate to severe crowding
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and make needed space for teeth alignment. Extraction can also help remove dental compen‐
sations. It should be taken into consideration that extraction should be avoided if the space of
the jaw permits favorable dental alignment. Incisor inclination, crowding, type of malocclusion
and surgical procedure are among the determining factors in deciding which teeth should be
extracted.
3.2. Decompensation
Most severe skeletal jaw discrepancies are partly compensated. This natural phenomena
called“dentoalveolar compensation” is a system which attempts to maintain normal interarch
relationship.[7]
Compensations can be dental or skeletal in nature. Dental compensations can be vertical,

transverse and/or sagittal. The factors responsible for dentoalveolar adaptation include: a
normal eruptive system, surrounding soft tissue pressures and the influence neighboring and
opposing teeth during occlusion. For example in class II skeletal malocclusions the upper
anteriors retrocline to compensate for maxillary prognathism and lower incisors procline to
compensate for mandibular retrognathism. While in class II skeletal malocclusion the upper
anteriors procline to compensate for maxillary retrognathism and lower incisors retrocline to
compensate for mandibular prognathism.
In contrast to dental camouflage, in preparation for orthognathic surgery, it is necessary to

remove any dental compensations present and to place the teeth in a favorable position with
their supporting bone. This is called presurgical decompensation. Presurgical orthodontic
decompensation is essential to enable the surgeon to make a considerable amount of surgical
correction. Failure to fully remove anterior incisor compensations presurgically will limit the
surgical correction, leading to compromised facial esthetics and occlusion. Such anteroposte‐
rior dental decompensation may involve specific extractions, anchorage needs, or use of class
II/class III elastics. For example, decompensation of skeletal class II malocclusion will often
require the use of class III elastics to upright lower incisors and decompensation of skeletal
class III malocclusion necessitates the use of class II elastics to procline lower incisors and
establish adequate reverse overjet.
Decompensation accentuates the patient’s deformity but is necessary for achievement of

normal occlusal relationships when skeletal bones are properly positioned at surgery.
3.3. Arch coordination
Arch coordination refers to coordinating the widths of the dental arches so that there is a
normal transvers relationship following sagittal jaw movements. Coordination often involves
arch expansion, arch contraction, and occlusal plane leveling and alignment. Orthodontic
expansion or contraction to coordinate the upper and the lower arches should be carried out
prior to the surgical procedure in order to provide correct post-operative occlusal interdigita‐
tion. Poor arch coordination, particularly in the transverse or vertical plane, will restrict or
destabilize jaw movements at the time of surgery and compromise postsurgical stability.
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3.4. Presurgical orthodontics objectives in the transverse plane

Ideally, the width of maxilla should be slightly more than the mandible in order to produce
normal buccal overjet. Transverse discrepancy happens when there is a defect in the widths
of the arches. The maxilla is more commonly affected in this discrepancy which can be either
unilateral or bilateral. This discrepancy is often combined with sagittal or vertical problems.
Pre-surgical orthodontic treatment consideration of transverse discrepancy:
i. The problem is the skeletal or dental
Dental discrepancies are usually treated by means of buccal tipping of the posterior teeth while
skeletal discrepancies are corrected by bodily movement of the posterior teeth. If the posterior
teeth are tipped lingually, presurgical orthodontic expansion (buccal tipping) should be used;
however, the tipping should not exceed 4 to 6 mm total. Bodily movement of the posterior
teeth should be done by means of segmental osteotomy, without the need for orthodontic
expansion.
ii. Is the problem relative or absolute
Articulation of the casts into a class I occlusion allows the clinician to easily distinguish
between relative and absolute maxillary constriction. If the occlusion is proper when the casts
are brought into class I canine relationship the discrepancy is relative; otherwise, if a crossbite
still exists, then the discrepancy is absolute. Absolute skeletal transverse discrepancy requires
planning for segmental osteotomies or surgically assisted rapid palatal expansion (SARPE).[5]
SARPE technique is used in cases with a severe discrepancy or when the transverse defect of
the maxillary bone is an isolated skeletal anomaly. While, segmental maxillary osteotomy is
used for more modest defects (up to 7 mm) or when the transverse deficit is one of a number
of maxillary skeletal deficits, including sagittal and vertical defects that would require surgical
attention.[8]
3.5. Presurgical orthodontics objectives in the vertical plane
3.5.1. Open bite cases

Treatment of anterior open bite has always been a great challenge in orthodontics. Extrusion
of anterior teeth and orthognathic surgery are among the possible options for treatment of
open bite in non-growing patients. However, dental extrusion of skeletal open bite will be
unstable in the long run. Furthermore, it may also create an excessive display of gingiva.
Unaesthetic results and lack of stability of dental correction make surgery the treatment of
choice for skeletal open bite cases. One of the chief considerations for treatment of these
patients is the choice between one piece or segmented maxillary osteotomy. The decision for
or against segmentation is made based on the patient’s baseline skeletal deformity. These
patients generally have an excessive curve of Spee in the upper jaw which is an indication of
skeletal problem rather than a dental one. The severity of the curve of Spee indicates the need
for segmental osteotomy. In other words, the more severe the curve of Spee, the more obvious
the need for segmental osteotomy. When surgical segments are planned, the orthodontist's
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role is to level presurgically within the segments but not across the osteotomy sites and to
make sure that there is enough space between the roots of the involved teeth to allow inter‐
dental osteotomies.
Pre-surgical orthodontic treatment considerations in open bite cases:
i. Avoid closing the anterior open bite presurgically by extruding the anterior teeth
ii. Avoid closing the anterior open bite presurgically by intruding the posterior teeth
iii. Accentuated or reversed curve of Spee should be levelled
a. Leveling the maxillary arch:
In the presence of a flat curve of Spee with no vertical discrepancies within the arch, leveling
is done with a continuous arch wire and the open bite can be corrected by a 1-piece Lefort I
osteotomy. However, if a segmental Le Fort I osteotomy is planned for open bite correction,
presurgical dental leveling and alignment should be carried out separately in each segment.
b. Leveling the mandibular arch:
Since patients with open bite generally do not have severe reverse curve of Spee in the lower
arch, continuous arch wire is used for complete leveling.
3.5.2. Deep bite cases
In patients with deep bite, there is nearly always an excessive curve of Spee in the lower arch
and occasionally a reverse curve in the upper arch. In these cases, the curve of Spee is leveled
intruding the incisors or extruding the posterior teeth. The decision to level by intrusion of the
incisors or extrusion of the posterior segment depends on the initial facial height of the patients.
As a general rule, the shorter the face height, the greater the need for extrusion.
3.6. Presurgical orthodontics objectives in the sagittal plane
3.6.1. Class II malocclusion
Skeletal class II malocclusion is naturally compensated to mask the skeletal discrepancy. This
natural dental compensation involves retroclination of the upper incisors and proclination of
lower incisors. The goals of presurgical orthodontics for these cases involve decompensation
of these natural compensations along with alignment of teeth and establishing compatible arch
forms.
Orthodontic decompensation of skeletal class II malocclusion cases involve proclining of

retroclined upper incisors and uprighting the proclined lower incisors. This decompensation
will increase the amount of overjet, which allows the maxillofacial surgeon to carry out
maximum mandibular advancement and subsequently establish class I canine relationship
after the surgery. (Figure 1)
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Figure 1. Orthodontic presurgical decompensation of class II malocclusion.
Alignment and leveling and the need for extraction in skeletal class II malocclusion cases
depends on the degree of crowding. In crowded cases, extraction of upper second premolars
and lower first premolars is a common orthodontic plan in preparation for surgical correction.
The extraction of upper second premolars prevent further retroclination of upper incisors and
the extraction of lower first premolars facilitate uprighting of lower incisors and subsequently
establish enough overjet for surgery. We should bear in mind that extraction space should be
closed before surgery
3.6.2. Class III malocclusion
In skeletal class III malocclusion cases the natural dental compensation involves proclination
of the upper incisors and retroclination of lower incisors. Therefore, in these cases, orthodontic
decompensation is achieved by uprighting the upper incisors and proclining the lower incisors
and thereby increasing the reverse overjet to the maximum which would allow the surgeon to
carry out maximum mandibular setback.
Similar to skeletal class II patients, in these cases also the alignment and levelling and the need
for extraction depends on the degree of crowding. The usual pattern of extraction in these cases
involves the extraction of upper first premolars in order to facilitate the uprighting of upper
incisors and extraction of lower second premolars in order to prevent further retroclination of
the lower incisors. These extractions also help to establish enough reverse overjet for the
surgical procedure. Extraction space should also be closed before surgery. (Figure 2)
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Figure 2. Orthodontic presurgical decompensation of class III.
4. Orthognathic surgery
Skeletal dentofacial deformities are associated with numerous problems including: esthetic,
functional, psychological, speech, mastication, digestion, and possible temporomandibular
joint dysfunctions.
Orthognathic surgery is a hospital based operation in which the elements of the facial skeleton
are manipulated to restore the proper anatomic and functional relationship in patients with
skeletal dentofacial deformities and overcome the above mentioned problems. The results of
orthognathic surgery can have dramatic and positive effects on many aspects of the patient’s
life.
Orthognathic surgery is done through a variety of osteotomies including maxillary segmental

osteotomies, Le Fort I maxillary osteotomy, Le Fort II osteotomy, Lefort III osteotomy, sagittal
split osteotomy of the mandibular ramus, vertical ramal osteotomy, inverted L and C osteot‐
omies, mandibular body segmental osteotomies, and mandibular symphysis osteotomies.
After the surgery, patients should expect the following:

• Swelling
• Nasal and sinus congestion
• Difficulty eating and chewing food for several weeks following surgery.
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5. Post-surgical orthodontics
Approximately four to six weeks after surgery the patient should return to the orthodontist to
begin post-surgical treatment. This short phase of orthodontic treatment postoperatively is
necessary to detail the final occlusion and improve the stability of surgery. The goal is to settle
the teeth in good occlusion and alignment and correct any possible skeletal relapse following
surgery. Post-surgical orthodontics usually takes about six months and may involve use of
intermaxillary elastics.
It is noteworthy to mention that precise and proper presurgical orthodontics minimalize post-
surgical orthodontics. After debanding and debonding the patients should be provided with
upper and lower retainers.
5.1. Common mistakes in presurgical orthodontics
The orthodontist should avoid:
• Masking skeletal discrepancies by dental camouflage

• Closing the anterior open bite presurgically by extruding the anterior teeth in open bite cases
• Closing the anterior open bite presurgically by intruding the posterior teeth in open bite
cases
• Aligning dental midlines in transverse plane discrepancy cases
• Correction of overjet in class II malocclusion cases
• Correction of reverse overjet in class III malocclusion cases
6. Summary
Successful treatment of patients who are candidates for orthognathic surgery requires close
cooperation between the orthodontist and surgeon. Prior to surgery, the patients undergo
orthodontic treatment in order to be prepared for corrective jaw surgery. Presurgical ortho‐
dontics involves dental decompensation, alignment of the dentition within the arches, leveling
of the curve of Spee, and coordination of the maxillary and mandibular dentition. These steps
vary from case to case based on the type of malocclusion and its severity.
7. Case report
7.1. Case summary
A 17 year-old boy with marked high angle skeletal class III malocclusion with severe maxillary
retrognathia and mandibular prognathism. The patient had crowding in the upper jaw and
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the lower incisors were tipped lingually due to Class III malocclusion compensation. Class III
molar and canine relationship with posterior cross bite with high maxillary-mandibular plane
angle and incompetent lips were noticeable. The patient did not complain from any TMJ signs
or symptoms.
Examination of head and face
In the frontal plane the face of the patient had an elongated shape. Skeletal Class III pattern
with severe maxillary retrusion, mandibular prognathism and concave profile.
Functional examination
The patient’s path of closure showed no deviation. Maximum jaw opening was normal at 49
mm.
Intraoral examination
Severe Class III molar and canine relationship with 9 mm of reverse overjet. Anterior and
posterior cross bite could be detected. Crowding was also seen in the upper jaw. The lower
incisors were retroclined.
Mandibular arch: Good arch form; Lingual displacement of lower incisors.
Maxillary arch: Good arch form; crowding in the upper anterior segment
Occlusion (Sagittal): Severe Class III with reverse overjet of 9 mm; Very severe Class III molar
and canine relationship on both sides
Occlusion (Vertical): Anterior open bite of 2 mm
Occlusion (Transversal): Upper midline coincided with facial midline; lower midline deviated
1 mm to the left
Cephalometric assessment
Cephalometric assessment shows skeletal Class III malocclusion with excessive growth of the
mandible and reduced growth of the maxilla. The mandible was elongated. It also shows a
degree of dento-alveolar compensation present in the lower anterior region. Upper incisors
are positioned labially (Figure 3).
The patient’s chief complaints:
• Severe maxillary deficiency

• Severe mandibular prognathism
• Crowding of upper arch
Treatment Plan:
Considering the severity of the malocclusion, the underlying skeletal discrepancy, age of the
patient, a surgical-orthodontic approach was chosen.
The treatment plan was as follows:
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Figure 3. Before treatment records of an orthognathic surgery case with high angle skeletal class III malocclusion, se‐
vere maxillary retrognathia, lingually tipped lower incisors, upper crowding and mandibular prognathism.
• Levelling and aligning
• Decrowding
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• Incisor decompensation by means of fixed appliance

• Bimaxillary surgery involving a maxillary advancement and impaction (Lefort 1), and a
mandibular setback (bilateral sagittal split ramus osteotomy). Chin Augmentation.
• Post-surgical orthodontics: Arch coordination, detailing, suitable interdigitation
• Debonding
• Retention
8. Presurgical orthodontics
Upper removable appliance with a screw was fitted in the midline to expand the maxillary
dentition and create space to relieve upper crowding. Upper and lower 0.018 standard
edgewise fixed appliances were placed and the teeth were levelled and aligned. Class II elastics
were used for decompensation of upper and lower incisors. At this stage the reverse overjet
of the patient increased from 9 mm to 11 mm. Surgical wires were placed in the upper and
lower jaws. After levelling, alignment, decrowding, decompensation and achieving increased
reverse overjet, the patient was referred to the maxillofacial surgeon. (Figure 4)
9. Orthognathic surgery
• Maxillary advancement (6 mm)

• Maxillary impaction (4 mm)
• Mandibular setback (6 mm)
• Chin augmentation with Medpor ®
10. Post-surgical orthodontics
After the surgery the patient had very mild paraesthesia in the lower lip. One month after the
surgery postsurgical orthodontics was started by replacing surgical wires with 0.016 stainless
steel wires. Class III elastics were placed and Torque adjustment was done in the upper and
lower jaws. After debanding and debonding upper and lower Hawley appliances were placed.
The post-surgical cephalogram of the patient showed significant improvement of the upper
and lower jaws. Facial profile was more balanced and had improved significantly. Advance‐
ment of the Maxilla and setback of the mandible were obvious in the cephalogram. Chin
augmentation with Medpor® could also be seen in the cephalometric image. The patient had
satisfactory positive overjet and overbite. Overall, a pleasing Class 1 occlusion had been
achieved in the patient. (Figure 5)
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Figure 4. Presurgical orthodontics of the same patient. Upper and lower 0.018 standard edgewise fixed appliances
Intraoral examination showed that the patient had molar and canine class I relationship with
no discrepancy between the jaws.
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The intercuspation was satisfactory and no signs of bruxism or other dysfunction was detected.
The lips were competent and the patient was very satisfied with his appearance. No clicking
or no signs and symptoms of temporomandibular dysfunction were noted.
Figure 5. Same patient after surgery and retention

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Author details
Abdolreza Jamilian1*, Alireza Darnahal1 and Letizia Perillo2
*Address all correspondence to: info@jamilian.net
1 Tehran Dental Branch, Department of Orthodontics, Islamic Azad University, Tehran, Iran
2 Departments of Orthodontics, Second University of Naples, Naples, Italy
References
[1] Roth R. Roundtable: Diagnosis and treatment planning. J Clin Orthod 1992;26:585.
[2] Ackerman JI, Nguyen T, Proffit WR. The Decision-Making Process in Orthodontics.
In: Graber TM, Vanarsdall Jr. RL, editors. Orthodontics : current principles and tech‐
niques. St. Louis, [Mo.]: Mosby; 2012.
[3] Jamilian A, Haraji A, Showkatbakhsh R, Valaee N. The effects of miniscrew with

Class III traction in growing patients with maxillary deficiency. International journal
of orthodontics. 2011;22(2):25-30.
[4] Showkatbakhsh R, Jamilian A, Ghassemi M, Ghassemi A, Taban T, Imani Z. The ef‐

fects of facemask and reverse chin cup on maxillary deficient patients. Journal of or‐
thodontics. 2012;39(2):95-101.
[5] Suri L, Taneja P. Surgically assisted rapid palatal expansion: a literature review.
American journal of orthodontics and dentofacial orthopedics : official publication of
the American Association of Orthodontists, its constituent societies, and the Ameri‐
can Board of Orthodontics. 2008;133(2):290-302.
[6] Sabri R. Orthodontic objectives in orthognathic surgery: state of the art today. World
journal of orthodontics. 2006;7(2):177-91.
[7] Solow B. The dentoalveolar compensatory mechanism: background and clinical im‐
plications. British journal of orthodontics. 1980;7(3):145-61.
[8] Marchetti C, Pironi M, Bianchi A, Musci A. Surgically assisted rapid palatal expan‐
sion vs. segmental Le Fort I osteotomy: transverse stability over a 2-year period. Jour‐
nal of cranio-maxillo-facial surgery : official publication of the European Association
for Cranio-Maxillo-Facial Surgery. 2009;37(2):74-8.
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Chapter 8
Surgically Assisted Maxillary Expansion
Sertaç Aktop, Onur Gönül, Hasan Garip and

Kamil Göker
http://dx.doi.org/10.5772/59285
1. Introduction
An adequate transverse maxillary dimension is a critical component of a stable and functional

occlusion. [1] Orthopedic rapid maxillary expansion in skeletally immature patients is the
procedure of choice to correct this condition in that age group. However, as skeletal maturity
approaches, bony interdigitation increases as the sutures fuse. [2,3] After suture closure or
completion of transverse growth, orthopedic transverse maxillary expansion is largely
unsuccessful because the expansion is primarily composed of no basal skeletal movement. [4]
This phenomenon leads to difficulty separating the maxilla with orthopedic forces alone and
bending of the alveolus, dental tipping and minimal maxillary expansion. The result is relapse
despite overcorrection, periodontal defects, and malocclusion. [5]
Rapid maxillary expansion can produce unwanted effects when used in a skeletally mature
patient, including lateral tipping of posterior teeth [6,7], extrusion [8-10], periodontal mem‐
brane compression, buccal root resorption [11-13], alveolar bone bending [7], fenestration of
the buccal cortex [13-16], palatal tissue necrosis [17], inability to open the midpalatal suture,
pain, and instability of the expansion [7,10,18-20]. Several reasons have been speculated
regarding factors that limit orthopedically induced maxillary expansion in skeletally mature
patients.
However, a few reports in the literature contradict these findings and state that nonsurgical
maxillary expansion is as successful in adults as it is in children [21, 22]. Experiencing more
complications, after attempts to orthopedically alter the transverse dimension of the maxilla
with advancing age, surgical procedures have been recommended to facilitate correction of
transverse discrepancies by Perrson [23], who found evidence of bony union at 17 years in the
midpalatal suture. Burston [24], however, found no evidence of synostosis in the same suture
by the age of 18 years.
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2. Correction of transverse discrepancy via orthodontics
This is successful until the age of approximately 14–15 years depending on the gender of
the patient. After this age, orthodontic widening becomes virtually impossible and very
painful. In general, it is assumed that closure of the midpalatal suture prevents this type
of expansion [25-27].
On the other hand, Mommerts outlined a basic treatment strategy for patients with maxillary
constriction, based on age that rapid maxillary expansion should be completed to treat
maxillary constriction in patients under the age of 12. From age 14 on, surgically assisted palatal
expansion is indicated to release areas of bony resistance in the midface [28].
3. Surgically Assisted Rapid Maxillary Expansion (SARME)
The areas of resistance to lateral forces in the midface are the pyriform aperture (anterior), the
zygomatic buttress (lateral), the pterygoid junction (posterior) and the midpalatal synostosis
suture (median). Many surgical interventions and techniques have been developed by the
identification of these areas of resistance. Surgery assisted maxillary expansion procedures
have conventionally been grouped into 2 categories:
1. Segmenting the maxilla during a LeFort osteotomy to reposition the individual segments
in a widened transverse dimension, and
2. Surgically assisted rapid maxillary expansion (SARME).

Advantages of SARME over orthodontic therapy and segmental Le Fort procedures include
decreased risk of periodontal damage, improved esthetics when smiling, improved nasal air
flow, and decreased risk of avascularity. SARME is also a relatively simple procedure and is
associated with minimal morbidity. Intraoperative complications are uncommon and there is
also less chance of avascularity leading to aseptic necrosis than with segmental Le Fort I
procedures. [29, 30] Brown [12] was probably the first who described a technique of SARME
with midpalatal splitting. [31] In 1961, Haas described the downward and forward movement
of the maxilla that occurs during rapid maxillary expansion because of the location of the
craniomaxillofacial sutures. He believed that the hemimaxillas separated from each other
develop tipping rather than separating in a parallel fashion due to the strength of the zygomatic
buttresses. [32]
Most methods consider the zygomaticomaxillary junction the major site of resistance and
perform a corticotomy through the zygomatic-maxillary buttress from the pyriform rim to the
maxillopterygoid junction. The midpalatal suture is historically considered the major place of
resistance. The pterygoid plates are also a considerable site of resistance but because of the
increased risk of injuring the pterygoid plexus by the osteotomy, some chose not to, without
losing much mobility. By not releasing the pterygoid junction, the pattern of opening of the
maxillary halves is more V-shaped with the point of the V located dorsally [33-37].
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Isaacson and Ingram [38] and Isaacson et al. [39] mention that historically, the midpalatal
suture was thought to be the area of resistance to expansion, but the facial skeleton increases
its resistance to expansion as it ages and matures, and that the major site of resistance is not
the midpalatal suture but the remaining maxillary articulations. Wertz stated that resistance
of the zygomatic arch prevents parallel opening of the midpalatal suture [40]. Many surgeons
release the midpalatal suture to improve mobility and to prevent deviation of the nasal septum.
Several authors describe two paramedian palatal osteotomies from the posterior nasal spine
to a point just posterior to the incisive canal [41-43].
In 1975 and 1976 Bell and Epker demonstrated that the area of increased facial skeletal
resistance to expansion was indeed not the midpalatal suture, but the zygomaticotemporal,
zygomaticofrontal and zygomaticomaxillary sutures. [44, 45] On the other hand, Shetty
concluded that exclusive use of bilateral zygomaticomaxillary buttress osteotomies to facilitate
SARME was inadequate. They therefore concluded that complete midpalatal and pterygo‐
maxillary osteotomies were essential for predictable maxillary expansion in adults. [46]
There is a lack of consensus among orthodontists and surgeons about the indications for
SARME. Although maxillary expansion may be required for many patients, an accurate
diagnosis of maxillary transverse distraction is somewhat ambiguous. This is further compli‐
cated by case reports in the literature about orthodontic maxillary expansion or other forms
of expansion in adults. The following have been reported in the literature as indications for
SARME, all applying to a skeletally mature patient with a constricted maxillary arch.
4. Indications for SARME
1. To increase maxillary arch perimeter, to correct posterior crossbite, and when no addi‐
tional surgical jaw movements are planned.
2. To widen the maxillary arch as a preliminary procedure, even if further orthognathic

surgery is planned. This is to avoid increased risks, inaccuracy, and instability associated
with segmental maxillary osteotomy.
3. To provide space for a crowded maxillary dentition when extractions are not indicated.
4. To widen maxillary hypoplasia associated with clefts of the palate.
5. To reduce wide black buccal corridors when smiling.
6. To overcome the resistance of the sutures when OME has failed. [47]
Several authors have shown that surgically assisted maxillary expansion can be carried out
using only sedation and local anesthesia when a more conservative surgical technique is
chosen. General anesthesia is preferred for invasive techniques. [48-50] Considering all these
surgical techniques and discussions of advantages of one technique to another, most surgeons
prefer to perform osteotomies on all four areas of resistance.
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5. SARME technique
In our clinic, we perform the following protocol routinely. A horizontal incision is made
through the mucoperiosteum above the mucogingival junction in the depth of the buccal
vestibule, extending from the canine region to the mesial of the first molar. Keeping the incision
more distally than the first molar region may cause damage to the pterygoid plexus or Bichat
fat sometimes due to abnormal anatomic variations. Damage to pterygoid plexus may not be
noticed intraoperatively. The vasoconstrictor effect of local anesthetics could curtail the
bleeding during the operation and a postoperative bleeding may occur.
This incision is made in two layers as a safety precaution to any leak after suturing. Any gap
or rupture of suture may cause exposure of the surgical bony area. The first layer incision is
made on the epithelium and the periosteum is reached with dissection of connective tissue
inferiorly, creating a pocket like formation of tissue. The second layer of the incision is then
made on the periosteum 6-8 mm below the first layer. This technique forms a two level wound.
Suturing this incisions layer by layer creates a more secure postoperative wound (Figure 1).
Figure 1. Dissection through the connective tissue from epithelial incision to periosteal incision beveled in order to cre‐
ate a pocket-like tissue wound.
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Nasal mucosa should be elevated gently from the lateral nasal wall. Because the SARME is not
a down fracture procedure, nasal bleeding can be easily controlled with nasal tampons which
should be considered as a minor complication if patient has no coagulopathy. The maintenance
of the blood supply requires an appropriate surgical procedure, with careful manipulation of
soft tissues and ensuring the periosteum remains intact. [51]
A horizontal low-level osteotomy is made through the lateral wall of the maxilla 5-6 mm
superior to the apices of the anterior and posterior teeth with tiny round burs (Figure 2) and
then an osteotome, microsaw or piezo-surgery device, on the same level is used to make the
bone cuts; the osteotomy extends from the inferolateral aspect of the pyriform rim posteriorly
to the inferior aspect of the junction of the maxillary tuberosity and pterygoid plate (Figure
2). Working with piezo-surgery devices would clearly be more secure but take more operative
time. At this point, retractors should be used gently to prevent infraorbital nerve damage.
Figure 2. After marking the osteotomy route with a tiny round bur
The maxilla is separated from the pterygoid plate with a curved osteotome (Figure 4).
The risk of bleeding increases if the pterygoid plates are separated from the maxilla. If the
pterygoid plates are separated from the maxilla, the most common sources of hemorrhage after
SARME are the terminal branches of the maxillary artery, especially the posterior superior
alveolar artery, and the pterygoid venous plexus. Turvey and Fonseca showed that the mean
distance from the most inferior part of the pterygomaxillary junction to the most inferior part
of the internal maxillary artery is 25 mm. During pterygomaxillary separation, pterygoid
osteotomes should be correctly positioned and variations of this anatomy should be taken into
account. [52] The pterygoid region should always be packed with moistened gauzes until
suturing to avoid excessive blood loss and less postoperative swelling or hematoma.
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Figure 3. Osteotomy with an osteotome through the marked osteotomy line
Figure 4. Separation of the pterygoid plate with a curved osteotome. Note the position of the finger to feel the osteo‐
tome intraorally
In conjunction, a sagittal palatal osteotomy is carried out, running from the midline of the
alveolar bone, between the central incisors, to the posterior nasal spine. First a vertical incision
is made along the labial frenulum between the central incisors. Then an osteotome is positioned
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in the central incisor interradicular space and manipulated to achieve equal and symmetric
mobilization of the anterior maxilla. The forefinger is positioned on the incisive papilla to feel
the redirected osteotome as it transects the deeper portion of the midpalatal suture (Figure 5).
Figure 5. An easy way of traction of midline incision to reach and perform midpalatal osteotomy
Releasing the anterior nasal spine to improve mobility and to prevent deviation of the nasal
septum is useful. Lateral nasal walls on both sides should be checked and released with
osteotomes. A lateral nasal wall osteotomy might cause damage to the descending palatine
artery and this could be minimized by limiting the extent of the osteotomy posterior to the
pyriform rim to 35 mm in men and 30 mm in women [52].
Before the osteotomies the Hyrax appliance is activated to obtain easy palatal separation for
about 8-10 turns, for maximum aperture and diastema formation. An immediate gap between
central incisors should be observed intraoperatively after the osteotomies are performed. This
is followed by immediate regression, leaving a 1 mm gap. Patients should receive postopera‐
tive prophylactic antibiotics and analgesics for 7 days postoperatively (Figure 6).
A surgically assisted maxillary expansion procedure is essentially a combination of osteogenic

distraction with controlled expansion of soft tissues. Some principles must be followed to
ensure that bone repair occurs in osteogenic distraction namely:
• Preservation of blood supply in the region
• Stability of the distractor and bone fragments
• Adequate latency period
• Adequate rate and frequency of activation and
• Observance of the retention period.

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Figure 6. View of a completed osteotomy. Also zygomatic retention plates are implemented for orthodontic purposes.
The technique is based on a 5-day period of rest after corticotomy before the expansion starts.
This gives the tissue time to form the first callus but is too short for consolidation.
Four phases of new bone formation can be described.
1. The first is a fibrovascular hematoma; between days 5 and 7 collagen fibers are formed
that will arrange parallel to the distraction vector.
2. Second, the bone formation follows the collagen fibers through intramembranous
ossification; from the outside to the inside.
3. Third, remodeling phase of the new bone.
4. Fourth, formation of solid compact bone with the same texture as the surrounding (old)
bones.
When the distraction is performed too fast, the collagen fibers lose contact and there is no
ingrowth of new bone, causing nonunion or malunion. In cases of a too slow distraction
premature consolidation can occur and the required elongation cannot be reached [53].
Latency is considered to be the time interval between osteotomy and the appliance start-up
and varies from 0 to 14 days in experimental and clinical studies. [54-56]
Activation rate is the amount of daily bone distraction (in millimeters); it varies from 0.25 to
1.0 mm.
Frequency represents the number of times the appliance is activated per day. [57] De Freitas
et al recommend the expansion procedure with an overexpansion index of 23% above the
desired measurements to compensate for relapse [58].
Retention period at the end of the distraction is necessary for the neoformed bone tissue to
acquire the necessary resistance to bear the tipping forces. In experimental and clinical studies
this period can vary from one to six months. [54, 59]
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SARME procedures have traditionally been reported to have low morbidity especially when
compared with other orthognathic surgical procedures. However, many complications have
been reported in the literature varying from life-threatening epistaxis to a cerebrovascular
accident, skull base fracture with reversible oculomotor nerve paresis and orbital compartment
syndrome. [60-64]
Rapid maxillary expansion can produce unwanted effects when used in a skeletally mature
patients, including lateral tipping of posterior teeth, extrusion, periodontal membrane
compression, buccal root resorption, alveolar bone bending, fenestration of the buccal cortex,
palatal tissue necrosis, inability to open the midpalatal suture, pain, and instability of the
expansion. [6-8,10-15,17,28,46]
Complications associated with SARME reported in the literature also include significant
hemorrhage, gingival recession, injury to the branches of the maxillary nerve, infection, pain,
devitalization of teeth and altered pulpal blood flow, periodontal breakdown, sinus infection,
alar base flaring, extrusion of teeth attached to the appliance, relapse, and unilateral expansion.
[60,61,65-73] Postoperative bleeding starting on the third week due to the rupture of greater
palatine artery, rupture of inferior nasal mucosa or any damage of venous plexus during the
expansion procedure may even be observed. Segments or sharp prominences of bone in the
intrapalatinal region could be considered to abrade or lacerate these tissues while the expan‐
sion procedure is processed. Moreover postoperative hemorrhage, pain, sinusitis, palatal
tissue irritation/ulceration, asymmetrical expansion, nasal septum deviation, periodontal
problems and relapse were reported as minor complications; and although SARME is consid‐
ered a procedure with little risk of serious complications, several complications were dis‐
cussed.
Author details
Sertaç Aktop*, Onur Gönül, Hasan Garip and Kamil Göker
*Address all correspondence to: sertacaktop@hotmail.com
Marmara University Dentistry Faculty, Department of Oral and Maxillofacial Surgery, Istan‐
bul, Turkey
References
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Orthod Orthognatb Surg 1994; 9:159,
[2] Melson B: Palatal growth studied on human autopsy material. Am J Orthod 1975;
68:42
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[3] Melson B, Melson F: The postnatal development of the palatomaxillary region stud‐
ied on human autopsy material. Am J Orthod 1982; 82:329
[4] BettsNJ,Vanarsdall RL, BarberHD,Higgins-Barber K, Fonseca RJ. Diagnosis and treat‐

ment of transverse maxillary deficiency.Int J Adult Orthod Orthognath Surg 1995;
10:75–96
[5] Haas AJ: Long-term post-treatment evaluation of rapid palatal expansion. Angle Or‐
tho 1980; 50:189
[6] Timms DJ. A study of basal movement with rapid maxillary expansion. Am J Orthod
1980;77:500-7.
[7] Wertz RA. Skeletal and dental changes accompanying rapid midpalatal suture open‐
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[10] Zimring JF, Isaacson RJ. Forces produced by rapid maxillary expansion. 3. Forces
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[11] Barber AF, Sims MR. Rapid maxillary expansion and external root resorption in man:
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[18] Greenbaum KR, Zachrisson BU. The effect of palatal expansion therapy on the perio‐
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[19] Haas AJ. Long-term posttreatment evaluation of rapid palatal expansion. Angle Or‐
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[20] 18. Moss JP. Rapid expansion. Int J Orthod 1976;14:15-9.
[21] Handelman CS. Nonsurgical rapid maxillary alveolar expansion in adults: a clinical
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[26] Ozturk M, Doruk C, Ozeç I, Polat S, Babacan H, Biçakci A. Pulpal bloodflow: effects
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[27] Profitt WR. Contemporary Orthodontics. 3rd edn. St. Louis, USA: Penny Rudolph,
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[28] Mommaerts MY: Transpalatal distraction as a method of maxillary expansion. Br J
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[29] Glassman AS, Nahigan SJ, Medway JM, Aronowitz H. Conservative surgical ortho‐
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[30] Lehman JA, Haas AJ, Haas DG. Surgical orthodontic correction of transverse maxil‐
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[32] Haas AJ. Rapid palatal expansion of the maxillary dental arch and nasal cavity by
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[33] Aziz SR, Tanchyk A. Surgically assisted palatal expansion with a bone-borne self-re‐
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[34] Isaacson R, Ingram A: Forces produced by rapid maxillary expansion: Forces present
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[36] Koudstaal MJ, Poort LJ, van der Wal KGH, Wolvius EB, Prahl-Andersen B, Schulten
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[37] Seeberger R, Kater W, Davids R, Thiele OC. Long term effects of surgically assisted
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[39] Isaacson RJ, Wood JL, Ingram AH. Forces produced by rapid maxillary expansion II.
Angle Orthod 1964: 34: 261.
[40] Wertz RA. Skeletal and dental changes accompanying rapid midpalatal suture open‐
ing. Am J Orthod 1970: 58: 41–66.
[41] Bierenbroodspot F, Wering PC, Kuijpers- Jagtman AM, Stoelinga PJW. Surgically as‐
sisted rapid maxillary expansion: a retrospective study. Ned Tijdschr Tandheelk
2002: 109: 299–302
[42] Booy A, Dorenbos J, Tuinzing DB. Corticotomie een chirurgisch aspect van ortho‐
dontie. Ned Tijdschr Tandheelkd 2000: 107: 213–214.
[43] Remmelink HJ. Corticotomie van de bovenkaak: een andere benadering. Ned
Tijdschr Tandheelkd 2000: 107: 417 [comment in 418].
[44] Lines PA. Adult rapid maxillary expansion with corticotomy. Am J Orthod 1975: 67:
44–56.
[45] Bell Wh, Epker Bn. Surgical orthodontic expansion of the maxilla. 1976: 70: 517–528.
[46] Shetty V, Caridad JM, Caputo AA, et al: Biomechanical rationale for surgical-ortho‐
dontic expansion of the adult maxilla. J Oral Maxillofac Surg 1994; 52:742
[47] Suri L, Taneja P. Surgically assisted rapid palatal expansion: A literature review Am J
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[48] Berger JL, Pangrazio-Kulbersh V, Borgula T, Kaczynski R. Stability of orthopedic and

surgically assisted rapid palatal expansion over time. American Journal of Orthodon‐
tics and Dentofacial Orthopedics 1998: 114: 638–645.
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[50] Byloff FK, Mossaz CF. Skeletal and dental changes following surgically assisted rap‐
id palatal expansion. European Journal of Orthodontics 2004: 26: 403–409.
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[51] R. R. de Freitas, A. J. Gonçalves, N. J. Moniz, F. A. Maciel: Surgically assisted maxil‐

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797–804
[52] Turvey TA, Fonseca RJ. The anatomy of the internal maxillary artery in the pterygo‐
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38(2):92-95.
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A. J. M. Schulten: Surgically assisted rapid maxillary expansion (SARME): a review
of the literature. Int. J. Oral Maxillofac. Surg. 2005; 34: 709–714
[54] do Amaral CMR, Di Domizio G, Tiziani V, Galhardi F, Buzzo CL, Rinco T. Gradual
bone distraction in craniosynostosis. Preliminary results in seven cases. Scand J Plast
Reconstr Surg Hand Surg 1997: 31: 25-37.
[55] Tavakoli K, Walsh WR, Bonar F, Smart R, Wulf S, Poole MD. The role of latency in
mandibular osteodistraction. Journal of Cranio-Maxillofacial Surgery 1998: 26: 209–
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[56] Troulis MJ, Glowacki J, Perrot DH, Kaban LB. Effects of latency and rate on bone for‐
mation in a porcine mandibular distraction model. J Oral Maxillofac Surg 2000: 58:
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797–804
[59] Cleall JF, Bayne DI, Posen JM, Subtelny JD. Expansion of the midpalatal in the mon‐
key. Angle Orthod 1965: 35: 23– 35.
[60] Mehra P, Cottrell DA, Caiazzo A, Lincoln R. Life-threatening, delayed epistaxis after
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[61] Li KK, Meara JG, Rubin PA. Orbital compartment syndrome following orthognathic
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[62] Kraut RA. Surgically assisted rapid maxillary expansion by opening the midpalatal
suture. J Oral Maxillofac Surg 1984: 42: 651–655.
[63] Pogrel MA, Kaban LB, Vargervik K, Baumrind S. Surgically assisted rapid maxillary
expansion in adults. Int J Adult OrthodonOrthognath Surg 1992: 7: 37–41.
[64] Messer EJ, Bollinger TE, Keller JJ. Surgical-mechanical maxillary expansion. Quintes‐
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[65] Lanigan DT, Hey JH, West RA: Major complications of orthognathic surgery: Hemor‐
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[66] Glassman AS, Nahigan SJ, Medway JM, Aronowitz H. Conservative surgical ortho‐
dontic adult rapid maxillary expansion: sixteen cases. Am J Orthod 1984;86:207-13.
[67] Carmen M, Marcella P, Giuseppe C, Roberto A. Periodontal evaluation in patients
undergoing maxillary expansion. J Craniofac Surg 2000;11:491-4
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[69] Ozturk M, Doruk C, Ozec I, Polat S, Babacan H, Bicakci AA. Pulpal blood flow: ef‐
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[71] Cureton SL, Cuenin M. Surgically assisted rapid palatal expansion: orthodontic prep‐
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Dent J 1997;42:38-42.
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Chapter 9
Orthodontic Considerations in Obstructive Sleep Apnea

— State of the Art
Hakima Aghoutan, Sana Alami, Samir Diouny and

Farid Bourzgui
http://dx.doi.org/10.5772/59086
1. Introduction
Obstructive Sleep Apnea (OSA) was described as early as 1837 in “The Posthumous Papers of
the Pickwick Club”. Dickens, a British author, described “Joe”, the main character, as a fat boy
who falls asleep easily and involuntarily (Figure 1). [1]
In The Pickwick Papers (c. 1836–1837)
Figure 1. Artist (Hablot Knight Browne- Phiz) rendering of Joe, Charles Dickens’ character.
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Later on, Osler (1914) used the term “Pickwickian syndrome” to describe obese and sleepy
patients, in homage to Dickens’ character “Joe”. As early as 1956, Bickelmann et al [2]
reported that the “Pickwickian syndrome” was associated with extreme obesity and alveolar
hypoventilation.
Gastaut’s research group described three different types of apnea, namely, obstructive apnea
central apnea, and mixed apnea. In 1973, Guilleminault introduced the apnea-hypopnea index
(AHI), which refers to the total number of apnea and hypopnea episodes per hour of sleep,
and proved, along with Dement, that obesity is not a prerequisite for OSA. In 1977, Guillemi‐
nault and Dement used the term “sleep apnea syndrome”, in association with hypertension
and electrocardiographic pathologies. [3]
Recently, much research on OSA has been conducted with a view to help elucidate the
characteristic features of OSA. Sleep is a process through which the body restores energy used
during the day. Not much is known about its biological purpose, but its evaluation can be
undertaken by muscle and brain electrical activity, and ocular movement. Good-quality sleep
entails several functions; these include physical recovery, biochemical refreshment, memory
consolidation and psychological well-being. [4]
In adults, sleep is regulated by a cycle of five periods. The first four periods belong to non-
rapid eye movement sleep (light and deep stage) and the fifth period is named the rapid-eye-
movement (REM) or paradoxical sleep (active stage). The progression from the first stage to
the RAM constitutes one sleep cycle. Generally, there are four to six sleep cycles per night;
during which activities of the brain, muscles, and the cardio-respiratory system fluctuate
(Figure 2, 3). [4]
Figure 2. A sleep cycle (non-REM to REM stages). [4]
During these sleep stages, several sleeping disorders can occur. International classification of
Sleep Disorders (ICSD-3), revisited in 2014, includes the following broad categories: [5]
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Orthodontic Considerations in Obstructive Sleep Apnea — State of the Art 363

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Figure 3. Consecutive wave of non REM to REM sleep cycles (I to IV). Throughout the night, REM becomes longer
than slow wave sleep (stage 3and 4). MT: movement time, WT: wake time. [4]
• Insomnia
• Sleep related-breathing disorders
• hypersomnomlence Central disorders
• Circadian rhythm sleep-wake disorders
• Parasomnias
• Sleep related-movement disorders

Sleep apnea is the most common sleep disorder related to breathing. There are 3 types of sleep
apnea: Obstructive, central, and mixed (a combination of both forms). Obstructive sleep apnea
(OSA) is caused by partial or complete obstruction at multiple levels of the upper airway,
producing reduction (hypopnea), or cessation (apnea) of airflow. Due to the lack of adequate
alveolar ventilation, oxygen saturation may drop and partial pressure of CO2 may occasionally
increase. Snoring and sleep fragmentation are common with OSA that can be graded as mild,
moderate and severe.[6] Adults and children are equally affected. However, the prevalence,
etiology and pathophysiology of the disorder differ from one group to another. It is important
to note that the physiopathology and etiology of OSA are poorly understood.
Furthermore, OSA is associated with neuropsychological impairment, sexual dysfunction,

metabolic and cardiovascular co-morbidities; and causes an increase in mortality. Quality of
life and economic potential are also affected: snoring affects the sleeping pattern of the partner,
and frequent arousals at night result in relative sleep deprivation and can cause excessive
daytime sleepiness, loss of concentration and motor vehicle accidents.[4]-[7] Therefore, OSA
is regarded as a public health condition and increases the consumption of health care resources.
Continuous positive airway pressure (CPAP) is considered a golden standard treatment; oral
appliances and surgical procedures for upper airway soft tissues and maxilla-mandibular
advancement are other alternatives. Hence OSA treatment requires a multidisciplinary
management. [8] Orthodontists, sleep specialists and surgeons should all be involved in
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managing and treating OSA. This chapter gives a comprehensive account of the literature on
OSA and underlines the role of orthodontists in managing OSA with a view to improve the
physical, mental and social status of patients diagnosed with OSA.
2. OSA epidemiology
2.1. Prevalence
Due to various definitions of respiratory events and differences in study design, contradictory
variable prevalence rates of OSA are reported. The American Academy of Sleep Medicine
published the first guidelines to standardize the definition of OSA; however, the standardi‐
zation of OSA definition only expanded the diagnostic criteria.[1] According to the Wisconsin
sleep cohort study, the estimated prevalence of moderate to severe sleep breathing disorder
in the United States for the period of 1988–2011 ranged from 3% to 17% in adults depending
on sex and age; OSA seemed to affect especially middle-aged and elderly men and has
increased substantially over the last two decades in the US. [9] In Morocco, however, OSA
prevalence ranges from 5, 4% to 7, and 9% in the general population. [10] De Backer (2013)
reported that epidemiological studies investigating the prevalence of OSA are all biased
because there is a lack of a uniform definition. He also indicated that the prevalence of an AHI
of >5 events per hour in the general population (without taking into account symptoms of
sleepiness) has been estimated to be 24% in the male population. When symptoms of sleepiness
are also taken into account, this prevalence goes down to 4% in males and 2% in females. [11]
2.2. Risk factors

In the literature on OSA, most researches agree that risk factors for OSA include obesity, upper
airway and craniofacial abnormalities, gender, age, alcohol consumption and cigarette
smoking. [12] Obesity, particularly central or upper body fat distribution, with increased neck
circumference (collar size) is a main risk factor for OSA. But this association may be less
important with the elderly. In non-obese patients, craniofacial abnormality like micrognathia
and retrognathia may also be considered as a risk factor leading to OSA. [13]
Aging is also associated with higher OSA prevalence. Still, it is not clear if OSA in the elderly
compared to middle-aged adults manifests itself the same way; middle age and over-weight
adult men seem to have the highest prevalence of OSA. However, after menopause, prevalence
seems to be the same for both women and men. [1]Some studies have examined craniofacial
features among different ethnic groups; their objective was to investigate whether ethnicity
differences had an effect on the prevalence of OSA. These studies reported an increased risk
of OSA among African-Americans, Latinos and Asians. [14]-[17] Wong et al. (2005) claimed
that the hyoid bone was located more caudally in Chinese subjects and may be a severity
indicator in this population. [18] In addition, OSA prevalence seems to be much higher in
patients with cardiac or metabolic disorders than in the general population. Other factors such
as heredity, hormonal change, sedative hypnotics and supine sleep position have also been
described as risk conditions for developing OSA. [11, 12]
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2.3. Mortality and morbidity
Epidemiologic data have shown a strong association between untreated obstructive sleep
apnea and incident cardio and cerebrovascular morbidity and mortality. [19, 20] These co-
morbid conditions may be due, in part, to common risk factors (i.e. obesity and hypertension),
and also to hypoxemia-hypercapnia, which can lead to vascular dysfunctions. [21] In an18-
year mortality follow-up conducted on the population-based Wisconsin Sleep Cohort sample
(n = 1522), Young et al. found a significant mortality risk with untreated sleep breathing
disorder (SBD). They underscored the need for early diagnosis and treatment of SBD, indicated
by frequent episodes of apnea and hypopnea, regardless of sleepiness symptoms.[20]A recent
review of OSA in adults reported an increased risk of morbidity and mortality associated with
OSA, which reached its peak at 55 years of age. [12], This association seems to disappear after
70 yrs. [22]Sampaio et al., 2012 suggested that women revealed more psychological morbidity
associated with OSAS. Therefore, it seems extremely important to look at women as potential
patients for sleep apnea. [23] However, Gozal and Kheirandish-Gozal highlighted the potential
interaction between gene polymorphisms, organ vulnerability, and the phenotypic expression
of OSA and suggested that it should be identified and incorporated into future prediction
schemes of morbidity risks associated with OSA. [24]
3. OSA pathophysiology
In recent years, the understanding of the pathophysiology of sleep-breathing disorder has

improved. Central nervous system regulation of breathing is now recognized as a significant
contributor to the pathogenesis of OSA. To understand the pathophysiologic mechanisms that
contribute to OSA, an overview of anatomical and physiological aspects of upper airway is in
order.
3.1. Upper airway anatomy and physiology
The upper airway is a complex, multifunctional, and dynamic neuro-mechanical system. It is

defined as the passageway for gas and food, beginning at the mouth and nose and ending at
the epiglottis and vocal cords. It is composed of bony structures (maxilla, mandible and hyoid
bone) and soft tissues (tonsils, soft palate, tongue, uvula, pharyngeal muscle, para-pharyngeal
fat pads and lateral wall of the pharynx). The mandible and hyoid bone are the principal
craniofacial bone structures that determine the dimensions of the upper airways. Soft tissues
form the walls of the upper airways and they are supported by bone structures.[1, 25] The
upper airways are typically divided into three segments: The nasopharynx (end of the nasal
septum to the margin of the soft palate), the oropharynx (free margin of the soft palate to the
tip of the epiglottis), divided into the retropalatal and retroglossal regions, and the hypophar‐
ynx (tip of the epiglottis to the vocal cords) (Figure 4).
The pharynx has several functions that enter into competition with each other; it requires
patency and closure.[1, 4] It serves the neurological (speech, taste, smell), but also gastro-
intestinal and respiratory system (chewing, swallowing, breathing).Speech and swallowing
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Figure 4. Sagittal magnetic resonance imaging of airway and division of oropharynx. (Clete A. Kushida)
require that the upper airway be collapsible. However, during breathing, the pharynx must
remain patent.
Oropharynx and hypopharynx compose the collapsible portion of the pharynx. Due to the
absence of bone and cartilage in these segments, their lumen patency, during awakening and
sleep, depends heavily on muscle activity and intrinsic airway collapsibility, which is dictated
by a combination of passive mechanical properties and active neural mechanisms.
During inspiration, negative intra-thoracic pressure is transmitted to the upper airways,

resulting in a reduction in the transverse area of the pharynx. [25] The permeability of the
upper airways is maintained through the balance between opposing forces from factors that
collapse the airway and those that promote its patency. This is called “the balance of pressure
concept” and involves the following determinants (Figure 5): [1,4, 26]
• The baseline pharyngeal area, determined by both craniofacial and soft tissue structures;
• The compliance or collapsibility of the airway;
• The negative intraluminal pressure within the airway (intraluminal pressure), transmitted
from inspiratory muscles (the diaphragm, the external intercostal muscles....), that tends to
narrow the airway;
• The pressure acting on the outside surface of the pharyngeal wall (tissue pressure), which
also tends to collapse the airway such as compression by the lateral pharyngeal and
submandibular fat pad and a large tongue confined to a small oral cavity;
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• The positive extra-luminal pressure from the abduction force of the pharyngeal dilator
muscles, which is directed outwards, and functions to increase cross-sectional area.
Pharyngeal dilating muscles can be divided into four groups: [1, 4]
• Muscles influencing hyoid bone position such as geniohyoid and sternohyoid
• Muscles of tongue: Genioglossus is the largest and the most important muscle
• Muscles of the palate such as tensor palatini and levator palatini
• Muscles protruding the mandible, principally the pterygoid muscles
In normal individuals in awake state, the upper airway dimensions remain practically constant
throughout inspiration by neuromotor mechanisms, like reflex muscle activation in response
to stimuli such as sub-atmospheric pressure and hypercapnia. However, during sleep,
neuromotor tone decreases and upper airway resistance increases considerably especially in
sleep onset and REM stages. These physiologic variations are counteracted by a reduction of
diaphragm and intercostal muscles activity and thus a decrease in inspiratory pressure. This
tendency for the human upper airway to collapse predisposes it to abnormal deformation
during sleep, mainly in susceptible individuals. [1,4, 27]
OSA results from a combination of structural upper airway narrowing and abnormal upper
airway neuromotor tone. It is believed that the upper airways collapse more easily in OSA
patients and occurs at slightly negative intra-thoracic pressures or even positive pressures. [27]
Narrowing can occur in more than one site. The retropalatal or velopharyngeal region is the
most common site; but the collapse usually extends to other locations. Since REM sleep is
associated with greater muscle hypotonia compared to non-REM sleep, sleep-breathing
disorder is more likely to occur during REM sleep. [13] In addition, the sleep-awake state in
the pathogenesis of OSA is important to highlight. OSA patients, even with the most severe
apnea, have generally no respiratory dysfunction during wakefulness through compensatory
systems. [28]
According to recent studies on OSA pathophysiology, anatomical factors are not the whole
story. The coordination between collapsing and dilating forces is an important concept and
there is increasing evidence that the quantity and pattern of ventilation plays a substantial role
in airway collapse [29] as well as the presence of upper airway neuropathology. [28] In
addition, not all individuals with OSA have the same anatomical features. Thus, OSA patho‐
physiological factors are usually divided into three categories, whose complex interplay may
explain the variable response to treatment:
1. Anatomic factors that effectively reduce airway caliber;
2. Non-anatomic factors that promote increased upper airway collapsibility and include:
mechanical factors that are passive and related to tissues properties; and
3. neurological factors that change with the state of awakening or sleep

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Figure 5. Determinants of upper airway caliber. PL = intraluminal pressure; Ptis = pressure in the tissues surrounding
the pharyngeal wall; Pmusc = pressure exerted by the pharyngeal dilating muscles; V = change in volume; P = change
in pressure. [1, 26]
3.2. Anatomic factors in OSA
There have been a number of studies comparing anatomic features of OSA patients and normal
individuals. Upper airway imaging techniques such as cephalometry, acoustic reflection,
nasopharyngoscopy, computed tomography and magnetic resonance imaging, have greatly
improved the understanding of OSA biomechanical aspect, and guided treatment modalities.
Over the past several decades, many studies have demonstrated that patients with OSA have
significant craniofacial and upper airway abnormalities when compared with age matched
and sex matched controls. [17, 30]
Typical abnormalities include retroposition of the mandible and maxilla, shorter mandibu‐
lar body length, longer anterior facial height, steeper and shorter anterior cranial base.... [1,
4, 13, 17]
However recent studies have shown no strong evidence for a direct causal relationship
between sagittal and vertical craniofacial features and sleep-breathing disorder. In contrast,
transverse width in the maxilla has a real impact with strong support for a narrow maxilla in
OSA patients. [31]-[32] In addition, there is theoretical evidence that the size and the shape of
the upper airway are also important and influence upper airway collapsibility.[4, 13] Imaging
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studies have shown reduced nasopharyngeal and oropharyngeal sagittal dimensions in OSA
cases, associated with longer soft palate and longer airway. Indeed, the upper airway long axis
of OSA patients is likely to be oriented transversely compared to the wide, elliptically shaped
airway of normal controls.[33]-[35]
Lung volume is also reported to influence upper airway caliber and compliance.[13, 29]
Decreased lung volume results in a caudal traction effect, which decreases the pharynx area
and increases its resistance and its collapsibility due to a loss of tracheal tug.
Nasal airway pressure required to maintain airway patency is defined as the critical closing
pressure (Pcrit). [4] It has been demonstrated that Pcrit is related to anatomical features and lung
volumes, and shown to correlate with soft palate length in obese patients and airway length
and hyoid-mandibular distance in non-obese patients [13]
On the other hand, the magnitude of extra luminal tissue pressure depends on the
interaction of the upper airway soft tissues and the bony compartment size (Figure 6).[36]
According to this model, soft tissues excess like in obesity, or restriction in bony compart‐
ment size such as retrognathia or both can lead to tissue pressure increase, thereby reducing
airway caliber and predisposing to OSA. Soft tissues excess can be seen in case of tongue,
soft palate and pharyngeal wall volume augmentation; but also in adenoids and tonsils
lymphoid tissue hypertrophy.
Figure 6. Figure 6: OSA pathophysiology: schematic explanation for anatomic factors interaction to regulate extralumi‐
nal tissues pressure (Ptissue) [36]
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Despite the relationship between structural features and function, some patients with OSA do
not have clear anatomic abnormalities. Evidence for a direct causal relationship between
craniofacial structure and OSAs has yet to be elucidated because several methodological
deficiencies in the literature and lack of research standardization methods and treatment
success definitions have been highlighted.
3.3. Non-anatomic factors
This category includes all factors underlying collapsibility. They are divided into pure
mechanic and neurologic factors. In OSA patients, airway dilation appears less coordinat‐
ed than normal subjects and intrinsic mechanical properties of airway tissues are altered
(Figure 7). [30, 37]
The respiratory control pattern generator responsible for automatic control ventilation is
located into the brainstem. Respiratory rhythm is regulated by chemoreceptors and neural
input from the upper airway and lungs to the brainstem neuronal network.[4] Instability of
ventilatory control contributes to OSA pathophysiology by leading to periodic breathing and
compromising airway patency during the ventilatory cycle. [28] It has also been suggested that
upper airway inflammation and trauma caused by snoring and the hypoxia caused by
intermittent upper airway collapse may impair the sensory pathways (upper airway mucosa)
and the activation of neuromuscular reflexes (pharyngeal dilator muscles) rendering the upper
airway prone to collapse. [38]
Other factors that may contribute to OSA pathophysiology include head posture, vascular
supply to the mucosa and tissues surrounding the airway and arousal threshold.
Strohl et al. (2012) [39] reported that changes in blood pressure and/or pharyngeal muscles
vascularity could affect airway stability and patency. Mucosal blood flow may either help resist
distortion or contribute to narrowing if engorged.
On the other hand, flexion and extension of the neck affect the mechanics of the upper airway
because the axis of rotation for extension and flexion is behind the airway. Thus, altered sleep
position, mainly supine, may increase upper airway collapsibility and predispose to OSA
particularly in adults because of tongue base prolapse. [40] In contrast, OSA children breathe
better in the supine than in the prone position; this may be true because obstruction in children
occurs usually at the level of the adenoids or soft palate rather than at the level of the tongue [1]
Although arousal is known to reinstate ventilation and thus to be protective in OSA, it is not
essential to terminate an obstructive event. Low arousal threshold can exacerbate instability
and worsen OSA.[1, 41] However, some authors who believe, that poor sleep is a secondary
cause of OSA have rejected this claim. [29]
OSA has been shown to aggregate significantly within families. Genetic factors are likely to
determine upper airway anatomy, neuromuscular activity and ventilatory control stability;
these factors produce the phenotype of the OSA syndrome.[1, 4, 25, 42].
In sum, it is probably reliable to conclude that, in OSA individuals, there is a multiplicity of
coexisting factors interacting to varying degrees at night; and everyone has biological sus‐
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30
ure 7. Schematic model proposed by Isono et al., 1997 and explaining pharyngeal airway pate
Figure 7. Schematic model proposed by Isono et al., 1997 [30] and explaining pharyngeal airway patency: When a
wake, upper airway (UA) muscle activity compensates the depression forces exerted by the air, both in normal subjects
e, upper airway (UA) muscle activity compensates the depression forces exerted by the air, both
(A) and the OSA (B) for which activity is most important. During sleep, activity decrease generates too much imbal‐
ects (A) and the OSA (B) for which activity is most important. During sleep, activity decrease gen
ance in the apneic and causes collapse (D). In panels B and D (subject with OSAS) the fulcrum that represents intrinsic
properties of the pharynx, is to the right of the normal subject (A and C)
h imbalance in the apneic and causes collapse (D). In panels B and D (subject with OSAS) the fulc
esents intrinsic properties of the pharynx, is to the right of the normal subject (A and C)
ceptibility and responds differently to environmental predisposing factors. Because OSA is a
public health problem, its treatment should target the specific pathophysiologic processes that
contribute to the collapse of the upper airway, in an attempt to alleviate symptoms and modify
her factors that may contribute to OSA pathophysiology include head posture, vascular supply to t
the long-term health consequences.
tissues surrounding the airway and arousal threshold.
ohl et al. (2012) 39 reported that changes in blood pressure and/or pharyngeal muscles vascularity
4. OSA diagnosis
ay stability and patency. Mucosal blood flow may either help resist distortion or contribute to narr
orged.
4.1. Definitions
the other hand, flexion and extension of the neck affect the mechanics of the upper airway becau
tion for extension and flexion is behind the airway. Thus, altered sleep position, mainly supine, ma
Aimed at maximal standardization and better care of patients, a task force of the American
Academy of Sleep Medicine (AASM) has recommended terminology and standards of practice
er airway collapsibility and predispose to OSA particularly in adults because of tongue base prolaps
for recording sleep and breathing, and assigned evidence-based definitions for abnormal
rast, OSA children breathe better in the supine than in the prone position; this may be true becaus
events, parameters and disorders. [43] These definitions are still valid today.
ildren occurs usually at the level of the adenoids or soft palate rather than at the level of the tong
though arousal is known to reinstate ventilation and thus to be protective in OSA, it is not essentia
1, 41
bstructive event. Low arousal threshold can exacerbate instability and worsen OSA. However, s
29
believe, that poor sleep is a secondary cause of OSA have rejected this claim.
SA has been shown to aggregate significantly within families. Genetic factors are likely to determin
ay anatomy, neuromuscular activity and ventilatory control stability; these factors produce the ph
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4.1.1. Respiratory events
Apnea is defined as cessation of airflow at the nose and mouth for 10 seconds or more with
an arterial oxygen desaturation of 2% to 4%. Apnea is central, obstructive or mixed. The
distinction between central and obstructive apnea is essential in determining the most
appropriate treatment. During obstructive apnea, patients display respiratory effort without
being able to ventilate because of upper airway obstruction, whereas central apnea occurs in
the absence of ventilatory effort. Mixed apnea is initially started without ventilatory effort (as
a ‘central’ pattern), and ends as obstructive with resumption of ventilatory efforts.
Hypopnea is defined as a decrease in airflow for 10 seconds or more with a concomitant drop
in arterial oxygen saturation. AASM distinguish two situations of hypopnea events:
• A clear decrease (> 50%) from baseline in the amplitude of a valid measure of breathing
during sleep;
• Or an amplitude reduction (< 50%) associated with either an oxyhemoglobin desaturation

(> 3%) or an arousal. [4]
The exact magnitude of desaturation for a hypopnea varies in the literature. In routine clinical
practice, it may not be necessary to differentiate apneas from hypopneas when both have
similar pathophysiological consequences.[13] It is recommended to associate these two events
in the form of an index of apnea / hypopneas (AHI).
4.1.1.1. Apnea and Hypopnea Indices (AHI)
This index, also termed respiratory disturbance index (RDI), refers to the total number of apnea
and hypopnea episodes per hour of sleep. It is calculated by dividing the total number of
apneas/hypopneas during a recording period by the total sleep time. AHI is usually employed
to quantify OSA severity, but also to compare individual patient data with normative as well
as pre-treatment and post-treatment values.
4.1.2. Obstructive sleep apnea syndrome
As noted previously, OSA is characterized by repeated partial or complete collapses of the

upper airway during sleep, which precludes or reduces airway flow. It is associated with
excessive daytime somnolence, sleep fragmentation and adverse sequelae attributable to
frequent obstructive apneas or hypopneas during sleep. According to the AASM, OSA refers
to an AHI ≥ 5 associated to one or both of these two criteria:
• Excessive daytime sleepiness (EDS) not explained by other factors
• Manifestation of at least two of following symptoms that should co-exist:
• Daily severe snoring
• Choking or suffocation during sleep
• Fragmented and non-restorative sleep

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• Diurnal tiredness
• Concentration difficulties
• Nocturia
However, the presence of 15 or more obstructive respiratory events per hour of sleep in the
absence of sleep related symptoms is enough proof for the diagnosis of OSA due to the greater
association of this severity of obstruction with important consequences such as increased
cardiovascular disease risk.[44] Two indicators must be taken into account for severity
estimation of OSA: AHI and the importance of diurnal hyper-somnolence after exclusion of
another cause of sleepiness. Patients in normal sleep have an AHI of 5 or less. Patients with
mild sleep apnea have an AHI of 5 to 15, with moderate sleep apnea typically 15 to 30 events
and severe apnea 30 or more events per hour.
4.2. OSA clinical approach
Despite its high estimated prevalence, awareness of OSA remains insufficient in the commun‐
ity.[4] Health professionals, including orthodontists, should not disregard the risk factors of
OSA and should detect and diagnose this disorder. OSA screening should be based on sleep-
oriented history and physical examination in conjunction with objective tests. When diag‐
nosed, OSA severity level must be determined for an effective treatment decision.[44]
4.2.1. Physical examination
According to the AASM, sleep history is sought to evaluate OSA symptoms and to determine
patients who present high-risk levels. A sleep examination is directed at modifying the OSA
probability based on the history, looking for associated or complicating disease, and excluding
other potential causes for symptoms.
Clinical assessment must encompass all sleep and physical features of the patient that may
provide helpful guidance for screening this condition such as:
4.2.1.1. Excessive Daytime Sleepiness (EDS)
EDS is caused by sleep fragmentation due to frequent arousals at night. It is still a very
subjective symptom that overlaps significantly with other factors such as tiredness and
lethargy. [4] Epidemiological studies estimate EDS prevalence at 8% to 30% in the general
population. [45]Sleepiness may occur during “passive” conditions, such as watching television
or, in severe forms, during “active” conditions, such as conversation or driving. Several
instruments have been developed to measure EDS. Currently, the most useful instrument is
the Epworth Sleepiness Scale.[46] This questionnaire provides sleep propensity measure and
has good test–retest reliability. It should be described with regards to onset, situation, and
chronicity of sleep problems (Figure 8). [45]Objective laboratory sleep tests, like multiple sleep
latency test (MSLT) or maintenance of wakefulness test (MWT) are also used for EDS assess‐
ment, but their limits are principally related to their costs and duration.
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Figure 8. Figure 8. 1997 version of Epworth sleepiness scale. [47]. A score > 10 is consistent with EDS, and a score >16
indicates a high level of EDS.
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4.2.1.2. Snoring and witnessed apneas with choking or gasping
The presence of snoring alone is a poor predictor of OSA. Thus, it must be correlated with
other accompanying clinical features. Similarly, snoring absence does not exclude OSA. If
severe, snoring can affect social relationship and become one of the main complaints of
patients. Talking to the partner and family members can be very helpful; they can often
report signs, such as apnea or falling asleep unintentionally (that the patient may be
unaware of or deny). Therefore, patients can report awakening during choking episodes.
But this is less common among females. OSA can also be associated with array of noctur‐
nal and daytime symptoms that are not necessarily specific to this affection, but can
complete its clinical pattern and give an idea about its impact on patients’ functionalities.
One can cite poor sleep quality, morning headaches, impaired memory, failed concentra‐
tion, nocturia, and depression....[4]
4.2.1.3. Obesity
Obesity is the main predisposing factor for OSA. It is usually quantified by BMI (Body
Mass Index). Increased BMI is closely correlated to OSA likelihood and severity. [4, 13]
Additionally, central obesity (i.e. fat around the neck and waist), evaluated by neck
circumference and hip-to-waist ratio, is simple clinical measurements that seem most
predictive for SDB. There is no evidenced threshold value for these measurements, but a
BMI ≥ 30 kg/m2 and a neck circumference >17 inches in men and >16 inches in women are
habitually used as critical values.[4] Moreover, a study found that waist-hip ratio is the
most reliable correlate of OSA in both sexes; while neck circumference is an independent
risk factor for males. [48]To establish OSA diagnosis, obesity indicators alone are not
sufficient and further diagnostic testing is needed. [26]
4.2.1.4. Craniofacial examination
Clinical examination should include anatomical features of craniofacial and oropharyngeal

structures as they can compromise airway patency. Particular attention should be paid to
upper airway narrowing signs such as tonsillar hypertrophy especially in children, nasal
obstruction, macroglossia with dental impressions at the edge of the tongue, elongated uvula
or soft palate inflammation. [44, 45] Oropharyngeal crowding can be assessed using the
modified Mallampati classification designed originally by anesthetists to grade intubation
difficulty (Figure 9). [49]
Other conditions that should be searched for when examining potential OSA patients are
skeletal abnormalities because they are high risk factors among either obese or non-obese
individuals. Actually, retrognathia, micrognathia, maxilla deficiency with high arched/narrow
hard palate, longer anterior facial height, cranial base abnormalities or inferior hyoid bone
position should be evaluated as they may suggest the presence of OSA. Cephalometric
radiographs enable health professionals to obtain quantitative measures of these features. [50]
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Figure 9. Modified Mallampati classification of oropharyngeal visualization. Class I: Soft palate, tonsils, pillars, and
uvula, are clearly visible. Class II: Soft palate, pillars, and uvula are visible. Class III: only part of soft palate and base
of uvula are visible. Class IV: Soft palate is not visible at all. 49
4.2.1.5. Associated comorbidities
A clinical examination should not ignore respiratory, cardiovascular, and neurologic systems.
In this area, medication history must be taken into account especially with regard to drugs that
are associated with OSA (Barbiturates, Benzodiazepines...), those that sedate and/or decrease
respiratory drive (Antihistamines, Antispasmodics, Anxiolytics, Muscle relaxants...) and those
that impair sleep onset or maintenance (Anticholesterol agents, Appetite suppressants,
Benzodiazepines, Caffeine, Nicotine, Diuretics...). Furthermore, since hypertension is descri‐
bed as independently associated with OSA, blood pressure has been integrated into several
clinical prediction rules for sleep apnea. [22, 44]
4.2.2. Objective testing
To establish OSA severity, objective testing is required. There are two accepted methods:
laboratory polysomnography (PSG) and home testing with portable monitors (PM)
Polysomnography is the golden standard method for diagnosing OSA. It records sleep-
breathing pattern and oxygen saturation overnight via a minimum of 12 channels of physio‐
logical signal such as electroencephalogram, electrocardiogram, electromyogram, oronasal
airflow, electroocculogram, respiratory effort, body position and oxygen saturation. This
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examination provides AHI by monitoring apnea and hypopnea occurrence. Clinical interpre‐
tation of OSA severity is based, in addition to AHI, on factors like oxygen desaturation and
sleep fragmentation degrees. In general, a single night PSG is sufficient to make an appropriate
OSA diagnosis. However, some variability can be identified in recordings between the first
and the second night of a PSG, a phenomenon known as the “first night effect”. This may be
due to factors such as sleep position and alcohol [44, 51]
Unlike PSG that is expensive and labor intensive, PM is performed at home and thus offers
greater convenience for patients. Nonetheless, this procedure has some limits related to the
lack of supervision, which can affect its reliability, but also to the impossibility to detect other
sleep disorders such central apnea or nocturnal epilepsy. The choice between PSG and PM
should take into consideration resource limitations and pre-test clinical evaluation. Thus, PSG
could be performed if PM is technically inadequate or fails to establish OSA patients with a
high pre-test probability.[44]
Furthermore, numerous imaging modalities are available for 2D or 3D craniofacial and airway
study. They have potential usefulness in understanding the pathogenesis of sleep- breathing
disorder, and planning of treatment (adenoidectomy, orthognathic surgery), but their routine
use in the evaluation and diagnosis of OSA is limited. All diagnosis components previously
studied (clinical examination and diagnostic testing) should be discussed with patients to
establish a program including risk factors, consequences, but also treatment options/outcomes
of OSA in the context of disease severity and patients’ expectations.[44]
5. Treatment of OSA syndrome
Therapeutic approach of OSA requires interdisciplinary communication among healthcare

professionals and long-term management with a regular follow-up. Patient adherence to
therapy, potential side effects and further stability of results must be continually moni‐
tored. On the other hand, outcomes assessment should be performed after all therapy has
been undertaken. The criteria used to determine successful treatment of OSA varies widely.
A task force of AASM have reported some indicators for assessment of treatment results;
these include resolution of sleepiness, OSA specific quality of life measures, patient and
spousal satisfaction, adherence to therapy, avoidance of factors worsening disease, obtaining
an adequate amount of sleep, practicing proper sleep hygiene and weight loss for over‐
weight/obese patients. Objectively, clinicians strive to achieve at least 50% reduction in the
baseline AHI in addition to reduction in AHI to <5 events per hour or <10 events per hour.
However, less stringent definitions can be adopted. Treatment modalities of OSA can be
divided into surgical and non-surgical treatment to which adjunctive therapies can be
associated. Less invasive treatment should be selected whenever possible. Also, patients
must be advised about surgical success rates and complications, the availability of alterna‐
tive options and their levels of effectiveness. [52, 53]
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5.1. Non-surgical treatments of OSA
This category includes continuous positive airway pressure (CPAP), behavior modifications,
and oral appliances.
5.1.1. Continuous positive airway pressure (Figure 10)
First described by Sullivan in 1981, CPAP was to become the golden standard of moderate to
severe OSA treatment. [54].It consists of delivering, during sleep, compressed air into the
airway to keep it open, by positive pressure across the airway walls and pneumatic splinting
effect. CPAP can be applied through oral, nasal or oro-nasal interface; and the optimal level
of positive airway pressure is determined by full-night, attended in-laboratory PSG. Successful
therapy with CPAP depends greatly on individual patient acceptance and compliance that can
fall for numerous reasons including functioning noise, discomfort, feelings of claustrophobia,
and skin irritation. Thus, CPAP prescription requires explanation of benefits and medical
reasons for its use. Patients should also be informed about the function and maintenance of
equipment. According to the American college of Physician (ACP), moderate quality evidence
has showed that CPAP improves sleep measurement in patients with at least moderate OSA
(AHI > 15events/h), and there are no data to determine which patients benefit most from
specific treatment strategies. [55] However, OSA remains at present the preferred treatment
for OSA, as it could effectively reduce AHI and arousal index scores, and increase the minimum
oxygen saturation. Finally, if CPAP use fails, based on objective monitoring and symptom
evaluation, more efforts should be implemented to improve PAP use or consider alternative
therapies.
Figure 10. CPAP device requiring the use of mask interface, sealed tubing and flow generator providing airflow. [56]
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5.1.2. Behavior modifications or conservative treatments
Behavior strategy includes all practices that enhance life routines and hygiene. It involves
weight loss (ideally to a BMI of 25 kg/m2 or less), positional therapy, and avoidance of smoking,
alcohol and sedatives 3h before sleep. Weight loss has been shown to improve AHI in obese
patients with OSA. It is recommended for all overweight OSA patients and should be com‐
bined with a primary treatment for OSA. Sleeping in the supine position can affect airway size
and patency with a decrease in the area of the lateral dimension of upper airway. Positional
therapy keeps the patient in a non-supine position by positioning device like alarm, pillow,
back-pack or tennis ball is an effective secondary therapy or can be a supplement to primary
therapies for OSA in patients who have a low AHI in the non-supine position. To ascertain
treatment outcomes, indicators, such as self-reported compliance, objective position monitor‐
ing, are used. However, studies argue that CPAP is still superior to positional therapy in
reducing the severity of sleep apnea and increasing the oxygen saturation level during sleep
in patients with positional OSA. [50]-[57]
5.1.3. Oral appliances (figure 11-13)
Pierre Robin was the first orthodontist to have used oral appliances (OAs) in the 1900s for
glossoptosis. Since the 80s, these oral devices were used as a non-invasive treatment for OSA.
This therapy has proven to be effective in reducing the apnea and hypopnea index, improving
oxygen saturation during sleep, and reducing snoring. OAs are recommended as an alternative
therapy to CPAP for mild to moderate OSA patients with CPAP adverse effects or for those
who do not tolerate or adhere to CPAP or those who refuse surgery. They are also appropriate
for patients with primary snoring, who do not respond to treatment with behavioral measures
such as weight loss or sleep position change. [44, 50]-[58]
Both Mandibular advancement devices (MADs) and tongue-retaining devices were described
(TRD). But MADs are the most commonly used and evaluated in the literature. Orthodontists
must indicate the most appropriate design of MADs for each patient, depending on dental
history and complete examination of the stomatognathic system (soft tissues, dental occlusion,
masticatory muscles and the temporomandibular joint). MADs cover the upper and lower
teeth and hold the mandible in an advanced position with respect to the resting position. The
appliance is constructed, adjusted, and gradually titrated (advanced forward) over several
weeks until the snoring and daytime sleepiness are reduced to an acceptable level, or the
patient cannot tolerate further advancement. They are worn during sleep and they act by
enlarging obstructed upper airway by moving the mandible and tongue anteriorly and then
the activation of airway dilator muscles. Craniofacial changes induced by OA were evaluated
using cephalometric analysis. Significant modifications were reported: Retroclination of the
maxillary incisors, proclination of the mandibular incisors, increased lower facial height, and
changes in molar relationship. Loss of edema, caused by snoring and repetitive apneas,
associating OAs seems to result in palatal length decrease and pharyngeal area increase. OAs
have some side effects: Dry mouth, excessive salivation, jaw discomfort, myofacial pain and
tooth grinding. However, they are frequently reported as mild, acceptable, and transient.
lower teeth and hold the mandible in an advanced position with respect to the resting position. The appliance is
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constructed, adjusted, and gradually titrated (advanced forward) over several weeks until the snoring and daytime
sleepiness are reduced to an acceptable level, or the patient cannot tolerate further advancement. They are worn
during sleep and they act by enlarging obstructed upper airway by moving the mandible and tongue anteriorly and
380 then
A Textbook of Advanced
the activation of Oral anddilator
airway Maxillofacial Surgery
muscles. Volume 2 changes induced by OA were evaluated using
Craniofacial
cephalometric analysis. Significant modifications were reported: Retroclination of the maxillary incisors, proclination
of the mandibular incisors, increased lower facial height, and changes in molar relationship. Loss of edema, caused
by snoring and repetitive apneas, associating OAs seems to result in palatal length decrease and pharyngeal area
Another inconvenience of OAs is the time needed for titration, which makes it a second choice
increase. OAs have some side effects: Dry mouth, excessive salivation, jaw discomfort, myofacial pain and tooth
for severe or high symptomatic OSA treatment. [58]
grinding. However, they are frequently reported as mild, acceptable, and transient. Another inconvenience of OAs is
the time needed for titration, which makes it a second choice for severe or high symptomatic OSA treatment. 58
The Academy of Dental Sleep Medicine suggested the use of cephalograms as a diagnostic aid
The Academy of Dental Sleep Medicine suggested the use of cephalograms as a diagnostic aid at the initial dental
at the initial dental examination of every patient receiving OA treatment. In addition, some
examination of every patient receiving OA treatment. In addition, some cephalometric predictors like longer maxilla,
shorter soft palate and decreased distance between mandibular plane and hyoid bone have been related to
cephalometric predictors like
successful MAD treatment of OSA.
4 longer maxilla, shorter soft palate and decreased distance
between

mandibular plane and hyoid bone have been related to successful MAD treatment of
OSA.

[4]

A B B B
Figure 11. A 27-year-old man with mild OSA: initial profile

view (A), and initial occlusal views (B). We can note a
Figure 11. A 27‐year‐old man with mild OSA: initial profile view (A), and initial occlusal views (B). We can note a

severe retrognathia compensated with a class I dental occlusion.
severe retrognathia compensated with a class I dental occlusion.

Figure 12. A MAD device was indicated for night.


Figure 13. Lateral Cephalograms before (left) and after (right) oral appliance positioning showing change in hyoid
bone position and slight enlargement of retroglossal area of pharynx

4.2. Surgical treatments of OSA
Surgical
bone management
position and slight was the first oftherapeutic
enlargement retroglossalmodality employed to treat SDB by placement of a tracheotomy
area of pharynx
bone position and slight enlargement of retroglossal area of pharynx
tube to bypass upper airway obstruction in Pickwickian patients. Currently, there are numerous surgical approaches

to upper airway treatment in OSA, which consist of upper airway tissue reduction or reconstruction at different
levels. OSA surgical management often involves several procedures that can be at times multi‐phased or a
Surgical management was the first therapeutic modality employed to treat SDB by placement of a tracheotomy
combination of multi‐level simultaneous surgeries. The selection of the most adequate surgery entails a meticulous
preoperative multidisciplinary assessment and rests on the surgeon’s experience. 59
tube to bypass upper airway obstruction in Pickwickian patients. Currently, there are numerous surgical approaches
to upper airway
OSA treatment
surgery in determined
should be OSA, which consist
after of diagnosis
clinical upper airway tissue reduction
and severity assessment or by reconstruction at It
objective testing. different
is
levels. recommended for patients who are medically and psychologically able to tolerate the operation ; primary surgery is
OSA surgical management often involves several procedures that can be at times multi‐phased or a
advocated in mild OSA and severe obstructing anatomy feasible to treat surgically such as tonsillar hypertrophy and
combination of multi‐level simultaneous surgeries. The selection of the most adequate surgery entails a meticulous
nasal obstruction; surgery is recommended secondarily in cases of ineffective treatment or intolerance to the other
preoperative multidisciplinary assessment and rests on the surgeon’s experience. 59
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Surgical management was the first therapeutic modality employed to treat SDB by placement
of a tracheotomy tube to bypass upper airway obstruction in Pickwickian patients. Currently,
there are numerous surgical approaches to upper airway treatment in OSA, which consist of
upper airway tissue reduction or reconstruction at different levels. OSA surgical management
often involves several procedures that can be at times multi-phased or a combination of multi-
level simultaneous surgeries. The selection of the most adequate surgery entails a meticulous
preoperative multidisciplinary assessment and rests on the surgeon’s experience. [59]
OSA surgery should be determined after clinical diagnosis and severity assessment by
objective testing. It is recommended for patients who are medically and psychologically able
to tolerate the operation ; primary surgery is advocated in mild OSA and severe obstructing
anatomy feasible to treat surgically such as tonsillar hypertrophy and nasal obstruction;
surgery is recommended secondarily in cases of ineffective treatment or intolerance to the
other non-invasive therapies in mild, moderate and severe OSA. Surgical treatment involves
evaluation of three anatomic sections of the airway for detection of collapse-related abnor‐
malities namely:
1. the nose (alar cartilage deformities, septal deviations, enlarged turbinates, nasal floor
constriction),
2. the retropalatal area (lymphoid hyperplasia, retrusive maxilla, long palate) and
3. the retroglossal area and the tongue (mandibular retrognathia).
Thus, surgical procedures can be classified as intra-pharyngeal or skeletal. Intra-pharyngeal

surgery includes all procedures directed towards soft tissues of upper airway, the most
common being uvulopalatopharyngoplasty (UPPP). Hard tissues surgery includes maxillo‐
mandibular advancement (MMA) (Figures 14-16) and genioglossus advancement (GGA)
(Figure 17)

A B

Figure 14: Profile views of a 34‐year‐old man with severe OSA. A: before treatment, B: after OSA management
Figure 14. Profile views of a 34-year-old man with severe OSA. A: before treatment, B: after OSA management includ‐
ing orthognathic surgery (mandibular advancement osteotomy)
including orthognathic surgery (mandibular advancement osteotomy)

A B
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382 A Textbook of Advanced Oral and Maxillofacial
A Surgery Volume 2 B



Figure
15. lateral cephalograms showing posterior airway space enlargement Before treatment (left) and after surgical
mandibular advancement (right)
Figure 15: lateral cephalograms showing posterior airway space enlargement
Figure 15: lateral cephalograms showing posterior airway space enlargement
Before treatment (left) and after surgical mandibular advancement (right)
Before treatment (left) and after surgical mandibular advancement (right)

Figure 16. PSG registration: before treatment (left) and after mandibular advancement and adenoidectomy (right).
Figure 16: PSG registration: before treatment (left) and after mandibular advancement and
adenoidectomy (right).
5.2.1. Sleep parameters evaluation for this clinical case
Sleep parameters evaluation for this clinical case:
Before treatment: total number of obstructive apnea events: 51, number of total hypopnea events: 30,
BeforeFigure 16: PSG registration: before treatment (left) and after mandibular advancement and
treatment: total number of obstructive apnea events:
AHI: 30/h, desaturation index: 27/h. BMI: 24 Kg/m 2 51, number of total hypopnea
(Severe OSA).
events: 30, AHI: 30/h, desaturation index: 27/h. BMI: 24 Kg/m 2
(Severe OSA).
After treatment: total number of obstructive apnea events: 22, total number of hypopnea events: 108,
adenoidectomy (right).
AHI: 22, desaturation index: 2/h, BMI: 25 Kg/m2. Moderate OSA.
After treatment: total number of obstructive apnea events: 22, total number of hypopnea
Sleep parameters evaluation for this clinical case:

events: 108, AHI: 22, desaturation index: 2/h, BMI: 25 Kg/m2. Moderate OSA.
Before treatment: total number of obstructive apnea events: 51, number of total hypopnea events: 30,

2
AHI: 30/h, desaturation index: 27/h. BMI: 24 Kg/m
Powell
et al. have created a two-phase directed protocol (Severe OSA).
(Powell-Riley surgical protocol) for

After treatment: total number of obstructive apnea events: 22, total number of hypopnea events: 108,
surgical treatment of upper airway obstruction at several levels in order to avoid unnecessary
2
surgery. Phase I surgery is designed essentially. Moderate OSA.
AHI: 22, desaturation index: 2/h, BMI: 25 Kg/m to treat the upper airway soft tissue (nose,

palate, and tongue base) without dental occlusion or facial skeleton modifications. Clinical
response is assessed, after adequate healing, four to six months following surgery by PSG.
Persistent OSA requires phase II surgery indications. Phase II surgery refers to maxilla-
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Figure 17. Genioglossus advancement technique. (A): rectangular osteotomy is created in the anterior mandible.
Figure 17. Genioglossus advancement technique. (A): rectangular osteotomy is created in the anterior mandible. (B) :
(B) : The genial tubercle and the attached genioglossus muscle are advanced anteriorly. The bony fragment is
The genial tubercle and the attached genioglossus muscle are advanced anteriorly. The bony fragment is rotated 90° to59
rotated 90° to overlap the inferior border of the mandible and secured to the mandible with a titanium screw.
overlap the inferior border of the mandible and secured to the mandible with a titanium screw. [59]
Powell et al. have created a two‐phase directed protocol (Powell‐Riley surgical protocol) for surgical treatment of
mandibular
upper advancement
airway obstruction osteotomy,
at several levels in which
order physically creates more
to avoid unnecessary space
surgery. forI the
Phase tongue,
surgery thus
is designed
enlarging the posterior airway space. [59]
essentially to treat the upper airway soft tissue (nose, palate, and tongue base) without dental occlusion or facial
skeleton modifications. Clinical response is assessed, after adequate healing, four to six months following surgery by
UPPP has been developed to alleviate isolated obstructing tissues of the soft palate, lateral
PSG. Persistent OSA requires phase II surgery indications. Phase II surgery refers to maxilla‐mandibular advancement
osteotomy, which physically creates more space for the tongue, thus enlarging the posterior airway space. 59
pharyngeal walls, and tonsils. However, according to ACP, it does not reliably normalize AHI
UPPP has been developed to alleviate isolated obstructing tissues of the soft palate, lateral pharyngeal walls, and
when treating moderate to severe OSA, as a sole procedure. Furthermore, with regards to
tonsils. However, according to ACP, it does not reliably normalize AHI when treating moderate to severe OSA, as a
MMA, there is a need for more understanding of the relative risks and benefits of MMA
sole procedure. Furthermore, with regards to MMA, there is a need for more understanding of the relative risks and
benefits of MMA compared to other treatment modalities. CPAP or OAs should generally be suggested ahead of
compared to other treatment modalities. CPAP or OAs should generally be suggested ahead
MMA if the patient is consenting. These recommendations do not corroborate with other findings having reported a
of MMA
success rate ifof the
89% patient isby
obtained consenting. These recommendations
physically expanding do not and
the facial skeletal framework corroborate
increasing with
tissue other
tension,
findings having reported a success rate of 89% obtained by physically expanding the facial
53,61
which decreases velopharyngeal and suprahyoid musculature collapsibility.

skeletal framework and increasing tissue tension, which decreases velopharyngeal and
Complications of maxilla‐mandibular advancement surgery have been reported, including side effects such as
suprahyoid
neurosensory deficit, musculature collapsibility.
infection, [53, 61]
bleeding, or temporomandibular joint problems; but patients’ satisfaction is
reported to be as high as 95%. Finally, long‐term stability depends on the body mass index, the amount of skeletal
Complications of maxilla-mandibular advancement
advancement, and the skill and experience of the surgeon .
60, 61
surgery have been reported, including
side effects such as neurosensory deficit, infection, bleeding, or temporomandibular joint
The palatal implant is a new treatment option for snoring that emerged in 2003. It is composed of polyethylene
terephthalate, a biocompatible material, and inserted into the soft palate to reduce vibration and collapsibility by
problems; but patients’ satisfaction is reported to be as high as 95%. Finally, long-term stability
stiffening the soft palate, thus reducing palatal flutter and snoring. Additional stiffening of the palate is achieved by
depends on the body mass index, the amount of skeletal advancement, and the skill and
fibrosis and formation of capsule in response to the inflammatory reaction. Studies have showed that they may be
experience
effective of the
in some surgeon.[60,
patients with mild 61]
obstructive sleep apnea, who cannot tolerate or do not adhere to positive
airway pressure therapy, or in whom oral appliances have been considered and found to be ineffective or
The palatal implant is a new treatment option for snoring that emerged in 2003. It is composed
undesirable. However, at the present time, it is difficult to predict if it will be a reliably effective intervention or not.
55, 59, 62

of polyethylene terephthalate, a biocompatible material, and inserted into the soft palate to
4.3. Adjunctive treatment:
reduce4.3.1. vibration and collapsibility by stiffening the soft palate, thus reducing palatal flutter
Pharmacological therapy
and snoring.
A wide range Additional stiffening
of medication of the
targeting OSA palate is achieved
treatment has been by explored
fibrosis and formation
in the literature. of capsule
Except for
in response to the inflammatory reaction. Studies have showed that they may be effective
hypothyroidism or acromegaly in which medication can improve AHI, there are no really in
effective
pharmacotherapies for OSA. Topical nasal corticosteroids can be used in patients with OSA and concomitant rhinitis
some patients with mild obstructive sleep apnea, who cannot tolerate or do not adhere
especially in children, and thus may be a useful adjunct to primary therapies for OSA. In addition, Modafinil, a to
positive airway pressure therapy, or in whom oral appliances have been considered and found
psychostimulant, is recommended for the treatment of residual excessive daytime sleepiness despite effective PAP
44,63
to be ineffective or undesirable. However, at the present time,
treatment and absence of other evident causes for their sleepiness. it is difficult to predict if it will
A Cochrane review issued in 2013 showed insufficient evidence to recommend any systemic pharmacological
be a reliably effective intervention or not. [55, 59, 62]
treatment for OSA; drug therapy needs to be targeted depending on the presence or absence of obesity and the
predominance of OSA in a particular sleep stage. The review also reported that among all drugs evaluated, Donepezil
is the most promising for further research. 64
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5.3. Adjunctive treatment
5.3.1. Pharmacological therapy
A wide range of medication targeting OSA treatment has been explored in the literature. Except
for hypothyroidism or acromegaly in which medication can improve AHI, there are no really
effective pharmacotherapies for OSA. Topical nasal corticosteroids can be used in patients with
OSA and concomitant rhinitis especially in children, and thus may be a useful adjunct to
primary therapies for OSA. In addition, Modafinil, a psychostimulant, is recommended for
the treatment of residual excessive daytime sleepiness despite effective PAP treatment and
absence of other evident causes for their sleepiness. [44, 63]
A Cochrane review issued in 2013 showed insufficient evidence to recommend any systemic
pharmacological treatment for OSA; drug therapy needs to be targeted depending on the
presence or absence of obesity and the predominance of OSA in a particular sleep stage. The
review also reported that among all drugs evaluated, Donepezil is the most promising for
further research. [64]
5.3.2. Bariatric surgery
Bariatric surgery consists of a variety of operative techniques performed to promote weight

reduction such reducing gastric banding, gastric and jujenoileal bypass or gastroplasty. It is
often recommended for treatment of morbid obesity, particularly when associated with other
medical complications (BMI ≥ 35 kg/m2) or those with a BMI ≥ 35 kg/m2 when dietary efforts
fail at weight control. Therefore women seem likely to be candidates for this method of weight
loss. [44, 65]
6. Obstructive sleep apnea syndrome in orthodontic practice
As cited above, OSA is associated with numerous craniofacial abnormalities. Orthodontics

improvement of dento-facial morphology may have a positive impact on OSA components.
Orthodontic professionals should provide treatment for OSA patients as well as diagnose
potential OSA patients. Medical history and clinical examination allows orthodontists to
identify the risk factors of OSA or signs related to OSA (obesity, allergy, nasal dysfunction,
maxillary constriction, retrognathia, long uvula, mouth breathing...) or record some symptoms
reported by patients. Moreover, several imaging modalities (lateral and frontal cephalogram,
cone beam computed tomography, MRI.) can assist Orthodontic professionals in assessment
of this condition.
Orthodontic management of OSA syndrome could be provided to children as a preventive

and interceptive modal or to adults by an interdisciplinary management. A significant number
of children suffering from respiratory problems and obstructive sleep apnea have nasal
obstruction associated with a narrow maxilla that may increase nasal resistance and alter the
tongue posture, leading to a narrowing of the retroglossal airway and OSA. Maxillary
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expansion with orthopedic appliances is very effective in these cases allowing for an increase
of nasal cavity dimension. It can be combined with adenotonsillectomy for best results in
children with OSA associated with adenotonsillar hypertrophy. [4, 66, 67] Among adults, this
expansion can be attained by RME or surgically assisted RME and has been reported to reduce
snoring and hyper-somnolence.
Maxillomandibular advancement can also be provided either by surgery or orthopedic
systems as therapeutic or preventive measure in OSA cases. A good finishing of dental
occlusion is desirable. On the other hand, It has been suggested [68] that the improve‐
ment observed in the respiratory symptoms with surgical MMA, namely apnea/hypopnea
episodes, should be correlated with SNA increase after surgery which may help maxillofa‐
cial surgeons establish selective criteria for the surgical approach to sleep apnea syn‐
drome patients. Mandibular advancement in case of retrognathia can be accomplished by
oral appliances in adulthood, functional appliance therapy in younger patients, mandibu‐
lar distraction osteogenesis or osteotomies, and is among the most frequently used
approaches in OSA management.
Orthodontists can also have a role in the treatment of OSA consequences especially those with
nocturnal bruxism, which differs from stress-related bruxism. Sleep bruxism has been shown
to be prevalent in children, and correlated with sleep disturbances (microarousals). It is
characterized by rhythmic masticatory muscle activity and may be related to the patients’
attempt to improve airway patency during episodes of oxygen desaturation via co-activation
of jaw opening and closing muscles. Its management requires use of night splints and restor‐
ative dentistry.
In brief, although the bi-directional cause and effect relationship between OSA and
craniofacial abnormalities remains to be proven, early identification and treatment of dento-
facial disorders may enhance OSA management with respect to preventive and curative
approaches. Interdisciplinary professional communication is crucial for the success of global
OSA management.
7. Conclusion
OSA is a common breathing disorder, which affects all age groups. It is a serious public health
problem. Because of its potential pathophysiological consequences, it associates alteration of
quality of life, decreased economic potential and increased morbidity and mortality in affected
patients. Assessment of OSA requires a thorough clinical examination as well as overnight
testing to determine PSA presence and severity before initiating treatment. Polysomnography
remains the most common and reliable test for OSA diagnosis. Additionally, several imaging
modalities can be used for upper airway structure and function during wakefulness and sleep.
Treatment modalities of OSA are aimed at increasing life expectancy, decreasing disease
problems and improving the quality of life. CPAP is still the mainstay for treatment of
moderate to severe OSA. However, medical or surgical alternatives can be used in case of
failure or non-compliance of the patients.
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OSA is also a condition that orthodontists may encounter in their daily practice; thus, they
are in a better position to diagnose and treat it using a multidisciplinary approach and
management.
Author details
Hakima Aghoutan1*, Sana Alami1, Samir Diouny2 and Farid Bourzgui1
*Address all correspondence to: hakimadental@yahoo.fr
1 Department of Dento-facial Orthopedics, Faculty of Dental Medicine. Hassan II Ain Chok

University. Casablanca, Morocco
2 Chouaib Doukkali University, Faculty of Letters and Human Sciences, El Jadida, Morocco
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Chapter 10
Advanced Adjunct Orthosurgical Esthetic Prodedures
Seied Omid Keyhan, Seifollah Hemmat,

Peyman Mehriar, Arash Khojasteh and
Mohammad Ali Asayesh
http://dx.doi.org/10.5772/59088
1. Introduction
Changes in the esthetic appearance of the face is highly depended on the bony structures of
the facial skeleton, including the malar-midface region, nose, and chin. Alterations of soft tissue
and skin alone will not satisfy all of our aesthetic demands. Multiple factors such as skin
(texture, color, thickness and...), soft tissue (symmetry, composition, location and...) and facial
bony contours (size, shape, location, symmetry and...) contributes to creating esthetically
appealing appearance of the face.
Since many years ago numerous surgical and office based techniques have been introduce to
augment, reduce or refine the most projected points of the face such as cheek, chin, nose, Para-
nasal area, angle of the jaw..According to the literature the techniques can be classified to: 1)
Office based or non-invasive techniques; such as fillers injection, facial lipostructure or facial
liposuction which modified the soft tissue coverage of the facial skeleton.2) Facial prosthesis.
3) Maxillofacial osteotomies. Based on our knowledge the first and second group have been
considered more in the literatures and text book of the Oral and Maxillofacial Surgery (OMFS)
or Plastic Surgery, it is perhaps related to the more complications of the osteotomy techniques
or easiness of the office –based one. OMFS are familiar with orthognatic surgeries and their
skill in this field can help them to plan the third one,especially in cases whom the long term
results should be considered. In current chapter we reviewed the esthetic osteotomy techni‐
ques of the facial skeleton and introduce a surgical techniques for management of the most
projected points of the face namely:
• Chin modification
Reduction genioplasty
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• Paranasal modification
Piriform augmentation osteotomies
• Mandibular Angle modification
Angle augmentation osteotomies
Angle reduction oeteotomies

• Malar modification
Malar augmentation osteotomies
Malar reduction osteotomies

• Forehead modification
Frontal Bossing reduction techniques
2. Chin modification
The creation or restoration of an esthetically pleasing facial contour can encompass many
surgical approaches. Several surgical techniques are available for correcting and giving
harmony to the lower third of the face.[1] In this respect, some well-known techniques seek to
correct the shape and size of the chin using different kinds of chin implants or osteotomies in
an effort to move it and change its spatial location, thus determining a new facial contour.
2.1. Augmentation genioplasty
Genioplasty (anterior horizontal mandibular osteotomy) means a plastic procedure on the chin
that involves both bony components (ie, anterior portion of the base of the mandible) and the
soft tissue component.The procedure can be performed either alone or as an adjunct to other
orthognathic and facial plastic surgeries. Either direct osteoplasty and soft tissue correction or
implantation of an alloplastic material/cartilage/bone has been recommended for genioplasty.
Since 1942, with first sliding advancement genioplasty that was described by Hofer, various
genioplasty techniques with various indications, advantages, and disadvantages have been
developed for correction of microgenia and macrogenia. In recent chapter we did not focused
on augmentation genioplasty techniques.The readers can update their knowledge by review‐
ing the other chapters or books.
2.2. Reduction genioplasty
In the event of anterior mandibular bony excess different surgical approaches can be used.
Each have their own limitations and disadvantages. For instance simple burring down removal
of bony excess from anterior mandible through an intraoperative approach will usually result
in an abnormal appearance and is not the best choice of treatment.
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Reduction genioplasty surgical procedure results in narrowing or shortening of the chin.

However, the literature lacks data about the best technique, indications, complications, and
long-term results. The soft tissue envelope of the chin area usually follows the genial osseous
movement approximately 90% or more, but the predictability ratio of horizontal reduction
genioplasty is limited; it follows approximately 50% to 60%.[1]
Reduction genioplasty surgical procedure results in narrowing or shortening of the chin. However, the
literature lacks data about the best technique, indications, complications, and long-term results.
The soft tissue envelope of the chin area usually follows the genial osseous movement
approximately 90% or more, but the predictability ratio of horizontal reduction genioplasty is
limited; it follows approximately 50% to 60%.1
Figure 1. reduction genioplasty technique described by Ukan and park.

+
Figure 1. reduction genioplasty technique described by Ukan and park.
Figure 2. Horizontal T genioplasty and modified reduction genioplasty techniques.

Figure 2. Horizontal T genioplasty and modified reduction genioplasty techniques.
To date, only 2 articles have been published about the narrowing of the chin by use of this
To date, only 2 articles have been published about the narrowing of the chin by use of this
technique.Minor step-off at the chin-mandible junction and mild transient numbness of the lower
technique.Minor step-off at the chin-mandible junction and mild transient numbness of the
lip, jowls, and bunching of the chin were reported as the most common complications of this
lower lip, jowls, and bunching of the chin were reported as the most common complications
technique. Because the lingual muscle is released, there is a risk of avascular necrosis of the
of this technique. Because the lingual muscle is released, there is a risk of avascular necrosis
distal segments, and the chin prominence should be minimally degloved to prevent this
complication. Furthermore, because the mid-symphysis area is removed, the chance of
asymmetry or unesthetic results could be increased(fig.1).1 another techniques such as horizontal
T osteotomy were also described but is not used widely(fig.2).10,46In 2013 we described1,47 a
novel technique to reduce the prominent chin 3-dimentionally(fig.3).This new genioplasty
(Zigzag genioplasty) makes it possible to decrease the vertical and transverse dimension of the
chin alone or simultaneously, symmetrically or asymmetrically. This genioplasty alsomakesit
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of the distal segments, and the chin prominence should be minimally degloved to prevent this
complication. Furthermore, because the mid-symphysis area is removed, the chance of
asymmetry or unesthetic results could be increased(fig.1).[1] another techniques such as
horizontal T osteotomy were also described but is not used widely(fig.2).[10, 46]In 2013 we
described[1, 47] a novel technique to reduce the prominent chin 3-dimentionally(fig.3).This
new genioplasty (Zigzag genioplasty) makes it possible to decrease the vertical and transverse
dimension of the chin alone or simultaneously, symmetrically or asymmetrically. This
genioplasty alsomakesit possible to decrease the mental sagittal projection,if indicated, and
simultaneously reduce the mandibular body height. Zigzag genioplasty allows one to properly
correct excess of the chin(3-dimensionally), avoiding the need for muscular repositioning
(except sometimes in types III and IV)(fig.4).A simple geometric calculation allows one to
mobilize the chin in a vertical, horizontal, and sagittal direction,according to the needs of each
patient. Furthermore, this design preserves the suprahyoid muscle attachmentsand the most
important anatomic portion of symphysis area; narrowing the wide chin by this technique
provides an esthetic and natural facial look.[1, 47]
Figure 3. Zigzag osteotomy design is based on the displacement of 2 bone fragments on the slopes of an inclined plane
with a superior-medial direction. The degree of inclination for these slopes (the α and β- angles) will be estimated pre-
surgically according to ; the extent of the vertical and transverse displacement wanted for a given case, mandibular
symphysis height and width, the size of remained bone fragments after ostectomy, the need for conventional or ex‐
tended (to the mandibular body) reduction, the position of anterior mandibular teeth apices, the position of mental
foramina and symmetrical or asymmetrical reduction.The posterior edges of the osteotomy, either could be finished
just beneath the mental foramina (obtuse degree of inclination) or extended to the Anti-Gonial notch(acute degree of
inclination),especially in such cases that, simultaneous reduction of inferior mandibular body osteotomy must be done,
also. The amount of β-angle must be equal bilaterally except in asymmetrical cases.The anterior edge of the osteotomy
which is extended medially from canine root apices (with a distance of 5 mm) to the mid-symphysis area, either could
be extended above the inferior border(especially; in such cases which simultaneous advancement or set back should be
done) or beyond it.As the same manner to posterior edge, the degree of inclination in the anterior part (the α-angle)
could be determined pre-surgically,and must be equal in both sides except in asymmetrical cases.[from Keyhan et al.
Zigzag genioplasty: a new technique for 3-dimensional reduction genioplasty. Br J Oral Maxillofac Surg.2013]
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Figure 4. Schematic views of osteotomy design modifications of zigzag genioplasty technique (type I-VII). The anterior
edge of the osteotomy could either be extended above the inferior border or beyond it. The posterior edges of the os‐
teotomy, could either be finished just beneath the mental foramina or extended up to the Anti-Gonial notch. For pure
chin narrowing with minimal reduction in vertical dimension, bone removal just near the strut of bone in the middle
should be done, and if vertical reduction is planned as well, bone strips should be removed above both posterior and
anterior slobs. [from keyhan et.al. Zigzag genioplasty; patients evaluation, technique modifications and review of the
literature. Br J oral amxillofac surg.2013] Figure reprinted with permission from The Br J oral amxillofac surg.
www.dentalbooks.co
Figure 5. A simple geometric calculation allows one to mobilize the chin in a vertical, horizontal andsagittal direction,
according to the needs of each patient the design of the planed osteotomy can be trace on the tracing paper and a sur‐
gical guide can be made simply.
Figure 6. A 29 years old man who underwent zigzag genioplasty(type III) in combination with rhinoplasty,buccal fat
pad lifting[48],malar prosthesis and paranasal augmentation.a,b,c,d) Incision of the oral mucosa was performed 5 to 7
mm labial to the depth of the vestibule and directed horizontally. Then, the muco-periosteal flap was released, and the
mental nerve was exposed. The chin prominence was degloved, and the lingual muscle attachments were maintained
for blood supply. The osteotomy sites (type III) were marked with a surgical marker and the ostectomy was done with
reciprocal saw and fissure bur In the next step, bone strips were removed bilaterally and the osteotomy was continued
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bilaterally, after down-fracturing, the interferences were removed,with high accuracy in maintain lingual pedicle tis‐
sues, detached supra-hyoids muscles was secured to the bone strut and medial and superior displacement was per‐
formed with the traction of two 10 centimeter wires.e) 2 L-shape miniplates were used for fixation.Any bone
irregularity could be removed with round bur although, most often they could be remodeled post operatively. Vestib‐
ular incision was closed with 3-0 vicryl sutures.f,g)pre-operative views.h,i)post-operative views, simultaneous rhino‐
plasty and malar and para-nasal augmentation were performed also. [from keyhan et.al. Zigzag genioplasty ;patients
evaluation,technique modifications and review of the literature. Am J Cosmetic surg,2013].Figure reprinted with per‐
mission from The American Journal of Cosmetic Surgery.
3. Paranasal modification
Clinical evaluation: There is no specific soft tissue or skeletal cephalometric landmark(s) or

values to quantify the “fullness” of this region, so deficiency assessment of para-alar region is
mainly based on qualitative profile judgment.[64]
Surgical technique: After general anesthésia and flap incision and elevation the osteotomy is
done 2cm above the nasal floor from one side to another side To allow adequate mobilization
the junction between septum and bony segment should be cut this can be done by a osteotomy.
)
Figure 7. U-7:U‐
Figure shapedshaped
osteotomy osteotomy
of piriform aperture. [from Hernańdez-Alfaro
of piriform aperture. F, Garcıa
[from E, Martı C, Porta A. U-shaped
Hernańdez‐Alfaro F,
osteotomy in management of paranasal deficiency. Int. J. Oral Maxillofac. Surg. 2006]
Garcıa E, Martı C, Porta A. U‐shaped osteotomy in management of paranasal
deficiency. Int. J. Oral Maxillofac. Surg. 2006]
4. Angle modification

Caucasians consider a prominent mandibular angle to be unappealing in their populations,
and mandibular angle ostectomy has been popular since Baek et al. introduced it in 1989.[66]
Standard procedure to correct prominent mandibular angles is mandibular angle ostectomy
with anoscillating saw through the intraoral approach, although a number of modifications
4. ANGLE MODIFICATION
and improvements in operative techniques have been reported in the last two decades.[68,
69]Kim et al.[70]
Caucasians classified
consider all the mandibular
a prominent patients with prominent
angle mandibular angle
to be unappealing according
in their to
populations, and
mandibular angle shape into four classes (I, II, III, and IV).[70] 66
mandibular angle ostectomy has been popular since Baek et al. introduced it in 1989. Standard
procedure to correct prominent mandibular angles is mandibular angle ostectomy with anoscillating
saw through the intraoral approach, although a number of modifications and improvements in
operative techniques have been reported in the last two decades.68,69Kim et al.70 classified all the
patients with prominent mandibular angle according to mandibular angle shape into four classes (I,
II, III, and IV).70
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Figure 8:Preoperative evaluation and planning for mandibular angle reshaping. [from Hirohi
Figure 8. Preoperative evaluation and planning for mandibular angle reshaping. [from Hirohi et al. Lower face reduc‐
et al.
tion with Lower face
full-thickness reduction withoffull-thickness
marginalostectomy marginalostectomy
mandibular corpus-angle followed byofcorticectomy.
mandibular J corpus-
Plast Reconstr
angle2010.]
Aesth Surg. followed by corticectomy. J Plast Reconstr Aesth Surg. 2010.]

Surgical technique: Firstly, the ostectomy of the marginal part of the mandibular corpus-
Clinical evaluation: For patients analysis it is important to consider the plans for correcting
angle was performed, then corticectomy after evaluating the thickness of the resected bone
the lateral and
fragment frontal appearances
Mandibular corticectomy of the
was lower face
performed to separately, because
improve the frontal the ideal66 correction
appearance. After
require two surgical techniques.
designing the ostectomy line with a pencil, a groove was hollowed out on the lateral cortex using a
66
round burr.
Surgical technique: Firstly, the ostectomy of the marginal part of the mandibular corpus-angle
was performed, then corticectomy after evaluating the thickness of the resected bone fragment
Mandibular corticectomy was performed to improve the frontal appearance.[66] After
designing the ostectomy line with a pencil, a groove was hollowed out on the lateral cortex
using a round burr. [66]
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Figure 9. Operative procedures for en-bloc mandibular corpus-angle ostectomy (MCAO) with a contra-angle hand‐
piece. [from Hirohi et al. Lower face reduction with full-thickness marginalostectomy of mandibular corpus-angle fol‐
lowed by corticectomy. J Plast Reconstr Aesth Surg. 2010.]
Figure 10:schematic view of sites of corticectomy and ostectomy.

Figure 10. schematic view of sites of corticectomy and ostectomy.

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Figure 11:A 28 year-old woman with a muscular and square face desired mandibular
reshaping and underwent mandibular corpus-angle ostectomy and corticectomy. The
Figure 11. A 28 year-old womanfrontal
postoperative with aview
muscular andthe
shows that square
width face desired
of his mandibular
lower face reshaping
was greatly reduced byand underwent man‐
dibular corpus-angleostectomy
ostectomy and corticectomy. The postoperative frontal view shows that the width of his lower
and corticectomy.

face was greatly reduced by ostectomy and corticectomy.
4-1-Reduction malarplasty
Reduction body malarplasty (RBM) can be done for patients with a hyperplastic anterior mid-
4.1. Reduction malarplasty
face. Reduction body and arch malarplasty (RBAM) is suited for patient with a hyperplastic
anterior and posterior midface which will soften their square and wide facial
appearance.90,94,95
Reduction body malarplasty (RBM) can be done for patients with a hyperplastic anterior
mid-face. Reduction body and arch malarplasty (RBAM) is suited for patient with a
hyperplastic anterior and posterior midface which will soften their square and wide facial
appearance.[90, 94, 95]
Surgical techniques: since many years ago numerous surgical technique have been introduce
to reduce the prominent malar.which some of these techniques are discussed here.
Zygoma shaving procedure: After intra oral flap elevation the entire zygomatic body and arch
is exposed and subperiosteal dissection is carried out. [89] The most prominent portion of the
zygoma, including part of the zygomatic arch, is shaved using a broad chisel or a bone bur. [89]
I-shaped osteotomy: Using a reciprocating saw, 2 parallel cuts are made on the zygomatic
body from inner cortex toward the outer cortex resembling an I shape. [89] Then, the zygoma
and the zygomatic arch complex are displaced antero-medially.
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Figure 12. A 38 year-old oriental woman with severe malar prominence. wide faces due to a prominent zygoma are
considered unsightly. frontal (left) and oblique (right) views.[from Zou C, et al. midface contour change after reduction
malarplasty with modified L-shaped osteotomy: a surgical outcomes study. Aesthetic plast surg.2014]
FIGURE 13. Illustration of zygomatic shaving procedure. Note the shaving area involved the
zygoma and the anterior part of zygomatic arch.
Figure 13. Illustration of zygomatic

I-shaped osteotomy: shaving
Using procedure. Note
a reciprocating saw, the shavingcuts
2 parallel areaare
involved
made onthethe
zygoma and the anterior
zygomatic
89
part of zygomatic arch. inner cortex toward the outer cortex resembling an I shape.
body from Then, the zygoma
and the zygomatic arch complex are displaced antero-medially .
FIGURE 14. Illustration of I-shaped osteotomy.

Figure 14. Illustration of I-shaped osteotomy.
L-shaped osteotomy: This technique is similar to I-shaped osteotomy which can be

considered in special cases.
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FIGURE 15.Illustrationof L-shaped osteotomy.

C-shaped osteotomy The main difference of this technique with L-shaped osteotomy is in
the oblique part of the osteotomy line; the oblique line is moved more toward the external
orbital rims in comparison with the L-shaped osteotomy and consists of 2 parallel lines unlike
L-shaped osteotomy in which we have only 1 line of osteotomy. 89
FIGURE 15.Illustrationof L-shaped osteotomy.
Figure 15. Illustrationof L-shaped osteotomy.
C-shaped osteotomy The main difference of this technique with L-shaped osteotomy is in
the oblique part of the osteotomy line; the oblique line is moved more toward the external
orbital rims in comparison with the L-shaped osteotomy and consists of 2 parallel lines unlike
L-shaped osteotomy in which we have only 1 line of osteotomy. 89
FIGURE 16. Illustration of C-shaped osteotomy.

Figure 16. Illustration of C-shaped osteotomy.
L-shaped osteotomy: This technique is similar to I-shaped osteotomy which can be considered
in special cases.
FIGURE 16. Illustration of C-shaped osteotomy.
C-shaped osteotomy The main difference of this technique with L-shaped osteotomy is in the
oblique part of the osteotomy line; the oblique line is moved more toward the external orbital
rims in comparison with the L-shaped osteotomy and consists of 2 parallel lines unlike L-
shaped osteotomy in which we have only 1 line of osteotomy. [89]
Modified L-shaped Osteotomy: The modified L-shaped osteotomy differed from the original
method mainly in that the two parallel osteotomy lines are made vertically so that the
zygomatic body and arch can be shifted (Fig. 17).
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FIGURE 17.A. Kim’s L-shaped osteotomy. B. The original L-shaped osteotomy. C. The
modified L-shaped osteotomy.[fromNakanishi Y, et al. The boomerang osteotomy - A new
method of reduction malarplasty . 2012]
Figure 17. A. Kim’s L-shaped osteotomy. B. The original L-shaped osteotomy. C. The modified L-shaped osteotomy.
[fromNakanishi Y, et al. The boomerang osteotomy - A new method of reduction malarplasty. 2012]
Figure 18. (Left Above) Location of the most prominent part of the zygoma body (red point) (Right Above) Incision of
the Boomerang Osteotomy (Left Below) Mobilization of the bone (Right Below) The complex of the zygoma body and
zygomatic arch is shifted medially.
Figure 19. With Kim’s method, the zygomatic arch shifts upward as the rotation for subtle
adjustment. The vertical height of the zygomatic arch presents no change with boomerang
Figure 19. With Kim’s method, the zygomatic arch shifts upward as the rotation for subtle adjustment. The vertical
method.
height of the zygomatic arch presents no change with boomerang method.
Horizontal v-shaped osteotomy : this technique is similar to L-shaped osteotomy .
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Horizontal v-shaped osteotomy : this technique is similar to L-shaped osteotomy.
Figure 20. Horizontal V-shaped osteotomy used to correct protrusion of the zygoma and zygomatic arch. Not that the
free part of the root of the zygomatic arch was locked into the gap between the rigid part and the temporal bone as a
mortice and tenon structure.[fromTang K, et al. New horizontal v-shaped osteotomy for correction of protrusion of the
zygoma and the zygomatic arch in East Asiansindication and results. Br J Oral Maxillofac Surg. 2014]
Figure 21. Preoperative views of the same patient (a, c). Postoperative views after an L-shaped malar osteotomy and
repositioning and mandibular reduction (b, d).[fromChen T, et al. correction of zygoma and zygomatic arch protrusion
in east Asian individuals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2011].
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4.2. Aumentation malarplasty
Clinical evaluation: Oval shaped face with the key component of malar prominence is
considered to be a sign of beauty and youth in Caucasians. [73] Many tricks using artificial
highlighting and darkening are developed by makeup artists to accentuate the malar promi‐
nence. [73] Flattened cheeks and narrow face makes people look sad and prematurely aged.
[73] This transverse midface deficiency can be addressed by widening the bimalar width.[73]
Hinderer[100] From the frontal view, draw a line from the lateral commissure of the lip to the lateral canthus
of the ipsilateral eye and another line from the tragus to the inferior edge of the nasal ala. The
area posterior and superior to the junction of these two projections should be the most
prominent area of the malar eminence. (Fig. 12a) [100]
Powell et al[77] Draw a vertical line through the middle of the face, then bisect the segment between the nasion
and the nasal tip with a line that curves gently upward to the tragus on both sides. Draw a line
from the inferior ala to the lateral canthus and another one, parallel to this one, from the lateral
oral commissure toward the ear. The intersection of the curvilinear horizontal line and the line
from the oral commissure marks the point where the malar area should be most prominent.
(Fig. 12b) [77]
Silver and Guilden[101] If the malar prominence in the true lateral projection is >5 mm posterior to the nasolabial
groove, then a deficiency in the malar area exists. Silver describes the malar prominence
triangle. [101] To create this triangle, draw a Frankfort horizontal line across the face in frontal
projection and a parallel line that bisects the upper lip. Then draw a perpendicular line
through both of these lines and through the lateral canthus. The intersection of the vertical line
and the line through the upper lip defines point A.[101] Create a line from point A though the
medial canthus and then a second line from point A toward the temporal area-but at the same
angle from the vertical that was created by the projection from point A through the medial
canthus. This creates the malar prominence triangle with the base being the Frankfort
horizontal and the apex being point A. Silver advises that the implant should be placed several
millimeters below the Frankfort line. (Fig. 12c)[101]
Wilkinson[102] The ideal high points as he has suggested is at or just lateral to the outer canthus of the eye on
a point a distant of approximately one-third from the lateral canthus to the inferior border of
the mandible. (Fig.12d)[102]
Schoenrock[103] On an oblique view (27 to 35 degrees of rotation from the frontal view) in natural head
position,A line from themost lateral point of the malar complex intersected at 90° the
commissure-canthus line at 66% of its lengthand The length of thisline was 17% the length of
the commissure-canthus line. (Fig. 13)[103]
Table 1. Analyses of malar projection
Malar recontouring involves not only the zygomatic region, but also the infraorbital,paranas‐
al, and buccal regions. Furthermore, imperfections of other facial areas may reflect negatively
on the malar region. The buccal region should be slightly concave or flat in adults,within the
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Figure 22.analyses of malar projection. a, hinderer analysis. b, pwell et al analysis. c, Silver and
Figure 22. Analyses of malar projection. a, hinderer analysis. b, pwell et al analysis. c, Silver and Guilden. d, Wilkinson
Guilden. d, Wilkinson analysis.
analysis.
confines
Malarof recontouring
a tangent from the cheekbone
involves not only thetozygomatic
the mandibular angle.
region, but also Fullness in the buccal region
the infraorbital,paranasal,
can give
and the illusion
buccal of Furthermore,
regions. a poorly developed malar
imperfections eminence.
of other In these
facial areas maypatients, partial excision
reflect negatively on
of thethebuccal
malar fat
region.
pad The
maybuccal region should be
be indicated.[104] slightly concave
Shadowing in theorconcavity
flat in adults,within
of the buccalthe area
confines of a tangent from the cheekbone to the mandibular angle. Fullness in the buccal region
highlights the malar eminence, giving it a sculptured, well-defined look. Caucasian women
can give the illusion of a poorly developed malar eminence. In these patients, partial excision of
tend to accentuate this effect by using makeup, whereas Asians prefer much softer contours.
the buccal fat pad may be indicated.104 Shadowing in the concavity of the buccal area highlights
But excessive buccal hollowness results
the malar eminence, giving it a sculptured, in an emaciated,
well-definedgaunt
look. appearance
Caucasian women with exaggerated
tend to
malaraccentuate
definition. Excessive width and prominence of the mandibular
this effect by using makeup, whereas Asians prefer much softer contours. angle and masseter
But
muscles makebuccal
excessive the malar eminence
hollowness resultslook
in ansmall and give
emaciated, gauntthe face a square
appearance or triangular
with exaggerated malarshape.
Reduction of the
definition. mandibular
Excessive angle
width and and masseter
prominence muscles might
of the mandibular be more
angle and adequate
masseter musclesthan
makemalar
augmentation. The malar eminence is also examined relative to the periorbital
the malar eminence look small and give the face a square or triangular shape. Reduction of the region. A high
and prominent malaand
mandibular angle eminence
masseterenhances the appearance
muscles might be more adequateof the beautiful
than eye. Fullness
malar augmentation. Theof the
area 10 mmeminence
malar lateral and 15–20
is also mm inferior
examined relativetotothe
thelateral canthus
periorbital should
region. A highbeand
obvious. (Fig.
prominent 21)[105]
mala
eminence enhances the appearance of the beautiful eye. Fullness of the area 10 mm lateral and
15–20 mm inferior to the lateral canthus should be obvious. (Fig. 21)105
Figure 23. Schoenrock analysis of malar projection in oblique view. (ME): malar eminence.
Surgical thechniques:
Zygomatic arch osteotomy: A subperiosteal flap is raised to expose the ascending malar
buttress and the zygomaticomaxillary suture. The position of an oblique sagittal cut is selected
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http://dx.doi.org/10.5772/59088
by deciding whether augmentation should include any of the anterior buttress or whether it
should be totally lateral to zygomaticomaxillary suture line. The cut is then made with a sagittal
reciprocating saw starting from the inferior portion of the zygomaticomaxilary suture to the
notch of both lateral orbital rim and malar zygomatic process. A previously selected graft may
now be placed between the two segments. The result is an increase in interarch width (zygion-
zygion).(Fig 22)
Figure 24. Surgical steps of zygomaticarch osteotomy.
Zygomatic sandwich osteotomy (ZSO): To solve some problems, modifications of zygomatic

arch osteotomy technique have been presented. Mommaerts et al [81]modified Powell’s
technique by connecting a vertical with a semihorizontal osteotomy which both transect the
maxillary sinus, thereby maximizing anterior as well as lateral augmentation.
Figure 25. Comparison of zygomatic arch osteotomy (Powell et al) and zygomatic sandwich osteotomy (Mommaerts et
al).(A) difference in design (zygomatic arch osteotomy [ZAO] = horizontal lines; zygomatic sandwich osteotomy [ZSO]
= verticallines). (B) amount of augmentation, caudal view (x = lateral displacement with ZAO; x’ = lateral displacement
with ZSO; y =anterior displacement with ZAO; y’ = anterior displacement with ZSO).
horizontal lines; zygomatic sandwich osteotomy [ZSO] = verticallines). (B) amount of
augmentation, caudal view (x =www.dentalbooks.co
lateral displacement with ZAO; x’ = lateral displacement with
ZSO; y =anterior displacement with ZAO; y’ = anterior displacement with ZSO).
FIGURE 24.a. vertical osteotomy, b. semihorizontal osteotomy,c. Opening of the vertical

Figure 26. a. vertical osteotomy, b. semihorizontal osteotomy,c. Opening of the vertical osteotomy and insertion of
osteotomy and insertion of spacer material.
spacer material.
Figure 27. Malar augmentation, differences in osteotomy design: Mommaerts et al (left) compared with Kim and Seul
(right).
Zygomatic Sagittal Split Osteotomy (ZSSO):in this technique the zygomatic arch is isolated
from its temporal origin to its zygomatic insertion both on its lateral and medial surfaces Using
a waver sewer, a sagittal full thickness osteotomy of the zygomatic arch is performed (Fig.
26).Later, 2 separate partial thickness osteotomies: one on the arch’s osteotomies are connected
with the previously released sagittal osteotomy. After correction of the zygomatic arch
according to presurgical programs. Stabilization is achieved using bicortical titanium screws
(Fig. 26).
Zygomatic Sagittal Split Osteotomy (ZSSO):in this technique the zygomatic arch is isolated
www.dentalbooks.co
fromZygomatic
its temporalSagittal
origin toSplit Osteotomy
its zygomatic (ZSSO):in
insertion both this technique
on its themedial
lateral and zygomatic archUsing
surfaces is isolated
a
from
waver its temporal
sewer, origin
a sagittal fulltothickness
its zygomatic insertionofboth
osteotomy the on its lateral arch
zygomatic and medial surfaces(Fig.
is performed Using a
waver 2sewer,
26).Later, a sagittal
separate full thickness
partial thickness osteotomy
osteotomies: of the
one on the arch’s
zygomatic arch isare
osteotomies performed (Fig.
Advanced Adjunct Orthosurgical Estheticconnected
Prodedures 177
with26).Later, 2 separate
the previously partial
released thickness
sagittal osteotomies:
osteotomy. one on the
After correction of arch’s
the osteotomies
zygomatic arch are connected
according
http://dx.doi.org/10.5772/59088
to presurgical programs. Stabilization is achieved using bicortical titanium screws (Fig. 26).according
with the previously released sagittal osteotomy. After correction of the zygomatic arch
to presurgical programs. Stabilization is achieved using bicortical titanium screws (Fig. 26).
FIGURE 26. Two vertical partial-thickness osteotomy are performed: one on the posterolateral
28. FIGURE
Figuresurface
Two of the26.
vertical Two vertical
partial-thickness
zygomatic partial-thickness
archosteotomy
and theare osteotomy
performed:
other on its one onare
the performed:
posterolateral
anteromedial surface. one on the
surface
left) of posterolateral
the zygomatic
Sagittal full-
arch and the other
surface
thickness on
ofitsthe
osteotomyanteromedial
zygomatic surface.
arch left)
of the zygomaticarch,and Sagittal full-thickness
theperformed
other onwith aosteotomy
its anteromedial of the zygomaticarch,
surface.
waver sewer.right) performed
left) Sagittal
Stabilization offull-
with a waver sewer.right)
thickness Stabilization
osteotomy of theof zygomaticarch,
the osteotomy with bicortical titanium
performed with a screws.[fromGasparini
waver sewer.right) G et al. Zygo‐ of
Stabilization
the osteotomy with bicortical titanium screws.[fromGasparini G et al. Zygomatic Sagittal Split
matic Sagittal
the Split Osteotomy:
osteotomy with A Novel and titanium
Simple Surgical Technique for Use in G Midface Corrections.Sagittal
J Craniofac
Osteotomy: A Novel andbicortical screws.[fromGasparini
Simple Surgical Technique for Use in Midface et al. Zygomatic
Corrections.
Surg.2010] Osteotomy: A Novel and Simple Surgical Technique for Use in Midface Corrections. J Craniofac
J CraniofacSplit
Surg.2010]
Surg.2010]
Figure 29. A 32 years woman with malar deficiency, No orthognathic surgery was performed in this case. The patient
desired definition of the cheekbones with zygomatic sandwich osteotomy (ZSO) (left) preoperative view, note the tri‐
angular shape of she’s face; (right) 18 month postoperative view.
5. Frontal modification
Frontal bossing reduction:Frontal Bossing known as a prominent supraorbital region and

considers as a masculine characteristic. Generally men have more prominent frontal bossing
than women which tends to have a smooth transition from brow area into a forehead. Frontal
Bossing patients range from those with craniofacial anomaly such as thalassemias, Crouzon/
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apert syndrome, Hurler syndrome to those without any underlying medical problem(figure
28,29). [112]
Figure 30. The main difference between male and female foreheads is that males often have a ridge of bone around the
upper edge of the eye sockets called the “brow ridge” or “brow bossing". Female foreheads tend to have little or no
bossing.Between the ridges of the two eye sockets a flat area can be visible. As women don't have the ridges, also the
flat area between them is not present. [from facialfeminization.eu]
Figure 31. Schematic view of the slob of the forehead. Because of the brow ridge the general angle of the forehead in
males (below-right) is steeper and the angle between the forehead and nose is sharper in lateral view. Women,(below-
left) because they don't have the brow ridge, have a more vertical appearance of the forehead in lateral view. The angle
between nose and forehead is more open. [from facialfeminization.eu]
The most common method of brow bone reduction is an open approach using a bi-coronal flap
with either a burring reduction, an infracture technique or osteotomies and reshaping. Simple
burring can be effective if the outer table of the brow bone is thick enough.
In the course of normal skull growth, satisfactory reduction of anterior bossing without direct
surgical correction of the shape of the forehead can be achieved through sagittal suturectomy
along with biparietal barrel stave cuts[113]. More correction of biparietal width and the
occipital deformity, on the other hand, may also result in a gradual correction of the frontal
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http://dx.doi.org/10.5772/59088
Figure 32. bi-coronal flap.
Figure 33. Frontal bossing re-shaping.With the thick bone, the surgeon only has to grind down the bone to the desired
level and there will still be plenty of bone left to cover the frontal sinus as you can see.With the thin bone sutgeons
can’t grind it down to the ideal line or very much at all without breaking through into the sinus. In this case, most FFS
surgeons will perform a forehead reconstruction so after grinding down what they can, they actually take the wall of
bone apart, re-shape it and move it backwards to the desired position. [from www.virtualffs.co.uk]
deformity to satisfactory. In severe cases, however, the natural development of the calvarial
shape with physiological skull growth following the described technique will not suffice as a
cosmetically compromising frontal bossing will be most likely to persist. In such cases, a direct
surgical correction, including radial osteotomies, rotation of bone flaps, “frontal to occipital
switch”, π-procedure, morcellation, use of distraction or contraction devices, total cranial vault
reconstruction, and other techniques have been suggested in the craniofacial literature.[114]
The general approach in these techniques includes excision, remodeling, transposition, and
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re-insertion of free bone flaps. The direct approach will then require complex bone fixations
using wires or plates and screws. More advanced modifications of these techniques to avoid
free bone flaps have been discussed where the shortened and re-approximated bone tongues
stay attached at their normal calvarial position at the base or the apex of the calvaria. For
example, in the technique described by Wagner and Wiewrodt[113] in 2008, following sagittal
suturectomy and parietalbarrel stave incisions, four or five lanceolate pieces of thefrontal bone
are excised resulting in three or four vertical bone bridges. These osteotomies are designed to
extend radially from thecranial base towards the fontanel. Small strips rectangular to the apico-
basal axis are then cut out from these bridges, leaving basal and apical bone tongues. [113] The
tabula externa at the base of the basal tongues is drilled off and the tongues are bent inward
to correct the inferior aspect of the frontal bossing. [113]
Corresponding basal and apical bone tongues arethen re-approached and fixated with sutures.
The gold standard procedure for correction of severe frontal bossing is still open approach
with osteotomy of the anterior table of the frontal sinus which provides excellent outcome.
Complications such as long coronal scars, alopecia, blood loss, forehead paresthesia, neuromas
and traction palsy of the facial nerve makes this operation invasive, with increased chance of
morbidity and less desirable for mild to moderate frontal bossing correction. [112]
Despite the widespread use of endoscopic frontal bone operations such as remodeling of bony
defects and removal of osteomas of the frontal bone, only recently has “endoscopic frontal
bossing correction” been introduced.[112] This emerging method seems to have rendered
frontal bossing correction much simpler, significantly safer, and minimally invasive.
Moreover, the introduction of the endoscope revolutionized the surgical approach to the
forehead, as it allowed for smaller incisions, magnified visualization, decreased risk of
bleeding, faster recovery, and decreased chance of neuropathy by preserving cutaneous
nerves. Endoscopic contouring of the forehead was first described by Song et al. on a Korean
woman with frontal bone deformities.[115] Since then, most published endoscopic manipu‐
lation of the frontal bone and supraorbital ridge has involved osteoma mass excision or frontal
sinus fracture repair. Retrospective reviews of patients receiving endoscopic correction of
frontal bossing have shown promising aesthetic results with minimal postoperative morbidity.
This method of improving forehead contour, however, should be carried out on properly
selected groups of patients. Mild deformities of frontal bossing and adequate bone thickness
over the frontal sinus makes patients a great choice for endoscopic frontal bossing correction.
[112] Some complications such as neurosensory damage, vascular injury, and extended
operative time. [112]. Similarities like incision line and dissection planes for this technique with
standard endoscopic forehead lift allows easy access to the frontal bone for contouring in
patients with frontal bossing and undergoing concurrent forehead rejuvenation.[112]
6. Summary
The major architectural promontories of the facial skeleton, including the malar-midface
region, nose, chin,angle of the mandible and frontal buttress provide the base upon which the
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http://dx.doi.org/10.5772/59088
soft tissues of the face drape. By altering these promontories, dramatic changes can be made
in the estheticappearance of the face—much more so than by changing soft tissue and skin
alone.Since many years ago numerous surgical and office based techniques have been
introduce to augment, reduce or refine the most projected points of the face such as
cheek,chin,nose, Para-nasal area, angle of the jaw.When reduction of these esthetic points is
planed not only we don't have multiple choices but also without using these methods the
precise and predictable correction is almost impossible. In case of augmentation although we
have the more options such as soft tissue office based procedures or facial prostheses[110,
111] a precise pre-surgical evaluation in according to patient complaints, social and economic
conditions, soft or hard tissue deficiency, amount of augmentation,the past similar procedure,
ect. should be considered and the best method for each patient should be selected.Aesthetic
adjunct facial osteotomy techniques have proved to be expedient techniques, with low
morbidity, producing a controllable and predictable increase or decrease of the facial promi‐
nences and stable short and long-term morphological results.The most common complication
of esthetic adjunct osteotomy techniques are under- correction and over-correction; pre-
surgical evaluation and precise estimation of amount of excess or deficiency is a best method
to reduce these complications the relation between hard and soft tissue change is also impor‐
tant,for example the hard tissue to soft tissue ratio in case of advancement genioplasty is almost
1:1 but in case of reduction genioplasty or chin narrowing is almost 1:0.5.Another complication
is bad split ; although it is a rare complication and often is simple to manage but in cases in
whom correction is impossible the best way is internat fixation,close the incision and set an
another appointment with patient. Other complications such as nerve injury, relapse or sever
bleeding is very rare. The more surgeon experience the less incidence of complications.
Acknowledgements
Special thanks to MS. Shahrzad Zojaji and Marjan Golpashafor illustrations.
Author details
Seied Omid Keyhan1,2*, Seifollah Hemmat3, Peyman Mehriar4, Arash Khojasteh5 and
Mohammad Ali Asayesh5
*Address all correspondence to: keyhanomid@ymail.com
1 Department of Oral and Maxillofacial Surgery, Shahid Sadooghi University of Medical

Sciences, Yazd, Iran
2 Department of Oral and Maxillofacial Surgery, Isfahan University of Medical Sciences,

Isfahan, Iran
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3 Department of Oral and Maxillofacial Surgery, Bandar Abbas University of Medical Sciences,
Bandar Abbas, Iran
4 Advanced Education in General Dentistry,Florida Institute, Miami, Florida, USA
5 Department of Oral and Maxillofacial Surgery,Shahis Beheshti University of Medical

Sciences,Tehran, Iran
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[109] Gasparini G, Saponaro G, Moro A, Boniello R, Cervelli D, Pelo S. Zygomatic Sagittal

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[110] Keyhan SO,Badri AA,Hemmat S ET AL.Use of platelet-rich fibrin and platelet-rich

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[111] Khiabani K,Keyhan SO,Hemmat S.Buccal Fat Pad Lifting: An Alternative Open Tech‐
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[112] Guyuron B, Lee M, Larson K, Amirlak B. Endoscopic correction of frontal bossing.

Plastic and reconstructive surgery. 2013 Mar;131(3):388e-93e.
[113] Wagner W, Wiewrodt D. A simple technique for the correction of frontal bossing in
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Chapter 11
Surgical Techniques to Improve the Smile
Mazen Almasri
http://dx.doi.org/10.5772/59213
1. Introduction
A smile has always been an important key in our social life, not to mention if it is an attractive
one. The type, degree, tone, at static or a dynamic figure concerns facial beauty as well as the
internal mood, or what might be called “ the internal smile.“ The society in the current century
is turning towards social media, gadgets, electronics and advertisements mainly based on
pictures. Those corporates seeking to recruit applicants for job positions assess the persons
photograph in addition to their CV because a photo can tell a lot about an applicant. Hence,
there is a growing trend towards enhancement of facial esthetics.
Among the medical professions, many specialties are dealing with smiles; however, the
approach to management can vary considerably due to improper diagnosis and lack of
knowledge toward the variable treatment options. Specialists such as restorative dentist,
prosthodontist, orthodontist, periodontist, maxillofacial surgeon, plastic surgeon, and
dermatologist are working around the “smile complex”; however, no clear inter-specialty
communication exists to provide the best intervention for patients. This might be a reason for
variable management to smile imperfections via different specialties.
In this chapter, the “unattractive smile”, is being discussed from different angles and in a totally
different manner. The objective is to collect the expertise of variable cosmetic specialties in a
single chapter to help practitioners in future decision-making processes in “smile manage‐
ment.” Hence, the concepts are presented along with multiple challenging cases with different
interventions. Interventions such as restorative veneers in the maxillary anterior teeth can be
the answer to all patients’ troubles if used in the right cases; while crown lengthening as a sole
procedure or in combination with veneers can be the ultimate solution for others [1].
Maxillary surgical procedures such as LeFort 1 may be the only solution in others. Laser
therapy for lip irregularities can provide more convenient results in case of fine wrinkles, while
Botox and fillers may provide better outcomes for some gummy smiles. The case can be a little
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bit more challenging if the patient is known to have a repaired cleft lip, previous lip trauma,
or secondary facial deformity [2].
Other situations where patients visit clinics with a clear demand of what can make them feel
happier, such as piercing or cheek dimples can be linked to the patient’s own personal
satisfaction. On other occasions, clients may be confused, and complain of resenting their
profile pictures without clear understanding of their problem needing correction. It is well
known, that in the current era of cosmetic revolution and subspecialty care and techniques,
continuous evaluation and research regarding the principles of “smile management” are
evolving. Therefore, practitioners should keep in mind that proper training in the field, careful
case selection, and inter-specialty communication can provide the best results with the least
possible complications.
2. Definition of smile
A smile is expressed as a form of one’s feature reflecting pleasure and happiness usually shown
by upturning the corners of the mouth [1]. It can be presented in a static state mostly during
taking pictures, or can be as part of a dynamic state during articulation. However, the personal
self-evaluation can be more complicated due to the era of advanced social networking. Hence,
it is not surprising that critics of smiles and perfectionism are increasing [2].
3. Components of the smile
Medical practitioners may describe the smile as a status of the orofacial complex where muscles
of the facial expression are harmonized. Muscles such as the frontalis, orbicularis oculi,
orbicularis oris, zygomaticus major, risorius, platysma and depressor anguli oris are working
in harmony to provide various facial expressions [3]. A common mistake is considering the
oral complex as the only item composing the smile, though midfacial muscles such as the
zygomaticus major and minor originate from the midface and hence affect the general
character and smile. The muscles around the orbital complex are critical to facial expression
as a reflection of youth and beauty when lacking heavy wrinkles [4]. Hence, the components
of a smile can be evaluated according to different factors namely:
a. Anatomical components
b. Smile lip line
c. Dental smile lines
d. Facial character
Anatomical components: The smile is composed of the upper lip, the maxillary bone, the
maxillary teeth, and the gingival tissue envelope [5, 6].
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The upper lip represents the area from the point subnasal to the upper lip stomion which
varies between 18-22mm (Figure 1) [5]. The width of the lip is composed of mucosa, orbicularis
muscle, fat, and skin, which varies between individuals in height and thickness. However, the
extension of muscles into the surrounding structures such as the nose can affect the nasal shape
when smiling. A lot of patients have their nasal tips turned downward when they smile, or
have the alae of the nose extremely widen or flare, which can be unsightly [7].
Figure 1. Lateral cephalometric analysis showing the lip form and position. Nasolabial angle (Cm-Sn-Ls), mentolabial
sulcus depth (Si to Li-Pog’), maxillary incisor exposure (Stms-1). Upper lip protrusion (Ls to Sn-Pog’), lower lip protru‐
sion (Li to Sn-Pog’), vertical lip-chin ratio (Sn-Stms/Stmi-Me’), interlabial gap (Stms- Stmi). [5]
The maxillary bone and teeth constitute the second and third parts. The maxilla extends from
the subnasal down to the alveolar component housing the teeth. The width of the smile is
correlated with the width of the maxilla, as transverse deficiency will lead to narrow V-shaped
maxillary arch and a wide buccal corridor which is not pleasant, and vice versa. While in the
vertical dimension, maxillary excessive growth will lead to over expression of gum and teeth
during smiling or a gummy smile; while extreme maxillary bone vertical deficiency will lead
to absence of teeth and gingival show at static or dynamic orofacial states reflecting an
unpleasant aging character. Evaluation of the maxillomandibular complex is accomplished via
clinical and radiographic modalities clarified later in this chapter [5].
The gingival architecture is the fourth factor. Gingival recession exposing more tooth structure
and roots is as unpleasant as gingival overgrowth -leading to short clinical crowns. As the
crown shape, including height, width, curvature, and alignment have an important role [3],
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once the dental smile arc line is upturned posteriorly it will reflect better cosmetic results
compared to a flat or downturned arc line. [6] Hence, a defect in a single component or
inappropriate harmony between each can provide patients with unpleasant smiles. Therefore
it is very critical to diagnose the major contributor to the disharmony and formulate the best
management plan accordingly.
Smile lip line: This is divided into high, moderate or low horizontal smile lines according to
the magnitude of upper lip coverage of the maxillary anterior teeth when static and smiling.
[6] A high lip line refers to a smile showing the maxillary anterior teeth and part of the gingival
tissue, while a low lip line shows 0-2mm of the anterior teeth. A high smile line is considered
to be a challenging factor when rehabilitating the anterior maxilla. As any defect in the crown
or gingival tissue can be disclosed; unlike patients with moderate or low smile lines (Figure 2).
Dental smile line (smile arc): This pertains to maxillary teeth from the incisor going along to
the 1st molar and describes the best cosmetic relation as evaluated by an expert restorative
dentist.[4,6] A smooth transition of dental lines, alignment, shape, and color can provide
pleasant smiles. The dental smile line is an imaginary line drawn from the incisal edges of the
maxillary anterior teeth and following the upper lip inferior border curvature. It can be flat,
upturned, or downturned. These lines do have more fine details that a specialist restorative
dentist can analyze. [3, 4, 6] The fine dental line details are beyond the scope of the chapter.
4. Case
A young female patient referred complaining that she does not like her smile. On examination
the patient was presented an option of orthodontic treatment to adjust the spaces and dental
relation before any final restorative esthetic procedures. However, the patient did not prefer
any orthodontic intervention. Hence, the cosmetic restorative team evaluated the patient for
possible prosthetic rehabilitation of the smile and anterior teeth via dental veneers. Proper
examination, impression and lab simulation using wax up models was performed and showed
a favorable outcome. Therefore, the team elected to proceed with the treatment. Although the
team advised the patient to receive restorative therapy of the premolar teeth, the patient
refused, as she was mainly interested in betterment of the anterior tooth show (Figure 2).
Facial character: The overall shape, color, and harmony of the face and maxillomandibular
relationship should be evaluated clinically as well as radiologically. Clinical pictures of the
frontal and profile views from different angles are necessary for documentation. Static
evaluation as well as dynamic evaluation of the facial expression is important and any facial
asymmetry should not go unforeseen. [2, 7, 8]
Beside the clinical examination of the head and neck region, radiographic evaluation is
important to investigate the maxillomandibular complex, temporomandibular joint, and
dentition using panoramic radiography and cephalometrics. [5, 7, 8]
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Figure 2: The left picture is showing a moderate smile lip line, with unfavorable
Figure 2. (Left) a moderate smile lip line, with unfavorable dento-gingival relationship and dental esthetics. (Right)
Postoperative results after treatment with restorative veneers (Courtesy of Professor Motaz Ghulman, King Abdulaziz
dentogengival relation and dental esthetic. The right figure is showing the
University).
postoperative results after treatment with restorative veneers at the anterior incisor
teeth. The patient refused extending the veneers into the premolars as her main chief
4.1. Principles of managing an unpleasant smile
complain was her anterior incisors. (with Courtesy of Professor Motaz Ghulman, King
Unpleasant smiles can be due to clear defect in one or more of the major smile components,
Abdulaziz University)
lack of harmony of the smile pillars, or loss of self-satisfaction, which can be due either to a
specific
demand the patient is requesting (such as cheek dimples) or pure personal psycho‐
logical
D‐ dissatisfaction. The most important principle in managing such patients is to diagnose
Facial character: total shape, color, and harmony of the face and
the etiology to see if it is actually an organic anatomical issue or is it an issue of self-concept.
maxillomandibular relation. The evaluation is accomplished in clinical as well as
The answer is usually explored via careful teamwork consultation that will help guide the
radiological evaluation. Clinical pictures to the frontal and side views in different
patient to the proper treatment channels.
angles are necessary for documentation. While, Static evaluation as well as
dynamic evaluation of the facial expression are important not to miss any pitfalls
4.1.1. The use of botox and fillers for smiles: [9, 10]
in dynamic related facial asymmetry. (2,7,8)
Beside the clinical examination of the head and neck region, radiographic
Botox (Botulinum toxin) is a neurotoxin that is derived from the bacterium Clostridium
evaluation is important to investigate the maxillomandibular complex,
Botulinum that has several serologically distinct subtypes, A, B, C, D, E, and G. It acts by
temporomandibular joint, and dentition, through panoramic radiograph and
blocking acetylcholine release at the neuromuscular junction, and hence preventing muscular
cephalometrics (5,7,8).
contraction leading to smoothening of the hyperkinetic unpleasant looking facial rhytids or
skin lines. The most common one is Botulinum A, Botox. [9, 10]

‐Botox has many applications in medical fields such as:
PRINCINPLES OF MANAGING UNPLESANT SMILE
Unpleasant smiles can be due to clear defect in one or more of the major smile
1. Treating facial rhytids: forehead, periorbital, and paranasal area
components, inharmony of the smile pillars, or it can be due to loss of self
2. satisfaction, which can be either due to a specific demand the patient is asking for
Treating neck vertical platysmal bands
such as cheek dimples, or due to pure personal psychological unsatisfaction.
3. Myofacial pain of the head and neck

4. The most important principle to manage such trouble is to diagnose the etiology. Is
Migraines
it actually an organic anatomical issue? Or it’s a factor contributing to self‐
5. Muscle palsy
satisfaction? The answer is usually explored via careful teamwork consultation that
6. will help guiding the patient into the proper treatment channels.
Muscle hypertrophy, commonly masseter and temporalis muscle hypertrophy.

For smiles with hyperactive muscular complex of the upper lip, Botox can be carefully

deposited in the main hyperactive areas to reduce the action and hence to allow better draping
THE USE OF BOTOX AND FILLERS FOR SMILES: (9,10)
of the upper lip complex on the maxillary teeth. [11]
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The advantages are: easier application, less invasive, quick procedure, reasonable price,
reasonably fast onset, and duration of about 6 months.
Disadvantages are: the action may start with fine dropping of the upper lip that patients may
perceive as unpleasant, it takes from days to weeks to stabilize, asymmetric smile, uncomfort‐
able injections, requiring re-injection after 6 months to stabilize results. [9, 11]
4.1.2. Case presentation
A 29-year-old woman complained that she was unsatisfied with her smile and that she had to
use her hand to cover her mouth while laughing. On examination it was noticed that she had
a hyperactive upper lip muscles, orbicularis oris and elevator labii alaeque nasi. She agreed to
start management with a simple non-invasive method such as Botox therapy of the hyperactive
areas (Figure 3, 4).

Figure 3: a 29 years old lady complained of uncosmetic Gummy smile.
Figure 3. A 29-year-old woman with a gummy smile.

Figure 4. The patient after treatment with selective Botox therapy at the hyperactive muscular areas. The pictures
Figure 4: The patient after treatment with selective Botox therapy at the
showing two pleasant smile poses, as compared to the preoperative smile in Figure 3.
hyperactive muscular areas. The pictures showing two pleasant smile
poses, as compared to the preoperative smile in Figure 3.
4.2. Lefort 1 maxillary surgery

A LeFort 1 maxillary procedure is a surgical intervention where the maxillary bone is osteo‐
‐ LEFORT 1 MAXILLARY SURGERY:
tomized in the semi-horizontal plane to disengage it from the cephalic end and allow moving
A Le Fort 1 maxilary procedure is a surgical intervention where the maxillary bone
the disengaged part into a more favorable position as dictated in relation to the opposing jaw
is osteotomized in semi‐horizontal plane to disengage it from the cephalic end and
and thus, improving the general facial harmony. The movement can be accomplished in three
allow moving the disengaged part into a more favorable position as dictated in
relation to the opposing jaw function and improving the general facial harmony. The
movement can be accomplished in variable three dimension as needed. A
maxillofacial surgeon trained in the field of orthognathics and facial reconstruction
usually performs the procedure (5,12). Preoperative evaluation and consultation
with an orthodontist trained in the field is necessary to estimate the defect and
treatment planning including a thorough preoperative work up. That usually
includes the following: Facial clinical pictures, intraoral pictures, panoramic
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dimensions as needed. A maxillofacial surgeon trained in the field of orthognathics and facial
reconstruction usually performs the procedure [5, 12]. Preoperative evaluation and consulta‐
tion with an orthodontist trained in the field is necessary to estimate the defect and treatment
planning including a thorough preoperative work up. This usually includes the following:
Facial clinical photographs, intraoral photographs, panoramic radiograph, lateral cephalo‐
metric radiograph, anteroposterior cephalometric radiograph, impressions to develop study
casts, mounting casts and a face bow transfer to aid in the cast mounting (Figure 5) [5,12]. Once
this is accomplished, a proper data analysis is required for each aspect to develop a preoper‐
ative documented record, a diagnosis, and a provisional plan.
Figure 5. Lateral cephalometric radiograph with superimposing face bow transfer is a method to insure proper dentos‐
keletal relation before sending the face bow and impressions to the laboratory.
One of the most common indications is in gummy smile cases due to maxillary vertical excess.
The procedure can be more challenging in cases with a short upper lip that contributes to the
unpleasant smile complex. The procedure is mainly directed toward reducing the maxillary
excess by moving the maxilla in the superior direction, and hence, it improves the smile.
The advantages of such a procedure are that it provides a major improvement in the shape of
the face and smile.
The disadvantages are that it is done under general anesthesia, requires hospitalization,
requires prolonged recovery time that can be up to a month (hence usually done during a
prolonged vacation), postoperative expectations include swelling, pain, midface paresthesia,
difficulty eating, minor changes in nasal shape, and general discomfort. [12, 13]
A 27-year-old patient with an unpleasant smile and difficulty eating. Clinical and radiograph‐
ic evaluation revealed vertical maxillary excess and mandible deviation. The patient under‐
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went multi-team comprehensive consultation and found it best to be treated via orthognathic
surgery. LeFort 1 maxillary osteotomy was done to position the maxilla in upward position and
correct the rotation, while the mandible underwent bilateral sagittal split osteotomy to optimize
symmetry and occlusion. The patient still requires final orthodontic treatment (Figure 6).
mandible underwent bilateral sagittal split osteotomy to optimize symmetry and
occlusion. The patient will still require the final orthodontic dental treatment.

Figure 6: Maxillary vertical excess that required Orthognathic surgery
Figure 6. Maxillary vertical excess that required orthognathic surgery intervention to correct the deformity seen on the
intervention to correct the deformity seen on the left picture. The right picture
left. The right picture shows the postoperative favorable results.
shows the postoperative favorable results.
4.3. Upper lip enhancement procedures

‐ Facial aging is a continuous process that can be accelerated by smoking, sun exposure, or
UPPER LIP ENHANCEMENT PROCEDURES:
personal genetic predisposition. The loss of elastic fibers and replacement with collagen fibers
Facial aging is a continuous process that can get accelerated by smoking, sun
leads to reduction in skin elasticity and sagging of the skin complex. Hence, cosmetic proce‐
exposure, or personal genetic predisposition. The loss of elastic fibers and
dures such as facial fillers, lipofillers, chemical peeling, surgical lifting procedures, and laser
replacement with collagen fibers leads to reduction in skin elasticity and sagging of
treatment can optimize the general results. [10-14]
the skin complex. Hence, cosmetic procedures such as facial fillers, lipofillers,
Other surgical procedures are not as common such as upper lip elongation or shortening that
chemical peeling, surgical lifting procedures, and Laser treatment can optimize the
can treat cases of short upper lip that require some elongation to redrape the maxillary teeth.
general results. (10,12,13,14)
The upper lip is measured from the subnasal point to upper lip stomion, and has an average
of 18-22mm length. [8]
Other surgical procedures are not as common such as upper lip elongation or
shortening that can treat cases of short upper lip that requires some elongation to
A subnasal upper lip-lift is a procedure used to shorten a long upper lip and to evert it outward.
This will allow more maxillary teeth show, upper lip outward eversion, and hence, a more
redrape the maxillary teeth. The upper lip is measured from the subnasal point to
pleasant youthful smile. It can be designed in a W-lift direction to provide better enhancement
upper lip stomion, and has an average of 18‐22mm (8).
of the cupid bow area. The W arms can be designed in asymmetric fashion to manage upper

lip asymmetric deformities. [2]
While a subnasal upper lip‐lift is a procedure used to shorten a long upper lip and to
evert it outward. This will allow more maxillary teeth show, upper lip outward
The lips can be in inverted, everted, hypoplastic, or with fine mucosal irregularities [13]. Such
lip irregularities can be managed using laser therapy to eliminate superficial folds, or even cut
eversion, and hence, a more pleasant youthful smile. It can be designed in a W‐lift
and plan the rotation movements needed (Figure 7). [13, 14]
direction to provide better enhancement of the cupid bow area. The W arms can be
designed in asymmetric fashion to manage upper lip asymmetric deformities. (2)
The lips can be in inverted, everted, hypoplastic, or with fine mucosal irregularities
(13). Such lip irregularities can be managed using Laser therapy to eliminate
superficial folds, or even cut and plan the rotation movements needed (Figure 7).
(13,14)

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A 23-year-old female referred complaining of unesthetic upper lip and unpleasant smile. The
CASE (Figure 7,8): a 23 years old female was complaining of uncosmetic upper lip and
patient hadunpleasant smile. The patient had had multiple cleft lip and palate repair procedures
had multiple cleft lip and palate repair procedures in the past. The patient was
presented an option of asymmetric upper lip lift and fat transfer to the upper lip. The procedure
in the past. The patient presented an option of asymmetric upper lip lift and fat
took place transfer to the upper lip. The procedure took place under general anesthesia and the
under general anesthesia and the results were immediately noticed (Figure 7, 8).
results were immediately noticed.

Figure 7: The patient at the preoperative stage; the upper lip is thin, inverted and flat.
Figure 7. The The plan surgically was to lift up the upper lip, evert it outward, and augment it using
patient at the preoperative stage (left); the upper lip is thin, inverted and flat. The plan surgically was to
fat transfer. The picture on the right showing the preoperative W‐lift marking. (2)
lift up the upper lip, evert it outward, and augment it using fat transfer. The picture on the right shows the preopera‐

tive W-lift marking. [2]

Figure 8: One‐week post operatively showing the upper lip volume, lip lift, and
outward eversion of the patient in figure 7

Figure 8. One-week postoperatively showing the upper lip volume, lip lift, and outward eversion of the patient in
Figure 7.
Upper lip volume enhancement can be accomplished using autogenous grafts such as fascia,
muscle, and periosteum especially if more volume is needed in compromised sites such as
repaired cleft lip with notching or whistle deformity (Figure 9). Synthetic fillers are a common
option now days to achieve lip volume enhancement or final border definition [7-9, 13].
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A 34-year-old male patient referred complaining of extramucosal fold of his upper lip that
shows more during smiling. The patient was presented an option of Erbium-Yag laser therapy
to remove the mucosal folds under local anesthesia (Figure 9).

Figure 9: The left picture presents a smile of a 34 years old male patient
complaining of extramucosal fold at his upper lip that shows more during
smiling. The patient presented an option of Erbium‐Yag laser therapy to
remove the mucosal folds under local aesthesia. The picture on the right
Figure 9: The left picture presents a smile of a 34 years old male patient
showing the result immediately post laser therapy, indicating dry field and a
complaining of extramucosal fold at his upper lip that shows more during
potential of favorable secondary intentional healing.
Figure 9. The left picture presents a smile of a 34-year-old male patient complaining of extramucosal fold of his upper
smiling. The patient presented an option of Erbium‐Yag laser therapy to
lip that shows more during smiling. The patient was presented an option of Erbium-Yag laser therapy to remove the
remove the mucosal folds under local aesthesia. The picture on the right
mucosal folds under local anesthesia. The picture on the right showing the result immediately after laser therapy, indi‐
showing the result immediately post laser therapy, indicating dry field and a
cating the dry field and a potential of favorable secondary intentional healing.
Upper lip volume enhancement can be accomplished using autogenous grafts such
potential of favorable secondary intentional healing.
as fascia, muscle, and periostrium especially if more volume is needed in
compromised sites such as repaired cleft lip with notching or whistle deformity
(Figure 10). Synthetic fillers are a common option now days to achieve lip volume
Upper lip volume enhancement can be accomplished using autogenous grafts such
enhancement or final border definition (7,8,9,13).
A 23-year-old female presented with severe whistle deformity and notching of the upper lip
as fascia, muscle, and periostrium especially if more volume is needed in
secondary to repaired cleft lip 6 years ago. She was presented an option of upper lip revision;
compromised sites such as repaired cleft lip with notching or whistle deformity
however, CASE (Figure 10): the following is a 23 years old lady presented with severe whistle
she was not keen to do so. Hence, she was presented the option of periosteum-
(Figure 10). Synthetic fillers are a common option now days to achieve lip volume
muscular deformity or notching of the upper lip secondary to repaired cleft lip 6 years ago. She
graft augmentation harvest from the lower lip / chin mass and transfer to the upper
was presented an option of upper lip revision, however, she was not keen to do so.
enhancement or final border definition (7,8,9,13).
lip (Figure 10).
Hence, she was presented the option of periostium‐muscular graft augmentation
harvest from the lower lip / chin mass and transfer to the upper lip.
CASE (Figure 10): the following is a 23 years old lady presented with severe whistle

deformity or notching of the upper lip secondary to repaired cleft lip 6 years ago. She
was presented an option of upper lip revision, however, she was not keen to do so.
Hence, she was presented the option of periostium‐muscular graft augmentation
harvest from the lower lip / chin mass and transfer to the upper lip.

Figure 10: Reconstruction of an upper lip severe notch deformity on the left
picture using autologous muscular graft. The Right picture is showing three
Figure 10. Reconstruction of an upper lip with severe notch deformity on the left picture using autologous muscular
graft. The photograph on the right is three months postoperative. Final fine-tuning of lip boundaries can be achieved
using synthetic fillers.

Figure 10: Reconstruction of an upper lip severe notch deformity on the left
picture using autologous muscular graft. The Right picture is showing three
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4.4. Crown lengthening
Crown lengthening is defined as a procedure used to increase the height of the clinical
crowns by removing part of the gingival tissue with or without the crestal alveolar bone
[14]. The procedure is usually designed according to the demand of the clinical crown
height or the planned prosthetic crown or veneer. The tissue ablation is performed using
blades, lasers, or less favorably, electrocautery, which has the tendency to damage the soft
tissue cuff when compared to laser-based precise cutting capabilities. However, Laser
treatment will require a set up to be ready, such as machine position, extensions, wires
plastic covers, goggle’s for the team and patient, surgical sites protections, and proper
infection control protocol (Figure 11). [14]
The dental gingival relation describes the maxillary teeth height, width, shape, and alignment
months follow up favorable presentation. Final fine‐tuning of lip boundaries
statuscan be achieved using synthetic fillers.
in relation to the gingival envelope. This can never be satisfying unless it was reflected
in
a beautiful smile [1, 2]. Therefore, a specialized restorative dentist should evaluate the case
to
verify the needed consultation and intervention, which can vary from simple odontoplasty,
placing
veneers, crowns, orthodontic treatment, or even extraction, alveolar bone reconstruc‐
‐ tion and implant-based rehabilitation (Figure 12).[15-17] Hence, teamwork is always the key
‐ CROWNLENGTHNING:
to reach the best dento-gingival relation to provide a satisfying smile. This can be clarified
Crown lengthening is defined as a procedure used to increase the height of the
through two examples, the first one illustrating the role of the oral and maxillofacial surgeon
clinical crowns by removing part of the gingival tissue with or without the crestal
to evaluate a poor alveolar bone supporting the gingival tissue that requires alveolar recon‐
alveolar bone (14). The procedure is usually designed according to the demand of
struction in horizontal and/ or vertical dimensions before prosthetic rehabilitation. [17] The
the clinical crown height or the planned prosthetic crown or veneer. The tissue
second example illustrates the role to manage patients with short lip and vertical maxillary
ablation is performed using blades, Lasers, or less favorably; electrocautery, which
excess that will never be managed properly if crown-lengthening procedure was only
has the tendency to damage the soft tissue cuff when compared to Laser based
performed. Such a case will require a LeFort 1 surgical procedure to reposition the maxilla
precise cutting capabilities. However, Laser treatment will require a set up to be
superiorly first. [5, 12]
ready, such as machine position, extensions, wires plastic covers, goggle’s for the
team and patient, surgical sites protections, and proper infection control protocol
(figures 11). (14)

Figure 11: Showing the Laser setup in the dental office as well as surgical site
preparation for Laser assisted labial frenoplasty.

Figure 11. Showing the laser setup in the dental office as well as surgical site preparation for laser assisted labial freno‐

plasty.
The dental gingival relation describes the maxillary teeth height, width, shape, and
alignment status in relation to the gingival envelope. This can never be satisfying
unless it was reflected on a beautiful smile (1,2). Therefore, a specialized restorative
dentist should evaluate the case to verify the needed consultation and intervention,
which can vary from simple odontoplasty, placing veneers, crowns, orthodontic
treatment, or even extraction, alveolar bone reconstruction and implants based
rehabilitation (Figure 12) (15,16,17). Hence, teamwork is always the key to reach
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The indication for crown lengthening is: cases of satisfying harmony of the upper lip height
and maxillary bone relation, healthy dentition and periodontium but with poor dentogingival
relation such as gingival overgrowth or poor architecture. It is used as well to optimize the
The disadvantages:
restorability Asymmetry,
of the coronal portion might
of teeth. [14, 15] require re‐treatment to remove
more gingival tissue or/ and bone, gingival recession, discomfort that lasts
The advantages: done under office local anesthesia, can be done using a laser for less bleeding
for few days. (14, 15)
and better postoperative recovery.

The disadvantages: Asymmetry, might require re-treatment to remove more gingival tissue
or/CASE PRESENTATION
and bone, gingival recession, discomfort that lasts for few days. [14, 15]
A young male patient referred complaining of unesthetic anterior maxillary
teeth. On clinical and radiographic evaluation, the patient had a poor
dentogingival relation of the anterior maxillary teeth, poor crown shape,
A young male patient referred complaining of unesthetic anterior maxillary teeth. On clinical
color and texture. The patient was presented to the team which advised a
and radiographic evaluation, the patient had a poor dentogingival relation of the anterior
maxillary teeth, intervention
multi‐step poor crown shape, color and
starting texture.
from The patient
proper was presented
planning to thethe
to restore teameight
which advised a multi-step intervention starting from proper planning to restore
anterior teeth after a crown lengthening procedure using laser therapy the eight
anterior teeth after a crown lengthening procedure using laser therapy (Figure 12).
(Figure 12).

Figure 12. The picture on the left showing poor dentogingival relation of the anterior maxillary teeth. The right figure
Figure 12: The picture on the left showing poor dentogingival relation
is showing the poor alveolar crestal bone relation to the first maxillary right crowned incisor, which looks short and
misshapen. Those poor relations lead to esthetically non-balanced anterior maxillary teeth.
of the anterior maxillary teeth. The right figure is showing the poor
alveolar crestal bone relation to the first maxillary right crowned
4.5. Internal smile procedures (patient’s personal satisfaction)
incisor, which looks short and misshapen. Those poor relations lead to
esthetically non‐balanced anterior maxillary teeth.
Some patients can be unsatisfied with their smiles regardless of the type of treatment planned.
Unless
the operator figures out the exact factor contributing to the problem treatment will not
really work. To provide examples, patients might be looking for cheek, lip, or chin piercing as
‐ INTERNAL SMILE PROCEDURES (patient’s personal satisfaction)
the major key factors to their internal satisfaction while others, regardless of the procedures
Some patients can be unsatisfied with their smiles regardless of the type of
performed on their teeth, a single cheek dimple may be the change that the patient desires.
treatment
And once that leftplanned.
cheek dimpleUnless the
procedure operator
is performed, figures out
self-satisfaction the exact
is reflected factor
positively
oncontributing
the actual smile to
(Figure
the 13). [18]
problem treatment will not really work. To provide
examples, patients might be looking for cheek, lip, or chin piercing as the
major key factors to their internal satisfaction while others, regardless of
the procedures performed on their teeth, a single cheek dimple may be the
change that the patient desires. And once that left cheek dimple procedure
is performed, self‐satisfaction is reflected positively on the actual smile
satisfaction reflected positively on her actual smile (Figure 13). (18)
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Surgical Techniques to Improve the Smile

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203

Figure 13: The patient had the desire to get a dimple on the left cheek that
made her satisfied with her smile. The postoperative picture on the right side
indicates a more pleasant smile.

Figure 13: The patient had the desire to get a dimple on the left
Figure 13. The patient had the desire to get a dimple on the left cheek that made her satisfied with her smile. The post‐
Other situation, where patients can be presented with acceptable jaw skeletal
operative picture on the right side indicates a more pleasant smile.
cheek that made her satisfied with her smile. The postoperative
relation, however, with microgenia (small chin bone) that reduces their self‐
picture on the right side indicates a more pleasant smile.
Another situation, is where patients can have acceptable jaw skeletal relations, however,
satisfaction to their smiles (Figure 14), or macrogenia (large chin bone). Such chin
microgenia (small chin bone) or macrogenia (large chin bone) reduces their self-satisfaction of
deformities can be treated with genioplasty; chin augmentation or chin reduction
their smiles (Figure 14). Such chin deformities can be treated with genioplasty, chin augmen‐
procedures (2,5,7,9,13).
Another
tation or situation, is where
chin reduction procedures patients
[2, 5, 7, 9, and 13].can have acceptable jaw skeletal

relations, however, microgenia (small chin bone) or macrogenia (large chin
bone) reduces their self‐satisfaction of their smiles (Figure 14). Such chin
deformities can be treated with genioplasty, chin augmentation or chin
reduction procedures (2, 5, 7, 9, and 13).

Figure 14. Although the patient presented with what looks like a retruded lower jaw (left), his occlusion is in an ac‐
ceptable relation, that clarifies that the defect is mainly at the chin level, microgenia (right).
5. Conclusion

In conclusion,
Figure 14: this chapter presents
Although the major components
the patient presented of a “smile” from thelooks
with what anatomical
like a
aspect as well as the evaluation methodology. A multi team approach can provide the best
retruded lower jaw (left), his occlusion is in an acceptable relation,
evaluation and management plan. Hence, the term “Smile Team” is appropriate to be em‐
that clarifies
braced that and
in the medical the defect
dental is mainly at the chin level, microgenia
professions.
(right).
Conclusion
In conclusion, this chapter presents the major components of a “smile”
from the anatomical aspect as well as the evaluation methodology. A multi
team approach can provide the best evaluation and management plan.
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The trick is always the proper diagnosis, treatment plan, and best implementation of one or
more of the treatment modalities.
6. Recommendations
It is recommended that dental students, medical students, general practitioners, and residents
dealing with the facial complex consider applying training rotations at the involved specialty
departments in order to get a clear exposure to the capabilities of each specialty. Such will help
expanding their skills in treatment planning and seeking interspecialty care. As well, it should
be noted that dealing with smiles is considered to be a very challenging task at every step of
treatment, hence, managing teeth in the anterior maxillary zone with veneers, placing dental
implants, or lips enhancement procedures should always be approached with caution and
perhaps under the supervision of specialized providers.
Acknowledgements
The author would like to thank:
The administration of Umm Alqura University for the research support.
My colleagues and friends; Professor Motaz Ghulman (Vice dean of the faculty of dentistry at
King Abdulaziz University) for his continuous support of the “smile team” patient manage‐
ment. As well as special gratitude to Dr Khalid Zawawi, Dr Ibrahim Yamani, Dr Mohammad
Khalil, and Dr Ahmad Halawani for their interspecialty patient care.
My dear colleagues; the resident at the Saudi Board of Oral Maxillofacial Surgery, the dental
students in Umm Alqura University and King Abdulaziz University whom have always been
of continuous help in research and case documentation.
Author details
Mazen Almasri*
Address all correspondence to: mazen_ajm@yahoo.com
Oral and Maxillofacial Surgeon, Umm Alqura University, Saudi Arabia

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References
[1] Manne P1, Zakkula S, Atla J, Muvva SB, Sampath A. Redefining smile-a multidisci‐
plinary approach. J Clin Diagn Res. 2013 Jul;7(7):1527-9
[2] Mazen Almasri. Cosmetic considerations in facial defect reconstruction, A text book
of advanced oral maxillofacial surgery, volume I. InTech Pub, 2013;573-592
[3] Nold SL, Horvath SD, Stampf S, Blatz MB. Analysis of Select Facial and Dental Es‐
thetic Parameters. Int J Periodontics Restorative Dent. 2014 Sep;34(5):623-629.
[4] Karen L. Schmidt, Jeffrey F. Cohn. Human Facial Expressions as Adaptations: Evolu‐
tionary Questions in Facial Expression Research. Am J Phys Anthropol. 2001; Suppl
33: 3–24.
[5] Mazen Almasri, Sara Bukhari. Considerations to planning orthognathic surgery in

different regions of Saudi and the Middle East. American Journal of Public Health
Research, 2014, Vol. 2, No. 1, 6-9
[6] Kourkouta S., Implant therapy in the esthetic zone: smile line assessment. Int J perio
Restorative Dent, 2011:31(2):195-201
[7] Niamtu J. Cosmetic oral and maxillofacial surgery options. Journal of the American
Dental Association. 2000;131:756-764. 2.
[8] Al-Gunaid, T., Yamada, K., Yamaki, M., Saitod, I, “Soft-tissue cephalometric norms
in Yemeni men.” Am. J. Orthod. Dentofacial Orthop. 132, 2007, pp. 576.
[9] Niamtu J. New technologies in cosmetic facial surgery. VaDent J. 2000;77:9-12. 3.
[10] Alster TS, West TB. Human-derived and new synthetic injectable materials for soft-
tissue augmentation: current status and role in cosmetic surgery. Plast Reconstr Surg.
2000;105:2515-2528.
[11] Burcu Bas, Bora Özan, Nükhet Çelebi. Treatment of masseteric hypertrophy with
botulinum toxin: A report of two cases, Med Oral Patol Oral Cir Bucal. 2010 Jul;15
(4):649-52.
[12] Liu X, Zhu S, Hu J. Modified versus classic alar base sutures after LeFort I osteotomy:
a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014 Jan;117(1):
37-44.
[13] John McLurdy, Sameul Lam. Cosmetic surgery of the Asian face. Thieme 2005.
[14] Flax H. Soft and hard tissue management using lasers in esthetic restoration Dent
Clin North Am. 2011 Apr;55(2):383-402, x. doi: 10.1016/j.cden.2011.01.008
[15] Ribeiro FV1, Hirata DY, Reis AF, Santos VR, Miranda TS, Faveri M, Duarte PM.
Open-flap versus flapless esthetic crown lengthening: 12-month clinical outcomes of
a randomized controlled clinical trial. J Periodontol. 2014 Apr;85(4):536-44
www.dentalbooks.co
[16] Mazen Almasri. Does Immediate Reconstruction of Postextraction Lost Buccal Plate
Reduce the Chances of Implant Surface Exposure after Crown Placement? Surgical
Science, 2013, 4, 110-113
[17] Mazen Almasri, Bone graft for future dental implants, the truthful reality. Lambert
publishing 2013.
[18] Bao S, Zhou C, Li S, Zhao M. A new simple technique for making facial dimples.
Aesthetic Plast Surg. 2007 Jul-Aug;31(4):380-3.
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Chapter 12
Surgical Treatment of Odontogenic Periapical Lesions
Onur Gonul, Kamil Göker and Sertac Aktop
http://dx.doi.org/10.5772/59270
1. Introduction
Periradicular surgical practise is done for the treatment or prevention of periradicular

pathologies. Abscess drainage, periapical surgery, corrective surgery, intentional replantation,
and root removal are the most commonly performed types of periradicular surgery. Conven‐
tional endodontic treatment is generally a successful procedure; however, in 10% to 15% of
cases the symptoms can persist or spontaneously recur. Findings such as a draining fistula,
pain on mastication, or the incidental noting of a radiolucency increasing in size indicate
problems with the initial endodontic procedure. Surgery then becomes a an important part of
treatment in such cases. A decision on whether to approach the case surgically or to consider
orthograde (through the coronal portion of the tooth) endodontic retreatment is dictated by
various clinical and anatomic situations. Apicoectomy, apical surgery, endodontic surgery,
root resection, root amputation are the terms which are used for surgery involving the root
apex to treat the apical infection. It is the cutting off of the apical portion of the root and
curettage of periapical necrotic, granulomatous, inflammatory or cystic lesions. In spite of
adequate endodontic treatment, if periapical lesions are not resolved, then apical surgery is
taken to consideration.
2. Indications
• Apical anomaly of root that blocks appropriate root canal theraphy
• Presence of lateral/accessory canal/apical region perforations
• Roots with broken instruments/overfillings
• Fracture of apical third of the root

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• Formation of periapical granuloma or odontogenic cyst related with apex

• Draining sinus tract/nonresponsive to RCT
• Extension of root canal sealant cement/filling beyond the apex
3. Contraindications
• Presence of systemic diseases—leukaemia, uncontrolled diabetes, anaemia, thyrotoxicosis,

etc.
• Teeth damaged beyond restoration
• Teeth with deep periodontal pockets and grade III mobility
• Traumatic occlusion
• Poor root crown ratio
• Acute infection which is nonresponsive to the treatment
• Anatomic structures (e.g., adjacent nerves and vessels)
• Structures interfere with access and visibility
4. Assessment for surgical procedures
The basic purpose of periapical surgery can be determined as follows:
• Elimination of disease
• Prevention of disease
• Removal of damaged or redundant tissue
• Improvement of function and esthetics.
In order to achieve these goals, following principles have to be estimated:

Preoperatively;
• Developing a surgical diagnosis
Intraoperatively;
• Aseptic technique
• Flap design
• Tissue handling
• Haemostasis
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• Dead space management
• Decontamination and debridement
• Suturing
Post operatively;
• Oedema control
• İnfection control
• Patient’s general health and nutrition
• Follow-up.
5. Incision and flap design
Surgical access is a compromise between the need for visibility of the surgical site and the
potential damage to adjacent structures. A properly designed and carefully reflected flap
results in good access and uncomplicated healing. Although several possibilities exist, the
three most common incisions are
• Submarginal curved (i.e., semilunar) (fig:1)
• Submarginal, and full mucoperiosteal (i. e., sulcular) (fig:2)
• Submarginal and full mucoperiosteal incision has a three-corner (i.e., triangular, trapezoi‐
dal, rectangular).(fig:3)
Figure 1. Semilunar incision

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Figure 2. Submarginal incision
Figure 3. Full mucoperiosteal incision
6. Semilunar incision
Despite the commonly use of semilunar incision among practitioners, it’s limitations and
potential complications should be considered deply before surgery. Semilunar incision
is a slightly curved half-moon horizontal incision in the alveolar mucosa. Although the location
allows easy reflection and quick access to the periradicular structures, it limits the clinician in
providing full evaluation of the root surface. The incision is based primarily in the unattached
or alveolar mucosa, which heal more slowly with a greater chance of dehiscence than a flap
based primarily in attached or keratinized tissue. In addition, the flap design carries the flap
over the inflamed surgical site, and this inflamed mucosa is at a high risk of breakdown. Other
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disadvantages to this incision include excessive hemorrhage, delayed healing, and scarring;
this design is therefore contraindicated for most endodontic surgery.
7. Submarginal incision
The horizontal component of the submarginal incision is in attached gingiva with one or two
accompanying vertical incisions. Generally, the incision is scalloped in the horizontal line, with
obtuse angles at the corners. The incision is used most successfully in the maxillary anterior
region or, occasionally, with maxillary premolars with crowns. Because of the design, prereq‐
uisites are at least 4 mm of attached gingiva and good periodontal health. The major advantage
is esthetics. Leaving the gingiva intact around the margins of crowns is less likely to result in
bone resorption with tissue recession and crown margin exposure. Compared with the
semilunar incision, the submarginal provides less risk of incising over a bony defect and
provides better access and visibility. Disadvantages include hemorrhage along the cut margins
into the surgical site and occasional healing by scarring, compared with the full mucoperiosteal
sulcular incision.
8. Full mucoperiosteal incision
The full mucoperiosteal incision is made into the gingival sulcus, extending to the gingival
crest. This procedure includes elevation of interdental papilla, free gingival margin, attached
gingiva, and alveolar mucosa. One or two vertical relaxing incisions may be used, creating a
triangular or rectangular design.
The full mucoperiosteal design is preferred over the other two techniques. The advantages
include maximum access and visibility, not incising over the lesion or bony defect, fewer
tendencies for hemorrhage, complete visibility of the root, allowance of root planing and bone
contouring, and reduced likelihood of healing with scar formation. The disadvantages are that
the flap is more difficult to replace and to suture; also, gingival recession can develop if the
flap is not reapproximated well, exposing crown margins or cervical root surfaces.
9. Periapical exposure
Periapical exposure must be achievedafter full thickness flap elevation by using a sterile round
surgical burr. Mostly the cortical bone overlying the apex has been resorbed due to underlying
apical pathosis, exposing a soft tissue lesion. If the opening is small, it is enlarged, until
approximately half the root and the lesion are visible. With a limited bony opening, radio‐
graphs are used in conjunction with root and bone topography to locate the apex. Regardless
of the handpiece used, there should be copious irrigation with a syringe or through the
handpiece with sterile saline solution. Enough overlying bone should be removed to expose
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the area around the apex and at least half the length of the root. Good access and visibility are
important; the bony window must be adequate. The clinician should not be concerned about
the bone removal because once the infection resolves, the bone will reform. The exposure of
the root is done before resecting the root to avoid the potential of blending the root in with the
bone and losing surgical orientation. This is especially critical in the mandible where the bone
is dense. Lower incisor roots are carefully exposed because the proximity with adjacent teeth
could lead to treatment of the wrong apex. Fig:4
Figure 4. Periapical exposure
10. Curettage
Granulomatous, inflamed tissue around the periradicular area should be removed to gain
access and visibility of the apex, to obtain a biopsy for histologic examination (when indicated),
and to minimize hemorrhage. If possible, the tissue should be enucleated with a suitably sized
sharp curette. Fig:5
11. Root end resection/prepertion/restoration
Apical third of the root is most likely the most difficult part to obturate properly. Presence of
accessory canals increases at the apex as well, which may have not been initially cleaned and
debrided, thereby leaving a source of continued infection. In general, approximately 2 to 3 mm
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of the root is resected more if necessary for apical access or if an instrument is lodged in the
apical region; less if too much removal would further compromise stability of an already short
root.Fig:5
Figure 5. Root resection
Figure 6. Root preperation for retrograd filling

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Figure 7. Suturing after retrograd filling
An angled micro handpiece and micro round bur or ultrasonic tip can be used for retropre‐
paration. The bur or tip is placed at the apical opening of the canal and guided gently deeper
into the canal as it cuts. Once the retropreparation is completed the prepared cavity is inspect‐
ed. The gutta-percha at the base is recondensedwith small 0.5 mm microplugger (Fig:6). After
that orot end filling material can be applied. The aim of placing root end filling material is to
establish an apical seal that inhibits the leakage of residual irritants from the root canal into
the surrounding tissues (Fig:7).
12. Flap replacement and suturing
After finishing surgical procedures the flap is returned to its original position and is held with
moderate digital pressure and moistened gauze. Primary closure of the elevated flap is gained
by basic or interrupted sutures. Absorbable monoflament or sling suture material is commonly
used. After suturing, the flap should again be compressed digitally with moistened gauze for
several minutes to express more hemorrhage. This limits postoperative swelling and promotes
more rapid healing and adequate positioning of the flap.
13. Postoperative care
Oral and written information should be supplied in simple, straightforward language. Patient
should be informed about the procedure and what is coming next. A chart like the one below
can be prepared and given to patient.
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• Do not raise the lip to look at the suture.

• Place an icepack on the outside of the face 20 min. out of every 1½ hour for the first
day of surgery
• Instruct to do salt wateror clorhexidine rinsing 3 times daily preferably after meal.
• Do not chew any hard food with the tooth for 1 week.
• Do not brush in the area of surgery for 1 week.
• Maintain good oral hygiene.
• Soft diet is suggested for the first 4 days.
14. Complications
Damage to the anatomic structures, bleeding, splattering of retrograd filling material at the
operation site, incomplete root resection and curettage process, inadequate flap closure,
healing problems of soft tissue, scar formation are the most common complications that may
occur should be considered during and after the surgical procedure.
15. Prognosis
Healing capacity of involved tissues after periapical surgery is considered as good. Under the
conditions that the diagnosis and treatment planning is held carefully and the intraoperative
procedures achieved successfully most of the cases reveals long term uneventful follow up.
16. Sample cases
16.1. Case 1
The patient applied to our our clinic with the complaint of swelling at right maxillar buccal
area. Via radiographic and clinical examination, an intrabony lesion was observed between
right maxillary lateral and first molar tooth apices about 5x2 cm in size. All teeth related to
lesion were devital. An aspiration biopsy performed and characteristic yellowish fluid which
has kollesterin crystals in it was gained which lead us to define the lesion as a radicular cyst
due to necrose pulp tissues.
Treatment plan was to have endodontic treatment after that to enucleate the cyst totally,
achieve apicoectomies to all related teeth apexes and reconstruct the intrabony defect by
cancellous-bone grafts and membranes. We receipt postoperative antibiotic theraupy per os
(amoxicillin 875 mg+clavulanate 125 mg 2x1) for ten days. Defect area started to filled with
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healing tissue from the base of the cavity and the complaints of the patient disappeared
considerably.
Figure 8. OPTG view before surgery
Figure 9. Incision
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Figure 10. Exposure of Cystic Lesion
Figure 11. Elevation of Cyst Epithelium

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16.2. Case 2
A 43-year-old female patient referred to our clinic with incidental OPTG examination finding
of a homogenous radiolucent, sharply lined lesion located between canine teeth in anterior
maxilla. On clinical examination, oral mucosa was intact and there was no evidence of bony
expansion on both buccal and palatal sides. Pulp vitality testing was performed for all
maxillary anterior teeth, 12 and 22 were found to be non-vital. With an inital diagnosis of
inflammatory dentigerous cyst, enucleation of the lesion was planned. Prior to surgery,
endodontic treatment of all involved teeth were completed. On surgical exploration, there was
no expansed buccal bone was observed. After reaching the cyst capsule and performing
resection of the involved roots, two seperate cystic cavities extending palatally behind the roots
that have been seperated on the midline with a bony septa were encountered. Lesions were
totally enucleated and submitted to histopathological examination. Result of histopathological
examination was fibrotic capsule with medium degree of mononuclear cell infiltration,
hyperplastic stratified squamous epithelium. In the postoperative period, healing was
uneventful.
Figure 12. Cystic cavity

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Figure 13. Graft material
Figure 14. Application of collagen membrane

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Figure 15. Adaptation of flap
Figure 16. Primary closure of area

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Figure 17. OPTG view
Figure 18. CT image

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Figure 19. CT image
Figure 20. CT image

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Figure 22. Histopathologic evaluation

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16.3. Case 3
36-year-old female patient admitted to our clinic with complaints of pain.Clinical and radio‐
graphic examination revealed a demarcated radiolucent leson at the the apexes of the teeth no:
25,26,27. An electrical vitality test examination related to the teeth 24, 25and 27 was performed
which found that teeth are non-vital, and these findings suggest that lesion was caused by non
vital pulp tissues of related teeth. CT results showed that maxillary sinus bone compact and
buccal cortex were perforated elevated and sinus floor was elevated by the lesion. After
completion of endodontic treatment of related teeth patient have been operated under
intravenous conscious sedation. During the operation, primarily by aspiration of cyst fluid
pressure is reduced and the 2,3x2x1 cm sized radicular cyst was enucleated. Apical resections
of relevant teeth were performed an operation region was primarily closed by 3.0 silk suture.
Enucleated lesionwas sent to histopathologic examination for definitive diagnosis sent for and
diagnosis was confirmed as periradicular cyst epithelium.
Figure 23. OPTG view

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Figure 24. CT image
Figure 25. CT image

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Figure 26. Exposure of lesion area
Figure 27. Aspiration of cystic liquid

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Figure 28. Enucleation of cyst epithelium
Figure 29. Cyst epithelium

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Figure 31. Primary closure of lesion area

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Figure 32. Histopathologic evaluation
Author details
Onur Gonul*, Kamil Göker and Sertac Aktop
*Address all correspondence to: onurgonul@yahoo.com
Marmara University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Is‐
tanbul, Turkey
References
[1] Sanghai S., Chatterjee P. A Concise Textbook of Oral and Maxillofacial Surgery, Jay‐
pee Brothers Medical Publishers (P) Ltd, New Delhi, 2009
[2] Archer WH. Oral and Maxillofacial Surgery.5th Edition, WB Saunders Co. Philadel‐
phia 1975.
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[3] Baumann L, Rossman SR. Clinical Roentgenologic and Histopathologic Findings in

Teeth with Apical Radiolucent Areas. Oral Surg 1956;9:1330.
[4] Shafer WG, Hine MK, Levy BM. Textbook of Oral Pathology. 4th Edition, WB Saun‐
ders Co. Philadelphia, 1983.
[5] Textbook of Oral and Maxillofacial Surgery 2008, Neelima Anil Malik Gutmann JL,
Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, 2008
[6] Harrison JW: Logical endodontics, Boston, 1994, Blackwell Scientific
[7] Zuolo ML, Ferreira MOF, Gutmann JL: Prognosis in periradicular surgery: a clinical
prospective study, lnl Enc1ad J 33:9 1, 2000.
[8] Contemprary Oral and Maxillofacial Surgery Fifth Edition James R. Hupp Edward
Ellis III Myron R. Tucker. Mosby, Inc., an affiliate of Elsevier Inc. 2008
[9] Illustrated Manual of Oral and Maxillofacial Surgery. Geeti Vajdi Mitra, Jaypee
Brothers Medical Publishers, New Delhi; 2009
[10] Oral Surgery. Fragiskos D. Fragiskos (Ed.), Springer-Verlag Berlin Heidelberg 2007
[11] Practical lessons in Endodontic surgery Donald. E. Arens. Quintessence Publishing

co,İnc 1998
[12] Barnes IE (1981) Surgical endodontics – introduction, principles,and indications.

Dent Update 8:89–92, 95–99
[13] Bellizzi R, Loushine R. A Clinical Atlas for Endodontic Surgery. Quintessence, Chica‐
go, Ill.1991
[14] Ferreira FB, Ferreira AL, Gomes BP, Souza-Filho FJ (2004) Resolution of persistent
periapical infection by endodonticsurgery. Int Endod J 37(1):61–69
[15] Harrison JW(1992) Surgicalmanagement of endodontically treated teeth. Curr Opin

Dent 2:115–121
[16] Taylor GN, Bump R (1984) Endodontic considerations associated with periapical sur‐
gery. Oral Surg 58:450–455
[17] Danin J, Linder LE, Lundqvist G et al: Outcomes o[periradicular surgery in cases
with apical pathosis and u ntreated canals, Oral Surg Oral Med Oral Pat/101 Oral Ra‐
dial Endad 87:227, 1999.
[18] Lubow RM, Wayman BE, Cooley RL: Endodontic flap design: analysis and recom‐
mendation for current usage, Oral 5urg Oral Med Oral Pathol 58:207, 1984.
[19] McDonald N, Torabinejad M : Surgical endodontics. I n Walton R, Torabinejad M,

editors: Principles and practice of endodontics, ed 3, Philadelphia, WB Saunders
2002.
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[20] Zuolo ML, Ferreira MOF, Gutmann JL: Prognosis in periradicular surgery: a clinical
prospective study, lnl Enc1ad J 33:9 1, 2000
[21] Sauveur G, Roth F; Sobel M et al: The control of haemorrhage at the operative site
during peri radicular surgery, lilt Endod) 32:225, 1999.
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Chapter 13
Treatment Approaches for Odontogenic Cysts of the

Maxillary Sinus
Hasan Garip, Sertac Aktop, Onur Gonul and

Kamil Göker
http://dx.doi.org/10.5772/59087
1. Introduction
Cysts of the maxillary sinus are detected primarily as incidental findings on radiographs. These
cysts often appear as rounded, dome-shaped, soft tissue masses, which are usually located on
the floor of the maxillary sinus. Ectopic teeth in the maxillary sinus are readily diagnosed
radiographically because they are radiopaque. Water’s view, panoramic radiography and
plain skull radiography are simple and inexpensive methods that can be used in daily practice.
The shape and extent of the cysts can vary widely, and the position of ectopic teeth may be
found very close to the eye; in such situations, conventional radiographs may not be sufficient
for determining their dimensions or relationship with anatomical structures. Thus, computed
tomography (CT) should be used, and patient observation should be initiated using a multi‐
disciplinary team that includes specialists from radiology, dentistry, and surgery departments.
Multidisciplinary treatment planning is an important key component in the long-term success

and quality of treatment. In some cases, endodontic treatment should be performed by a dentist
or endodontist before the operation, and the vitality of the teeth should be observed closely
after the operation. Generally, treatment includes enucleation of the cyst and/or surgical
excision, including endoscopic observation in some cases. Long-term multidisciplinary
postoperative patient observation should be performed, especially in cases with high recur‐
rence. The aim of this section is to shed new light on treatment approaches for cysts localized
in the maxillary sinus.
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2. Anatomy of the maxilla
The maxillae are the largest bones of the face, after the mandible. Each assists in forming
the boundaries of three cavities: the roof of the mouth, the floor and lateral wall of the
nose, and the floor of the orbit. They also enter into the formation of the fossae infratempo‐
ral and fossae pterygopalatine, and two fissures, the inferior orbital and pterygomaxil‐
lary. [1] The body of the maxilla is somewhat pyramidal in shape, and contains a large
cavity, the maxillary sinus (antrum of Highmore). [1]
2.1. Blood supply and venous drainage of the maxillary teeth
The arteria (a.) maxillaris arises from the a. carotis externa, which supplies the maxillary teeth.
The maxillary arch is supplied by a plexus of three arterial branches: the a. alveolares superi‐
ores anteriores, a. alveolares superiores medialis, and a. alveolares superiores posteriores. The
a. alveolares superiores posteriores arises from the third division of the a. maxillaris before the
a. maxillaris enters the fossa pterygopalatine (Figure 1). It continues on and enters the
infratemporal surface of the maxilla to supply the maxillary sinus, the premolars, and the
molars (Figure 1).
Figure 1. A. maxillaries and a. alveolares superiores posteriores.
During operations performed in this area there may be spontaneous bleeding from these
vessels during surgery and sometimes serious bleeding in the postoperative period after local
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Treatment Approaches for Odontogenic Cysts of the Maxillary Sinus 237

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anesthetics lose activity. This situation may put the patient in a dangerous situation at two
time points: immediately after the operation, because of bleeding, and later, after the operation,
because of infection of formed clots. Careful CT examinations before the operation and
appropriate surgical management will help to avoid all intraoperative and post-operative
bleeding complications.
The a. alveolares superiores medialis arises from the a. infraorbitalis as does the a. alveolares
superiores anteriores. It arises within the infraorbital canal where it descends to supply the
maxillary sinus and plexus at the level of the canine. The a. alveolares superiores anteriores
also arises at the level of the middle superior alveolar artery and runs with it to supply the
anterior portion of the maxillary arch, maxillary sinus, and anterior teeth.
The venous (v.) drainage of v. alveolares superiores posteriores, v. alveolares superiores
medialis, and v. alveolares superiores anteriores drain into the plexus venosus pterygoideus.
[3] Some of the most important points during operations in the maxillary part of the body are
first, during the design of the flap, to protect the plexus venosus pterygoideus and lymphatic
drainage and, second, to be gentle during the retraction of soft tissues.
2.2. Innervation of the maxilla and of the maxillary teeth
The nervus trigeminus (the fifth cranial nerve) is a mixed nerve (n.) responsible for sensation
in the face and certain motor functions, such as biting and chewing. It has three major branches:
the n. ophthalmicus, n. maxillaris, and the n. mandibularis. The n. ophthalmicus and n.
maxillaris are purely sensory. The n. mandibularis has both sensory and motor functions
(Figure 2). [1]

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Figure 2. The nervus trigeminus
• The n. ophthalmicus carries sensory information from the scalp and forehead, the upper
eyelid, the conjunctiva and cornea of the eye, the nose, the nasal mucosa, the frontal sinuses,
and parts of the meninges.
• The n. maxillaris carries sensory information from the lower eyelid and cheek, the nares and
upper lip, the upper teeth and gums, the nasal mucosa, the palate and the roof of the
pharynx, the maxillary, ethmoid and sphenoid sinuses, and parts of the meninges. It leaves
the ganglion trigeminale between the n. ophthalmicus and the n. mandibularis lateral to the
sinus cavernosus. The nerve leaves the cranium forward, through the foramen rotundum
and enters the fossa pterygopalatina where it divides into three main branches: the n.
zygomaticus, n. infraorbitalis, and truncus pterygopalatinus.
• The n. infraorbitalis is a direct extension of the n. maxillaris. It leaves the fossa pterygopa‐
latina and enters the orbit through the fissura orbitalis inferior, together with a. infraorbi‐
talis. The nerve runs forward on the floor of the orbita in one fulcrum, which turns anteriorly
to the canalis infraorbitalis. Going forward it leaves the maxilla through the foramen
infraorbitale (Figure 3), positioned on the anterior wall of the maxilla under the sutura
zygomaticomaxillaris, and gives rise to terminal branches.
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Figure 3. N.infraorbitalis, c. infraorbitalis and f.infraorbitalis
The n. alveolares superiores arises from the n. maxillaris in the fossa pterygopalatina just before
n. infraorbitalis enters the orbita or arises from the n. infraorbitalis in the sulcus infraorbitalis.
The upper alveolar nerves are divided in three groups: the n. alveolaris superior posterior, the
n. alveolaris superior medius, and the n. alveolaris superior anterior. [4] Working 5 mm above
the roots of the teeth in the maxilla will avoid damage to the neurovascular plexus. [5] This is
one of the most important points during surgical procedures performed in the maxillary
sinuses when the teeth are vital (Figure 4). A second important point is to avoid damage to the
n. infraorbitalis, which is commonly damaged during elevation and retraction of mucoper‐
iosteal flaps.
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Figure 4. N. infraorbitalis, c. infraorbitalis and f. infraorbitalis (part of figure adapted from Netter).
The n. mandibularis carries sensory information from the lower lip, the lower teeth and gums,
the chin and jaw, parts of the external ear, and parts of the meninges. The mandibular nerve
carries touch/position and pain/temperature sensation from the mouth. It does not carry the
taste sensation; the chorda tympani is responsible for taste. However, one of its branches, the
lingual nerve, carries somatic sensation from the tongue.
3. History and anatomy of the maxillary sinus
The maxillary sinus was first discovered and illustrated by Leonardo da Vinci (1452-1519), but
the earliest scientific description is attributed to the British surgeon Nathaniel Highmore
(1613-1685). [2] The sinus maxillaris is located behind the anterior wall of the os. maxillaris,
under the orbital cavities and above the alveolar bone of the teeth. It has the shape of a pyramid,
with a volume of ~15 cc, inferosuperior length of 33 mm, a mediolateral length of 23 mm, and
anteroposterior length of 34 mm (Figure 5). The deepest point of the maxillary sinus is normally
located in the area of the molar roots; the next deepest area is at the premolar roots. Thus, the
risk of exposing the maxillary sinus intraoperatively is greatest when molar teeth are extracted
(Figure 6). [6-10]
Kiliç et al. [8] evaluated the maxillary sinus regions from 92 patients, using dental cone-beam
CT. This study showed that ~10.5% of molar roots were located in the maxillary sinus. Jung
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and Cho [9] in their study showed that 28.1% of molar roots were located in the maxillary
sinus. Hirata et al. [10] investigated 1337 patients after 2038 molar extractions and found 3.8%
maxillary sinus perforations. In addition to the relationship between the roots and the
maxillary sinus floor, exposing the maxillary sinus intraoperatively when molar teeth are
extracted depends on the shape and distance of the roots from each other, extraction technique,
skill and experience. Knowledge of the anatomical shape of the maxillary sinus and the
relationship between the sinus floor and tooth apices, careful planning, and good extraction
technique will avoid maxillary sinus perforations.
The paranasal sinuses and the majority of the nasal cavity itself are lined with pseudostratified
columnar ciliated epithelium (respiratory type). The cilia suspend a mucous blanket, which is
secreted by goblet cells in the mucous membrane. [11] The sinus maxillaris has an opening for
drainage, the ostium, located on the medial wall into the hiatus semilunaris. The position of
the ostium does not help draining of sinus contents when the head is in an upright position.
Before operation, this opening should be checked in CT scans for any obstruction. Ordinarily,
it has a diameter of 5-7 mm and a length of 1-2 mm.
Figure 6. Maxillary sinus exposed after second molar tooth extraction.
Janner et al. [12] reported that the thickness of the Schneiderian membrane showed a wide
range, with a minimum value of 0.16 mm and a maximum value of 3.461 mm. The highest
mean values, ranging from 2.16 to 3.11 mm, were found for the mucosa located in the mid-
sagittal regions of the maxillary sinus. Dagassan-Berndt et al. [13] stated that in the molar
regions with periodontal destruction, Schneiderian membrane thickening occurred, particu‐
larly in combination with small bone layers above the root tips or periapical lesions.
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Figure 5. The sinus maxillaries. Volume ~15 cc and pyramidal shape. 1. inferosuperior length 33 mm, 2. Mediolateral
length 23 mm, 3. Anteroposterior length 34 mm.
4. Etiology of cysts localized in the maxillary sinus
A cyst is a lesion consisting of an epithelial sac, filled with fluid or semisolid material, and is
surrounded by a connective tissue capsule. Cysts are more commonly seen in the maxilla than
the mandible. The most common causes of cysts localized in the maxillary sinus are chronic
infection, allergic sinonasal disease, trauma, previous surgery, obstruction of the sinus ostium,
accumulations of secretions, ectopic teeth, foreign bodies (e.g., dental implant, tooth roots,
graft materials), dental infections, incomplete sealing of all communications between the root
canal system and periradicular tissues during endodontic treatment, mechanical obstruction
of mucociliary flow, defects in ciliary capabilities to propel the mucous blanket and genetic
factors. Pathologically, a cyst can develop and grow in the sinus until it reaches a large size
with no serious complaint by the patient because of the anatomy of the sinus. [14-16]
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5. Cyst treatment options
Marsupialization (Partsch I) procedure is a technique for making a surgical incision in the cyst
capsule, minimizing intracystic pressure, and evacuating its contents, then suturing the edges
of the cyst to the healthy surface of the oral mucosa to establish a large permanent opening
(Figure 7).[17]
Decompression is a technique that relieves the pressure within the cyst by making a small
opening in the cyst and keeping it open. This can be achieved with a drain or obturator. Each
day the obturator should be removed and the cyst cavity should be irrigated. The cyst size will
decrease and any damage to important structures upon enucleation will be diminished
(Figures 8, 9). [18]
The decompression and marsupialization of cysts were first suggested by Partsch in the
German literature in the late 19th century. [18] Indications for such marsupialization and
decompression are large cysts with thin bony walls that may cause spontaneous fracture, cysts
that are very close to structures such as the n. alveolaris inferior or nasal floor, and infected
cysts. [17, 18, 19]
Enucleation (Partsch II procedure) is a procedure in which all pathological tissue is removed
and wound edges are closed (Figure 10). [18]
Figure 7. Marsupialization (Partsch I) procedure of a ranula.

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Figure 8. Decompression technique for a dentigerous cyst.

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Figure 9. Enucleation after 12 months of decompression.

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Figure 10. Enucleation (Partsch II procedure) of an odontogenic keratocyst.
6. Cases
6.1. Case 1
A 19-year-old male was referred to our department of oral and maxillofacial surgery with a 3-
week history of swelling on the right side of the face. There was no history of trauma, pain,
paresis, paresthesia, or lymphadenopathy. There was slight but obvious facial asymmetry
caused by the swelling over the right maxillary region. The mass was firm and non-tender on
palpation and not adherent to the overlying skin. Intra-oral examination showed little
expansion of the upper right third molar region.
A panoramic radiograph and CT showed a well-defined unilocular radiolucency involving

the right maxillary sinus along with the impacted third molar in the top part of the maxillary
sinus in conjunction with the orbital floor. A vitality test was performed; all the teeth were
vital.
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Figure 11. Panoramic radiograph and CT views.
In cases like this, careful examination is important. Points that should be checked include
possible obstruction of the sinus ostium (Figures11, 12), the need for an antrostomy procedure,
the route of the canalis nasolacrimalis, resorption of the posterior bony wall of the sinus,
continuity of the orbital floor, and eye examinations before and after the operation. In such
operations where visualization is a problem, an endoscopic-assisted approach is mandatory.
[20] Endoscopic sinus surgery has been performed for various indications in maxillofacial
surgical practice. It has been used for the assessment of antral pathologies, removal of foreign
bodies, orthognathic procedures, and the treatment of facial fractures. [21, 22] Especially after
finishing the removal of a cyst and tooth in operations like this using endoscopy, the surgeon
should check any remaining pathology of the cyst, continuity of the orbital floor, to assess the
possibility of a blow-out fracture [23], root tips of the teeth and any possible damage, check
the aperture of sulcus nasolacrimalis, and perform an antrostomy using endoscopic assistance
as needed. [24]
The operation was performed under general anesthesia, combined with local anesthesia. A
mucoperiosteal flap was opened in two layers (Figure 13). Through a modified Caldwell-Luc
approach, the cyst was exposed (Figure 14). At this stage in the operation, saving teeth vitality
is the most important point, so it is important to work at least 5 mm away from the teeth apices.
After the pus was removed from the cyst, the tooth was carefully extracted under endoscopic
assistance and the remaining part of the cyst was then enucleated (Figure 15, 16). Using
endoscopy, the cavity was checked (Figure 17) and packing of the sinus (Figure 18) was
performed; this was removed 3 days later. Vitality of the teeth were checked for the last time
at 3 months after the operation and all teeth were vital.

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Figure 12. Panoramic radiograph, lateral cephalometric and CT views showing tooth in the right maxillary sinus.
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Figure 13. Mucoperiosteal flap preparation.
Figure 14. Exposure of the cyst. Endoscopic view (right).

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Figure 15. Enucleation of the cyst.
Figure 16. Extraction of the tooth.

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Figure 17. Postoperative cavity checking.
Figure 18. Packing of the sinus after antrostomy.
6.1.1. Intranasal inferior meatal antrostomy technique
An intranasal inferior meatal antrostomy is a process of making an opening in the nasoantral

wall of the inferior meatus by an intranasal route. The nasoantral wall of the inferior meatus
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is perforated with a curved hemostat and then this opening is enlarged. The opening should
be 1.5-2 cm in diameter and as close to the floor of nose as possible (Figure 19). Intrasinus pus/
debris should be removed by suction. Packing into the sinus is achieved from the posterior,
packing layer-by-layer upwards and forwards (to facilitate removal through the antrostomy)
and nose packing may also be required if there is severe bleeding (Figure 20). [25]
Figure 19. Intranasal inferior meatal antrostomy technique.
Figure 20. Packing of the sinus maxillaris.
6.2. Case 2
During an incidental radiological exam (orthopantomograph, OPG, Figure 21 at our depart‐

ment of radiology, a 51-year-old male with no complaints and no history of any trauma, pain,
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paresis, paresthesia, or lymphadenopathy, was discovered to have an ectopic tooth in the right
maxillary antrum. A CT scan (Figure 21) was performed and all important points were
checked. An operation was performed under general anesthesia with combined local anes‐
thesia. Using a crestal incision, a trapezoid mucoperiosteal flap was designed and carefully
elevated. The tooth was extracted under endoscopic assistance (Figures 22, 23) and a dentig‐
erous cyst was enucleated (Figure 24). Using endoscopy, all cavities were checked and packing
of the sinus was performed; this was then removed 3 days later.
Figure 21. OPG and CT views.

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Figure 22. Extraction under endoscopic assistance.

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Figure 23. Extraction under endoscopic assistance.
Figure 24. Enucleated dentigerous cyst.
6.3. Case 3
A 23-year-old female was referred to our department of oral and maxillofacial surgery with
headache, fatigue, and difficulty in nasal breathing. After a radiological examination (figure
25), it was seen that there was an ectopic third molar in the left sinus and a wisdom lower left
third molar in conjunction with a cyst. A CT scan (Figure 26) was performed and all important
points were checked and it was seen that the third molar in the maxillary sinus was associated
with a cyst that had occupied over two-thirds of the left maxillary sinus.
An operation was performed under general anesthesia with combined local anesthesia. A
trapezoid mucoperiosteal flap was designed and carefully elevated (Figure 27). The tooth was
extracted (Figure 28) and the cyst was enucleated (Figure 29). An intranasal inferior meatal
antrostomy was performed with packing of the sinus (Figure 30); this was removed 3 days
later. After the operation, all symptoms of headache, fatigue, and difficulty in nasal breathing
resolved. Pathological specimens were sent for examination and the report showed that the
cyst was an orthokeratotic odontogenic cyst.
During the operation, using envelope incision, the lower-left-third molar was also extracted
and its cyst was enucleated (Figure 31). The pathological report for the lower cyst showed it
to be dentigerous. The patient remains under observation (Figure 32).

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Figure 25. OPG view.
Figure 26. CT views.

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Figure 27. Mucoperiosteal flap preparation.
Figure 28. Tooth extraction.

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Figure 29. Enucleated cyst and extracted tooth.
Figure 30. Intranasal inferior meatal antrostomy and packing of the sinus maxillaris.
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Figure 31. Extracted lower tooth.
Figure 32. 5 year postoperative OPG.
6.4. Case 4
A 26-year-old female was referred to our department with severe headache, fatigue, difficulty
in nasal breathing, halitosis, and a slowly growing facial deformity on the right site of the face.
After radiological assessment (OPG and CT) and clinical examination (Figure 33), it was seen
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that there was a cyst that almost completely filled the right maxillary sinus and there was slight,
but obvious, facial asymmetry caused by the swelling over the right maxillary region. The mass
was firm and non-tender on palpation and not adherent to the overlying skin. Intra-oral
examination showed expansion of the upper right molar region.
Endodontic treatment was performed for the upper right first and second premolars and for
the second molar tooth. It was decided that the first molar roots and third molars would be
extracted. All important anatomical points were carefully checked on CT scans.
An operation was performed under general anesthesia, with combined local anesthesia. A
trapezoid mucoperiosteal flap was designed and carefully elevated (Figure 34). The teeth were
extracted and the cyst was enucleated (Figure 35); and apical resection was performed (Figure
36). An intranasal inferior meatal antrostomy was performed as was packing of the sinus
(Figures 37, 38); this was removed 3 days later. Endoscopic assistance was not used because
of good visualization. Pathological specimens were sent for examination and report confirmed
a radicular cyst (Figure 39).

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Figure 33. Radiological (OPG and CT) and intraoral clinical views.
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Figure 34. Mucoperiosteal elevation and cyst exposure.

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Figure 35. Cyst enucleation.

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Figure 36. Apical resection.

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Figure 37. Intranasal inferior meatal antrostomy and packing of the sinus maxillaris.
Figure 38. Closed mucoperiosteal flap and enucleated cyst.
Figure 39. 5 year postoperative OPG

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6.5. Case 5
A 33-year-old male was referred to our department with difficulty in nasal breathing, halitosis,
and a slowly growing facial deformity on the left side of the face. From radiological (OPG and
CT) and clinical examinations (Figure 42), it was seen that there was a cyst, which was related
to the left maxillary teeth and nasal floor, uplifting the sinus floor, although it did not obliterate
the sinus ostium and the sinus mucosa was not infected. This information was important for
the decision as to whether to perform an intranasal inferior meatal antrostomy or not. In this
case, because the parameters for maxillary sinus ventilation were ideal, we did not perform
an antrostomy. Before the operation all teeth on the left site underwent endodontic treatment
(Figure 41).
An operation was performed under general anesthesia combined with local anesthesia. A
trapezoid mucoperiosteal flap was designed and carefully elevated (Figure 42). The buccal
cortex was decorticated using a round bur without damaging the cyst wall (Figure 43).
Intracystic liquid was aspirated with a 20-cc syringe (Figure 44). During aspiration, cholesterol
crystals were observed clearly in the cyst fluid. After enucleation of cyst (Figure 45), apical
resection plus MTA retrograde filling was performed and the mucoperiosteal flap was sutured.
Pathological specimens were sent for examination and the report was a radicular cyst.
Endodontic surgery involves a combination of curettage of infected tissue and removal of an

infected or damaged root apex. Among the causes of failure in endodontic surgery, the most
frequent is the incomplete sealing of all communications between the root canal system and
periradicular tissues. Many studies have shown that bacteria that remain in the root canal
system have access to the periradicular tissues after resection [26, 27] The main purpose of the
root-end filling material is to provide an apical seal that prevents the movement of bacteria
from the root canal system into the periapical tissues. Recently, an experimental substance,
MTA, was suggested as a potential root-end filling material. In a series of in vitro studies, the
sealing ability of MTA was evaluated, compared with commonly used root-end-filling
materials. It was shown that MTA had significantly less dye and bacterial leakage. [26, 28, 29]
Some studies have shown that when the root canal is confined hermetically and an adequate
retrograde cavity depth is prepared, then variation in the root-end cutting angle does not
necessarily cause any difference in microleakage. [26]
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Figure 40. Radiological (OPG and CT) examination.

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Figure 41. Endodontic treatment of the teeth.
Figure 42. Preparation and elevation of the mucoperiosteal flap.

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Figure 43. Buccal cortex decortication.
Figure 44. Intracystic liquid aspiration with a 20-cc syringe and view of cholesterol crystals.
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Figure 45. Enucleation of the cyst.
7. Conclusions
Because of the anatomy of the maxillary sinus, pathological structures that develop and grow
in the sinus can reach a large size without any serious complaint by the patient, making early
diagnosis unlikely and treatment is important to address morbidity.
OPG and CT scans aid in the diagnosis of cysts localized in the sinus and CT scans are
indispensable in surgical strategy planning. Good visualization during the operation provides
a better opportunity for good cleaning of pathologies, better bleeding control, and minimal
trauma. For better visualization, the use of endoscopy during the operation can simplify and
enhance the procedure. Also, close observation of patients in the early postoperative period
and regular follow-up in the later postoperative period are important.
Author details
Hasan Garip*, Sertac Aktop, Onur Gonul and Kamil Göker

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*Address all correspondence to: hasangarip@yahoo.com
Dear Authors, Add Your Respected Institutions, Town, Country
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[20] Bello SA, Oketade IO, Osunde OD. Ectopic 3rd molar tooth in the maxillary antrum.
Case Rep Dent. 2014;2014:620741.
[21] Varol A, Türker N, Göker K, Basa S. Endoscopic retrieval of dental implants from the
maxillary sinus. Int J Oral Maxillofac Implants. 2006 ;21(5):801-4
[22] Kim JW, Lee CH, Kwon TK, Kim DK. Endoscopic removal of a dental implant
through a middle meatal antrostomy. Br J Oral Maxillofac Surg. 2007, 45(5):408-9.
[23] Chen CT, Chen YR. Endoscopically assisted repair of orbital floor fractures. Plast Re‐
constr Surg. 2001 Dec;108(7):2011-8
[24] Nour YA. Variable extent of nasoantral window for resection of antrochoanal polyp:
selection of the optimum endoscopic approach. Eur Arch Otorhinolaryngol. 2014 Jul
11.
[25] Dhingra PL, Dhingra S. Diseases of Ear, Nose and Throat. Chapter 82 5th edition,
Elsevier 2010
[26] Garip H, Garip Y, Oruçoğlu H, Hatipoğlu S. Effect of the angle of apical resection on
apical leakage, measured with a computerized fluid filtration device. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2011 Mar;111(3):e50-5.
[27] Lin LM, Pascon EA, Skribner J, Langleland K. Clinical, radiographic, and histologic
study of endodontic treatment failures. Oral Surg Oral Med Oral Pathol
1991;71:603-11.
[28] Torabinejad M, Watson TF, Pitt FTR. Sealing ability of a mineral trioxide aggregate
when used as a root end filling material. J Endod 1993;19:591-5.
[29] Torabinejad M, Higa RK, McKendry DJ, Pitt FTR. Dye leakage of four root end filling
materials: effects of blood contamination.J Endod 1994;20:159-63.
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Chapter 14
Multidisciplinary Management of Benign Jaw Tumors in

Children
Mehmet Cemal Akay, Mert Zeytinoğlu,

Birant Şimşek and Işıl Aras
http://dx.doi.org/10.5772/59341
1. Introduction
A tumor is defined, in brief, as abnormal growth of tissue; tumoral formations are classified
under two main headings, benign and malignant. The oro-facial region including the jaw
bones, maxilla and mandible, is a site for a multitude of neoplastic conditions. Odontogenic
tumors (OTs) constitute a wide range and diverse kind of lesions derived from tooth forming
apparatus and its remnants. OTs originate from epithelium or ectomesenchyme or from both,
showing varying degrees of inductive interaction between these embryonic components of the
developing tooth germ. [1]. The majority of these tumors occur intraosseously within the
maxillofacial skeleton, while extraosseous odontogenic tumors occur nearly always in the
tooth-bearing mucosa. Due to their specific structure and location they have been identified
and classified by pathologists into a separate group, differing in histogenesis, biology, clinical
findings and radiological signs from other tumors developing in the oral cavity and facial
bones (Figure 1).
The aim of the chapter is to review multidisciplinary treatment approaches to pediatric patients
with benign jaw tumors from a radiological and clinical point of view and assess advantages
and disadvantages of the current treatment techniques, possible complications and their
prevention in the light of the recent literature.
1.1. Etiology of odontogenic tumors
According to current literatures, it is known that the potential sources for development of an
odontogenic tumor are varied, and these include:
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1. The pre-functional dental lamina (odontogenic epithelium with ability to produce a

tooth), which is more abundant distal to the lower third molars.
2. The post-functional dental lamina, a concept that covers those epithelial remnants such
as Serre´s epithelial rests, located within the fibrous gingival tissue; the epithelial cell rests
of Malassez in the periodontal ligament and the reduced enamel organ epithelium, which
covers the enamel surface until tooth eruption.
3. The basal cell layer of the gingival epithelium, which originally gave rise to the dental
lamina.
4. The dental papilla, origin of the dental pulp, which has the potential to be induced to
produce odontoblasts and synthesize dentin and/or dentinoid material.
5. The dental follicle.
6. The periodontal ligament, which has the potential to induce the production of fibrous
and cemento-osseous mineralized material [2].
Figure 1. Odontogenic tumors arising from odontogenic tissues
From a biological point of view, some of these lesions represent hamartomas with varying
degrees of differentiation, while the rest are benign or malignant neoplasms with variable
aggressiveness and potential to develop metastases. These tumors constitute a heterogeneous
group of diseases with diverse clinical and histopathological features [3]. The relative fre‐
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quency of OTs obtained from studies from different parts of the world, have varied widely.
Some authors have reported that OTs are rare with a relative frequency of 1%, while others
have reported OTs constitute up to 32% of jaw lesions [4-6]. These disparities have been
suggested to be due to the differences in terminology and classification and also, possibly due
to racial and or genetic differences in the occurrence of the various types of OTs. OTs comprise
a large heterogeneous group of lesions originating from the epithelium and/or odontogenic
ectomesenchyme and remnants. OTs include entities of a hamartomatous nature, such as
odontoma, benign neoplasms, some of which are aggressive as is the case of ameloblastoma
and myxoma and malignant neoplasms capable of metastasis [2, 7].
Primary jaw tumors are broadly classified into odontogenic and nonodontogenic groups. The
World Health Organization (WHO) classified this group of lesions in 1971 and 1992. In 2005,
the WHO published the latest updated edition of the classification of OTs. There were 6 major
changes in this schema from the previous versions namely:
1. parakeratinized variant of odontogenic keratocyst is now classified as a benign tumor and
termed KCOT
2. adenomatoid odontogenic tumor (AOT) originates from the odontogenic epithelium with
mature fibrous stroma and without ectomesenchyme
3. calcifying odontogenic cyst (COC) is divided into 2 benign and 1 malignant groups
4. clear cell odontogenic tumor is a malignant lesion and termed clear cell odontogenic
carcinoma (CCOC)
5. odontogenic carcinosarcoma is not included due to the lack of evidence for the existence
of this type and
6. some changes were made regarding terminology and subtypings [5-7].

The latest WHO classification has been used as a global standard for the last 10 years but our
knowledge of odontogenic tumors continues to evolve.
The latest WHO classification of odontogenic tumors
1. Malignant odontogenic tumors
Odontogenic carcinomas
Metastasizing (malignant) ameloblastoma
Ameloblastic carcinoma - primary type
Ameloblastic carcinoma - secondary type (dedifferentiated), intraosseous
Ameloblastic carcinoma - secondary type (dedifferentiated), peripheral
Primary intraosseous squamous cell carcinoma solid type
Primary intraosseous squamous cell carcinoma derived from keratocystic odontogenic tumor
Primary intraosseous squamous cell carcinoma derived from odontogenic cysts

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Clear cell odontogenic carcinoma
Ghost cell odontogenic carcinoma
Odontogenic sarcomas
Ameloblastoma fibrosarcoma
Ameloblastic fibrodentino-and fibro-odontosarcoma
2. Benign odontogenic tumors
Odontogenic epithelium with mature, fibrous stroma without odontogenic ectomesenchyme
Ameloblastoma, solid/multicystic type
Ameloblastoma, extraosseous/peripheral type
Ameloblastoma, desmoplastic type
Ameloblastoma, unicystic type
Squamous odontogenic tumor
Calcifying epithelial odontogenic tumor
Adenomatoid odontogenic tumor and Keratocystic odontogenic tumor
Odontogenic epithelium with odontogenic ectomesenchyme, with or without hard tissue

formation
Ameloblastic fibroma
Ameloblastic fibrodentinoma
Ameloblastic fibro-odontoma
Odontoma
- Odontoma, complex type
- Odontoma, compound type
Odontoameloblastoma
Calcifying cystic odontogenic tumor
Dentinogenic ghost cell tumor
Mesenchyme and/or odontogenic ectomesenchyme with or without odontogenic epithelium
Odontogenic fibroma
Odontogenic myxoma and myxofibroma
Cementoblastoma
Bone-related (Fibro-osseous) lesions
Ossifying fibroma
Fibrous dysplasia
Osseous dysplasia
Periapical Osseous Dysplasia
Focal Osseous Dysplasia

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Florid Osseous Dysplasia
Central giant cell granuloma
Cherubism
Aneurysmal bone cyst
Solitary (Simple) bone cyst
Other tumors
Melanotic neuroectodermal tumor of infancy
Classification of the Latest Benign Fibro-Osseous Lesions of the Craniofacial Complex: [8]
1. Bone dysplasias
a. Fibrous dyspla
i. Monostotic
ii. Polyostotic
iii. Polyostotic with endocrinopathy (McCune-Albright)
iv Osteofibrous dysplasia
b. Osteitis deformans
c. Pagetoid heritable bone dysplasias of childhood
d. Segmental odontomaxillary dysplasia
2. Cemento-osseous dysplasia
a. Focal cemento-osseous dysplasia
b. Florid cemento-osseous dysplasia
3. Inflammatory/reactive processes
a. Focal sclerosing osteomyelitis
b. Diffuse sclerosing osteomyelitis
c. Proliferative periostitis
4. Metabolic Disease: hyperparathyroidism
5. Neoplastic lesions (Ossifying fibromas)
a. Ossifying fibroma
b. Hyperparathyroidism jaw lesion syndrome
c. Juvenile ossifying fibroma
i. Trabecular type
ii. Psammomatoid type
d. Gigantiform cementomas
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In pace with new findings of new genetic and molecular changes, classification of odontogen‐
ic tumors will necessitate further modification and subsequent changes in the classification
system. Hence a new and revised version of the classification will always be dynamic. Charac‐
teristics and epidemiology of jaw tumors have been described mostly in adults. Compared with
their adult counterparts, jaw tumors in childhood show considerable differences. Tumors of
the head and neck represent only 2% to 5% of all pediatric tumors. OTs in children constitute
approximately 3% of all tumor like growths in the oral cavity, jaws and salivary glands in all
age groups [9]. In general, OTs in the pediatric population are rare and considerably more so
than in the adult population. There are differences in the spectrum of diseases seen in this group
and in adults. When the diseases are similar, there are sometimes differences in their clinical
behavior. There are additional management concerns when working with children. Treat‐
ment burden is given relatively greater consideration in children since they are growing and
developing and treatment may exert untoward influences therein. It is important for the
clinicians involved in the diagnosis and treatment of pediatric head and neck tumors to
understand certain patterns that follow the development of these lesions, so that misdiagno‐
sis and delays in treatment can be avoided. Because of their relative rarity, this broad spec‐
trum of lesions require careful attention and close collaboration between pediatricians, medical
oncologists, radiotherapists, pathologists and surgeons working in the head and neck area.
Pathology is uncommon among the pediatric age group, its incidence and prevalence has been
increasing in recent years, and it remains a significant cause of morbidity and mortality in this
population. Recently, Jones and Franklin performed a retrospective investigation of oral and
maxillofacial pathologies within a 30-year period. Those authors verified that biopsies in
patients aged between 10 and 16 years represented 8.2% of all cases reported.[10]
Classification of pediatric jaw tumors
The various classifications systems proposed by authors are enumerated as below:
1. Jaw Tumors in Children (11)

1.Classification of non-odontogenic jaw tumors in children
I. Benign mesenchymal tumors
a) Giant cell lesions
b) Fibro-osseous lesions
c) Myxoma
II. Hematopoietic and reticuloendothelial tumors
a) Langerhans cell histiocytosis
b) Burkitt’s lymphoma
c)Lymphoma
III. Neurogenic tumors
a) Neurofibroma
b) Neurilemmoma
c) Neuroma
d)Ganglioneuroma
e) Neuroblastoma
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f)Melanotic neuroectodermal tumor

IV. Vascular lesions
a)Vascular malformation (capillary, lymphatic, venous, arterial, combined)
b)Hemangioma
c)Aneurysmal bone cyst
V. Malignant mesenchymal tumors
a) Osteogenic sarcoma
b) Chondrosarcoma
c) Fibrosarcoma
d) Ewing’s sarcoma
VI. Malignant epithelial tumors
a)Squamous cell carcinoma
b)Mucoepidermoid carcinoma
c)Adenoid cystic carcinoma
d)Adenocarcinoma
2. Classification of odontogenic jaw tumors in children
I. Epithelial tumors
a) Ameloblastoma (Peripheral, Unicystic, Solid, Multicystic)
b) Adenomatoid odontogenic tumor
c) Calcifying epithelial odontogenic tumor
II. Mesodermal tumors
a)Cementoma
b)Periapical cemental dysplasia
c)Cementifying fibroma
d)Cementoblastoma
e)Odontogenic fibroma
III. Mixed tumors
a)Ameloblastic fibroma
b) Odontoma
3. Classification of Small Round Cell Tumors in children
1. Soft tissue Rhabdomyosarcoma
Soft tissue (extraosseous) Ewing’s sarcoma
Hemangiopericytoma
2. Osseous Ewing’s sarcoma
Small cell osteosarcoma
Mesenchymal chondrosarcoma
Hemangiopericytoma of bone
3. Neural
Neuroblastoma
Peripheral neuroectodermal tumors
- Askin’s tumor
- Neuroepithelioma
Pheochromocytoma
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4. International classification of childhood cancer (12)

Malignant Bone tumors
a) Osteosarcomas
b) Chondrosarcomas
c) Ewing tumor and related sarcomas of bone
d) Other specified malignant bone tumors
e) Unspecified malignant bone tumors
Soft tissue and other extraosseous sarcomas
a) Rhabdomyosarcomas
b) Fibrosarcomas, peripheral nerve sheath tumors and other fibrous neoplasms
c) Kaposi’s sarcoma
d) Other specified soft tissue sarcomas
e) Unspecified soft tissue sarcomas
2. Clinical sign and symptoms of pediatric jaw tumors
Pediatric patients encompass a very interesting study group, as several long term physiological
changes take place in the maxillofacial area. During the mixed dentition period, children can
refer with a complaint of swelling in the maxillofacial area, which may or may not be associated
with pain. These mostly include both hard and soft tissue pathologies. When involving bone,
only odontogenic cysts or odontogenic tumors as a category have been considered. Intra-
osseous pediatric jaw lesions can present in diverse clinical patterns and their diagnoses can
vary from odontogenic to non-odontogenic pathogeneses, which can rarely include connective
tissue pathology. The great majority of pediatric jaw tumors are non-odontogenic [13,14].
OTs can be observed casually or after the appearance of nonspecific symptoms. Because of
their slow-growth tendency, usually they do not cause pain. The odontogenic tumors grow in
the jaw, through the haversian system, without metastases but with a high probability of
relapse. In the majority of cases, tumors of the head and neck in children are first seen by
general practitioners or pediatricians with subsequent delays in investigations and diagnosis.
Some of these tumors may disappear spontaneously without any treatment. During the mixed
dentition period, children can report with complaint of swelling in the maxillofacial area,
which may or may not be associated with pain. A history of trauma also needs to be elicited,
because they are prone to falling down during playing, which can affect the jaws. Because of
the complex anatomy and development of the head and neck, neoplasms during infancy and
childhood arising at this site represent the most difficult challenges in clinical practice. [15]
3. Diagnosis of pediatric jaw tumors
The odontogenic cysts and tumors are a diverse group of lesions that represent deviation from
normal odontogenesis. The physical signs and symptoms of odontogenic cysts and tumors
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will depend to a certain extent on the dimensions of the lesion. A small lesion is unlikely to be
diagnosed on a routine examination of the mouth because signs will not be demonstrable. Such
lesions are only likely to be detected at an early stage as the result of routine radiographic
examination. Exceptions are some early lesions that may present in conjunction with a
devitalized tooth, which is detectable on clinical examination. Some cystic lesions may become
secondarily infected, leading to their diagnosis. Clinical absence of one or more teeth without
the history of extraction may also be a clinical indicator of an undiagnosed odontogenic cyst
or tumor because many of these lesions are associated with impacted or congenitally missing
teeth. As the lesion grows, other indirect changes may occur. An enlarging lesion between two
teeth can cause the crowns to converge and the roots to diverge. Growth that is nearly
undetectable visually may lead to difficulty with denture retention. As the lesion enlarges even
further, expansion of the bone may be seen directly. This is usually toward the buccal surface
of the alveolar bone because this is the thinnest area and expansion occurs here most easily.
Clinically evident expansion is often a late finding, especially in lesions developing within the
ramus or angle of the mandible or within the maxillary sinus. Lesions in these areas may
become extremely large before expansion is observed clinically. Masses in the neck confront
the pediatrician with greater opportunities for evaluation before a decision regarding biopsy
or excision is reached. Signs of systemic involvement must also be determined.
3.1. Radiographic and imaging studies
• The primary goals of radiographic assessment are to more precisely define the primary
lesion and to detect metastatic disease for clinical staging
• Chest radiographs are useful screens for mediastinal lymphadenopathy
• Ultrasound is able to differentiate a solid from a cystic mass, and give general relationships
of the mass to adjacent structures
• Axial and coronal computerized tomography (CT) allows documentation of bone erosion
and invasion of adjacent structures
• Magnetic resonance imaging (MRI) offers improved tissue contrast and definition
• Angiography delineates the blood supply to a lesion, and offers the ability to embolize
specific factors to decrease blood loss associated with excision of vascular lesions
• Bone scans and liver spleen scans offer modalities to detect systemic disease. [9, 16]
A tissue diagnosis becomes necessary in order to diagnose and initiate proper therapy.
3.2. Biopsy
• Biopsy of OTs allows histologic evaluation of the mass
• Excisional biopsy is often therapeutic as well as diagnostic
• Incisional biopsy is required in cases where the lesion is large, or the lesion is relatively
inaccessible
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• Fine needle aspiration for cytologic study is useful in salivary gland and thyroid gland
lesions. However, its generalized use for all pediatric head and neck masses is limited due
to the rarity of squamous or glandular neoplasms developing in children
• Large bore needle biopsy has no established role in the evaluation of head and neck
malignancies in children and has been reported to cause seeding along the needle tract in
children. [9, 16]
OTs have a specific histological structure reflecting various stages of odontogenesis and are
located mainly in the jaws, rarely in other parts of the skeletal system. Due to their specific
structure and location they have been identified and classified by pathologists into a separate
group of neoplasms differing from other lesions developing in the oral cavity and facial bones
[17]. Odontogenic tissue is programmed to produce dentin and enamel due to active interac‐
tions between odontogenic mesenchyme and epithelium. Tooth formation is achieved via
odontogenic mesenchyme and epithelium stage- and spatial-specific differentiation from early
tooth development to late maturation [18]. Therefore, when odontogenic tissue becomes
undifferentiated and undergoes tumoral changes, it has the potential to produce abnormal
calcifications with enameloid, dentinoid, and cementum-like material histologic features. For
this reason, these odontogenic calcifications are important odontogenic tumor characteristics
and occasionally are accompanied by odontogenic epithelium ghost cell change and amor‐
phous odontogenic mesenchyme hyalinization [19].
Aspiration cytology, a well established diagnostic tool in adult oncology, is recently gaining
acceptance in pediatric population, as clinicians add this technique to their diagnostic arma‐
mentarium. Fine-needle aspiration cytology is a useful and reliable tool in the diagnosis of
head and neck OTs with no contraindications and minimal complications even in children [20].
More than 95% of all OT reported in large series are benign and around 75% are represented
by odontomas, ameloblastomas and myxomas (which could be considered as “relatively
frequent OT”). Due to the inclusion of the odontogenic keratocyst as a tumor, these figures
will be modified significantly, as this lesion is more frequently diagnosed than the other three
entities. Some studies have shown epidemiological data that demonstrate that there is a second
group of OT, which, although rare in terms of general pathology, are of “intermediate
frequency” with respect to other OT, which have to be considered in the differential diagnosis
of tumors of the oral and maxillofacial regions; therefore they have to be included within the
contents of pathology of the graduate and post-graduate courses of oral and general pathology.
The lack of specific markers to confirm the odontogenic origin of all the lesions included in the
current WHO classification makes diagnoses mainly on anatomic considerations, or on the
histomorphological similarities among some tumors with the above mentioned odontogenic
structures. However, as most OT contain variable amounts of epithelium, and the fact that
such tissue may express several of the more than 20 cytokeratin markers (intermediate
filaments of the epithelial cells) known to date, there are some studies that have demonstrated
that cytokeratins 14 and 19 are the more frequently expressed by OT, and that these are also
expressed in the different epithelial structures of the developing tooth [21, 22], leading to
promote their use as a diagnostic tool to support the odontogenic nature of these entities.
Additionally, the expression of amelogenin, a representative protein of the enamel matrix,
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which is produced by secretory ameloblasts and that seem to actively participate in the process
of production and mineralization of enamel, has been consistently demonstrated within the
enamel matrix and the cytoplasm of the cells of the reduced enamel epithelium, stratum
intermedium and stellate reticulum of the enamel organ, as well as in some epithelial OT,
particularly at the basal endings of the cuboidal or columnar cells of ameloblastomas and in
cells of calcifying epithelial odontogenic tumor, malignant ameloblastoma and ameloblastic
carcinoma [22]. Therefore, the use of these markers is a valuable tool to discard other types of
epithelial lesions that may develop within the oral and maxillofacial regions. More recently,
calretinin, a 29-kDa calcium-binding protein has been shown to be expressed in both unicystic
and solid ameloblastomas but not in other types of odontogenic cysts, and this finding led
some authors to propose it may be considered a specific immunohistochemical marker for
neoplasitic ameloblastic epithelium [23] and an important diagnostic aid in the differential
diagnosis of cystic odontogenic lesions, particularly the keratocystic odontogenic tumor [24].
In the same way, the expression of cytodifferentiation of neoplastic epithelium via epithelial-
mesenchymal interactions and mineralization markers, such as bone morphogenetic protein
(BMP) is of great value to study those lesions that are characterized by the production of hard
dental tissues [25, 26].
4. Treatment of pediatric jaw tumors
The majority of tumors of the mouth and jaw in children are benign. Tanaka et al. reported
that only 3% of their cases were malignant in nature. In another study, benign tumors
composed 93% of the cases (13, 14, 27).
Treatment consists of a range of surgical methods, from surgical curettage to hemimandibu‐
lectomy and reconstruction with bone graft. Generally, surgical excision, curettage, cryosur‐
gery or en bloc resection are adequate for treatment of these tumors. However, some patients
need multiple treatment because of its specific criterias such as the clinical behavior and extent
of the lesion. Odontogenic lesions encompasses a wide spectrum of lesions and their variants,
which either can be a cyst or a tumor. Odontogenic cysts are derived from the epithelium
associated with the development of the dental apparatus while a tumor forms through some
aberration from the normal pattern of odontogenesis. But the fact, that these lesions can mimic
each other can complicate the diagnosis. The Adenomatoid Odontogenic Tumor is a benign,
nonaggressive odontogenic tumor which has been known by a number of descriptive names
since it was first reported. In almost all instances, the lesion may be removed by surgical
enucleation. Unicystic Ameloblastoma is another tumor of the odontogenic series which has
been described as benign but locally invasive. The Dentigerous Cyst, a cyst of odontogenic
origin, has the potential of transforming into an Ameloblastoma. The Odontogenic Keratocyst,
is characterized by aggressive behavior has debatable treatment options. All OTs can have a
similar clinical and radiographic features which can mislead the dentist and a biopsy is needed
to make a final diagnosis. Of all odontogenic tumors, ameloblastomas are the most controver‐
sial in terms of treatment. Treatments range from surgical curettage to bloc excision or resection
[28]. Surgical excision in the infant or child is sometimes met with resistance by both parents
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and physicians, yet with many tumors surgery is clearly the best treatment. A wide resection
for some tumors may pose psychological and cosmetic difficulties that parents can learn to
accept if these difficulties are discussed in an open and helpful manner. When parents accept
their children disabilities, the children in turn, can adjust very well functionally and psycho‐
logically following operations [29]. Cryosurgery is relatively new to the management of head
and neck tumors in children. Local freezing has the ability to destroy tumor cells. A wide
variety of probe tips are available to treat lesions of the skin, nose, mouth, nasopharynx,
oropharynx, hypopharynx and larynx. Unlike surgical excision or radiation therapy, cryosur‐
gery has the capability of destroying the tumor and only minimally affecting the surrounding
normal tissue; also unlike radiation therapy,cryosurgery can be repeatedly administered to a
specific area should the tumor persist or recur. The role of cryosurgery is still being assessed,
but the potential is both great and exciting [29]. In planning treatment for pediatric tumors,
authors stress the importance of the growth development of the jaw, and of esthetics and
functional concerns in later periods of life [30].
5. Benign odontogenic tumors
5.1. Odontogenic epithelium with mature, fibrous stroma without odontogenic

ectomesenchyme
5.1.1. Ameloblastomas have been classified as follows (WHO 2005 classification)
• Ameloblastoma, solid/multicystic type

• Ameloblastoma, extraosseous/peripheral type
• Ameloblastoma, desmoplastic type
• Ameloblastoma, unicystic type
Ameloblastoma is a tumor of the odontogenic epithelium, first described by Cusick in 1827.

Ameloblastoma is perhaps the most perplexing of all odontogenic neoplasms due to its
unexplainable clinical and histopathological behavior [31] It accounts for less than 1% of all
odontogenic cysts and tumors. Although all ameloblastomas have the same cell of origin, there
are several biologically distinct forms. The differences are especially important in pediatric
cases. Central ameloblastomas occur as unicystic, multicystic or solid lesions. Ameloblastoma
is non-encapsulated and infiltrates surrounding bone marrow. Even though they are locally
infiltrative, they can rarely metastasize. They may occur in any part of both jaws but most are
in the middle and posterior regions of the mandible. Ameloblastomas are always purely
radiolucent and may be unilocular but frequently become multilocular as they increase in size.
If not found and treated early, they will expand the jaws. Despite being categorized as benign
tumors, ameloblastomas have a high rate of recurrence, and there is a risk of malignant
transformation when treated inadequately. Clinically, ameloblastoma frequently manifests as
a painless swelling, which can be accompanied by facial deformity, malocclusion, and loss of
dentition, ulceration and periodontal disease. Sometimes pain occurs with varying intensities,
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but often quite low. It is not known whether the cause of the pain is pressure from the tumor
on peripheral nerves or secondary infection [32].
The unicystic ameloblastoma resembles a dentigerous or primordial cyst clinically and

radiographically and often occurs in teenage patients. Multicystic or solid ameloblastomas
occur most commonly in patients 30 to 50 years of age and are extremely rare in childhood.
Choung and Kaban in review of pediatric jaw tumors found only one case in 10 years. In the
pediatric population, ameloblastoma must be considered in the differential diagnosis of
radiolucent lesions of the jaws. In the vast majority of pediatric cases, however, these turn out
to be either odcontogenic or non-odontogenic cysts or non-odontogenic primary jaw tumors.
The two ameloblastic lesions that are found in childhood are the ameloblastic fibroma and the
unicystic ameloblastoma.The ameloblastic fibroma appears as an asymptomatic radiolucent
lesion, often associated with an impacted tooth and indistinguishable from an odontogenic
cyst. The patients are usually under 12 years of age. The unicystic ameloblastoma occurs in
teenagers, most commonly in the mandible. The patient exhibits a painless facial swelling or
radiolucency, usually associated with an impacted third molar. The lesion is most commonly
unilocular and may produce cortical expansion or perforation. Roots of adjacent teeth may be
displaced or resorbed. Aspiration reveals clear serous fluid from a cystic mass [33].
There has been some debate regarding the most appropriate method for surgical removal of
ameloblastomas. These range from conservative to radical modes of treatment. The conserva‐
tive modalities include curettage, enucleation and cryosurgery; while the radical modalities
are marginal, segmental and composite resections. The recommended treatment for amelo‐
blastoma in children should be radical resection, 0.5 to 1 cm past what appears to be normal
bone [34]. Treatment of both unicystic ameloblastomas and ameloblastic fibromas consists of
enucleation [33] Simple curettage is usually met with recurrence. It has been reported that
pediatric ameloblastomas are generally unicystic and do not extend beyond the cystic wall of
the tumor cell. [30] This type of tumor has a much better prognosis (Figure 2).
Early diagnosis is the most important component of therapy for this odontogenic tumor,
which does not have specific radiographic features in the early stages. In particular,
unilocular ameloblastoma may be difficult to diagnosis for the surgeon. Surgical enuclea‐
tion with bony curettage and intra-operatory cryostat examination of the lesion allows
preservative treatment and reduction of the risk of relapse [35]. The loss of permanent teeth,
removed during the surgical treatment, will require orthodontic-prosthetic rehabilitation
when the patient reaches adult age. Peripheral ameloblastoma occurs in soft tissue outside
and overlying the alveolar bone. This neoplasm arises from the basal layer of the surface
epithelium or remnants of the dental lamina. It occurs most frequently in the fourth to sixth
decade and has a slight male predilection. The mandible is affected twice as frequently as
the maxilla. Seldom does this neoplasm exhibit any radiographic findings. Superficial
erosion in the alveolar region is occasionally observed. The microscopic pattern of periph‐
eral ameloblastoma is similar to that of central ameloblastoma; however, it lacks the
invasiveness of its central counterpart. Most peripheral ameloblastomas are acanthoma‐
tous. This lesion can be confused with peripheral odontogenic fibroma because features of
both lesions may be present. However, in the hands of an experienced oral pathologist the
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(a)

(b)

(c)

(d)

Figure 2. (a): Ameloblastoma: Orthopantomograph of a 12-year-old boy who had a painless bony- hard swelling of the
left mandible associated with cortical expansion. (b): Radiological appearance after surgical treatment. (c): Radiological
appearance taken 24 months post-operatively. (d): Presurgery photographs showing the left mandible associated with
cortical expansion and postoperative clinical control at 12 and 24 months
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diagnosis is generally not difficult. Because this lesion is relatively innocuous, noninva‐
sive, and displays little tendency for recurrence, it is treated by local excision. Despite its
behavior, 1-year follow-up examinations are recommended [36, 37].
5.1.2. Squamous odontogenic tumor
The squamous odontogenic tumor (SOT) is a rare and benign neoplasm frequently located
within the jaws. In 1975, Pullon et al. identified this entity and reported it for the first time in
a series of 6 cases. This benign tumor has a slow and gradual growth that might invade the
trabecular bone, destroying the cortical bone and infiltrating adjacent structures. Its aetiology
remains unknown although it could be originated from the epithelial remnants of the Malassez.
It usually appears over the lateral radicular surface of an erupted tooth and diminishes the
height of alveolar bone causing tooth mobility. There is a similar entity that is characterized
by squamous odontogenic tumor like proliferations (SOTLP) with a very similar histological
pattern than the SOT. This lesion commonly is located in the wall of an odontogenic cyst and
has a non-neoplastic character like in the SOT, representing probably, an hamartomatous
lesion. [38]
5.1.3. Calcifying epithelial odontogenic tumor
The calcifying epithelial odontogenic tumor (CEOT) is a rare tumor. It was first described as
a separate pathologic entity by a Dutch pathologist Jens Jorgen Pindborg in 1955. The term
“Pindborg’s tumor” was first used by Shafer and colleagues in 1963. CEOT is a rare benign
odontogenic epithelial neoplasm representing about 0.4-3% of all odontogenic tumors. This
tumor more frequently affects adults in the age range of 20-60 years, with a peak incidence in
the 5th decade of life with equal sex predisposition. CEOT is a rarely seen odontogenic tumor
in pediatric patients. It is a benign, but locally aggressive tumor; of all the odontogenic tumors,
CEOT accounts for 1% of the cases. Approximately 200 cases have been reported to date.
Although the tumor is clearly of odontogenic origin, its histogenesis is still uncertain. It usually
involves the premolar-molar area of the mandible with about 50% cases associated with
unerupted or embedded teeth. Etiology of this lesion is not clear. In the 113 cases reviewed by
Franklin and Pindborg, patients ranged from 8 to 92 years with a mean age of 40 years.
Radiographically, this tumor is often mistaken for a dentigerous cyst or ameloblastoma [39].
The diagnosis of CEOT is based on histological examination, revealing polyhedral neoplastic
cells which have abundant eosinophilic, finely granular cytoplasm with nuclear pleomorphism
and prominent nucleoli. Most of the cells are arranged in broad ramifying and anastomosing
sheet-like masses with little intervening stroma. An extracellular eosinophilic homogenous
material staining like amyloid is characteristic of this tumor with concentric calcified deposits,
resembling psammoma bodies called “Liesegang rings. A painless, slow-growing swelling is
the most common presenting sign. The differential diagnosis includes adenomatoid odonto‐
genic tumor, calcifying odontogenic cyst, dentigerous cyst, ameloblastic fibro-odontoma and
odontoma. It is an infiltrative neoplasm and causes destruction with local expansion. Definitive
resection of the entire mass with tumor-free surgical margins (en bloc resection) is the preferred
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treatment as tumor will recur if not completely removed. Long-term follow ups are recom‐
mended (Figure 3). Local recurrence rates of 10-15% have been reported [40]

(a)

(b)

(c)

(d)

(e)

Figure 3. (a): Pindborg (CEOT) tumor associated with impacted premolar. Preoperative clinical (left) and radiological
appearance of CEOT (right). (b): Clinical appearance of CEOT and impacted premolar tooth. (c): Postoperative opera‐
tion site and macroscopic appearance of the mass. (d): Application of surgical obturator. (e): Postoperative clinical (left)
and radiological control (right) at 12 months.
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5.1.4. Adenomatoid Odontogenic Tumor (AOT)
This is a tumor mostly of teenagers. It occurs in the middle and anterior portions of the jaws
in contrast to ameloblastoma which is found mostly in the posterior segment. Two-thirds occur
in the maxilla and it is more common in females. The tumor may be partially cystic, and in
some cases solid lesion may be present as masses in the wall of a large cyst. It is believed that
lesion is not a neoplasm” Philipsen et al. subdivided this condition into three groups referred
to as follicular, extrafollicular, and peripheral. These variants have common histologic
characteristics that indicate a common origin as derived from the complex system of dental
lamina or its remnant [41].The follicular and extrafollicular variants account for 96% of all AOT
and of these 71% are follicular variants.The peripheral variant is the rarest with only 18 cases
reported so far [42]. The follicular variant is predominantly associated with the crown and
often part of the root of an impacted (unerupted) tooth (Figure 4). The most frequently
associated tooth is the maxillary canine rarely the permanent molars. Based on the clinical and
radiographic examination the follicular variant is often initially mistaken as dentigerous cyst.
This tumor is encapsulated and is treated by curettage with a recurrence rate approaching zero.
The radiographic appearance is a unilocular radiolucency, often around the crown of an
unerupted tooth in which case they resemble a dentigeous cyst.. A homogeneous, eosinophilic
and amorphous material may occasionally be found in AOT [43]. If they are present in
sufficient size and number, they may show on the radiograph as a “snow-flake” pattern
5.1.5. Keratocystic odontogenic tumor
The Keratocystic Odontogenic Tumor (KCOT) has been defined by the World Health Organ‐
ization In 2005, as a benign intraosseous neoplasm of odontogenic origin with characteristic
lining of parakeratinized squamous epithelium. It represents approximately 10 percent of all
jaw cysts and may occur in a wide age range of patients. About 70 percent or more cases involve
the mandible, especially in the molar, angle and ramus regions. The clinical features associated
with the keratocystic odontogenic tumor show it to be a unilocular or multilocular radiolu‐
cency. It is generally believed that these lesions originate from remnants of the dental lamina
in the same way as the primordial cyst. However, a tooth is generally not missing and,
therefore, they are believed to originate from additional remnants of the lamina not involved
in tooth formation. Alternatively, in some cases they may arise from the oral mucosa, partic‐
ularly in the retromolar region, because daughter cysts are found between the oral mucosa
and the cyst in the retromolar region [44].
Symptoms such as pain, swelling and drainage may be present, especially with larger lesions.
However, at least half of all lesions are discovered as incidental radiographic findings. Due to
the propensity of KCOTs to grow within the medullary bone, they have the potential to become
extremely large without causing any clinical signs or symptoms. Radiographically, the KCOT
presents as a well defined radiolucency with thin corticated margins. These tumors are
normally diagnosed histologically from a sample of the lining. With simple enucleation, it
seems that the recurrence rate may be from 25% to 60%. Approximately 20-40 percent of these
tumors are associated with an unerupted tooth and can be identical in appearance to a
dentigerous cyst (Figure 5). Root resorption is relatively uncommon. The classic treatment of
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(a)

(b)

(c)

(d)

(e)
Figure 4. AOT associated with canine tooth. Oral photograph showing an anterior maxillary swelling in a 16-year-old
Preoperative radiological appearance of AOT. (b): Oral photograph showing large buccal anterior exspansion.
girl.
Clinical appearance of the mass being removed. (c): Clinical appearance of the encapsulated mass and the operation
site after enucleation. (d): Postoperative appearance of the operation site
this lesion is surgical marsupialization, enucleation and curettage being performed through
an intraoral approach. KCOTs have a high recurrence rate and develop more aggressively than
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any other jaw cyst. Based on the high rate of recurrence, most authors advocate radical
enucleation for small unilocular keratocysts and suggest resection and bone grafting for very
large lesions. But there is a general agreement that complete removal of large multilocular
KCOTs of the mandible ramus may be difficult because of the possibility that remnants of
cystic tissue or that satellite microcysts may be left behind. Most authors have shown the
successful treatment of large KCOTs using the technique of decompression and irrigation. The
benefits of this protocol over more conventional approaches (enucleation, en bloc resection)
lie in the minimal surgical morbidity. In addition, the associated structures such as the inferior
alveolar nerve and developing teeth are less vulnerable to damage. Morgan et al. reported that
treatment with Carnoy’s solution did not show a significant association with recurrence. Most
reports point out that recurrence will appear within the 5 to 7 years [45, 45].

(a)

(b)

(c)

Figure 5. (a): KCOT. Frontal photograph and radiograph showing
(d) a 14-year-old boy presenting a posterior mandibular
radiolucency associated with impacted left third molar. (b): Oral and radiographic appearance of the operated area

with gauze tamponade after cystostomy and application of the surgical obturator.
(e)

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5.2. Odontogenic epithelium with odontogenic ectomesenchyme, with or without hard

tissue formation
5.2.1. Ameloblastic fibroma
This tumor, at least conceptually, is a compound odontoma and which includes the amelo‐
blastic fibradentinoma, ameloblastic odontoma and complex odontoma [46]. All show
evidence of inductive interaction between odontogenic epithelial and ectomesenchymal
components, but only the ameloblastic fibroma lacks hard tissue formation. The ameloblastic
fibroma presents as a jaw swelling and multilocular radiolucency in the lower premolar or
molar region or, less commonly, in the maxilla. This is a tumor of childhood, the typical patient
is about 12 –14 years old, seldom is it seen beyond age 20 yrs. The posterior segment of the
mandible is the most common location. Local swelling or failure of teeth to erupt on time or
in proper alignment may call attention to the tumor. Ameloblastic fibromas are purely
radiolucent. Small lesions may be unilocular but larger lesions are ordinarily multilocular.
Both odontogenic epithelium and odontogenic ectomesenchyme contribute to this tumor (an
odontogenic mixed tumor not to be confused with the mixed tumor of the salivary gland). The
epithelium grows in small islands and cords. This tumor is clearly benign and is ordinarily
treated by vigorous curettement. The recurrence rate is placed at about 15 %. Even though this
tumor is comprised of both odontogenic epithelium and odontogenic ectomesenchyme, it does
not secrete either enamel matrix or dentin. Its microscopic structure like its radiographic
appearance, is reminiscent of that of the ameloblastoma, but with two major differences: the
connective tissue component resembles dental papilla; and the stellate reticulum zone of the
epithelium is poorly developed. The ameloblastic fibroma poses two further problems: for the
histopathologist, it must be distinguished from a developing complex odontoma; and for the
surgeon, the requirement for complete excision must be weighed against the need to preserve
the developing jaw bones and dentition [40].
5.2.2. Ameloblastic fibrodentinoma and Ameloblastic fibro-odontoma
Ameloblastic fibrodentinoma (AFD) and ameloblastic fibroodontoma represent, at least for

didactic purposes, intermediate stages between the ameloblastic fibroma and the complex
odontoma. They also represent the interface between hamartomas and neoplasms, and occur
in late adolescence or in early adulthood. A classic site for the formation of an ameloblastic
fibrodentinoma is within, or adjacent to, the follicle of an unerupted tooth, typically a lower
third molar, in its path of eruption. Most often it presents as a symptomless radio-opacity and
may not be the cause of the failure of the underlying tooth to erupt (Figure 6). The ameloblastic
fibro-odontoma is a more variable entity and, as already noted, may be hard to distinguish,
clinically, radiographically and histopathologically, from a developing complex odontoma or
ameloblastic fibroma. The majority of ameloblastic fibro-odontomas are small, mixed radio-
opaque ⁄ radiolucent lesions that occur across a similar age-range to the ameloblastic fibro‐
dentinoma, and most are small and unilocular with limited growth potential after completion
of tooth formation. They show features that suggest the formation of tooth-like structures,
complete with tubular dentine and varying degrees of enamel matrix calcification. That this is
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not a developing odontoma is suggested by its perceived continued growth potential (hence
the belief that at least some are true neoplasms) and its presentation at an age when odontomes
have normally “matured” and become quiescent, as well as incorporating an extensive soft
tissue (radiolucent) component that somewhat resembles ameloblastic fibroma [40, 46]. A
regular follow-up protocol should be established to rule out any evidence of recurrence and
malignant transformation. A detailed study is required in order to understand the relationship
of AFD and related lesions, their biological behavior and management strategies [47].
Figure 6. Ameloblastic fibro-odontoma. This combines the radio-opaque component that resembles a complex odonto‐
ma with radiolucent soft tissue that histologically combines the features of ameloblastic fibroma with the early stages
of tooth germ development.
5.2.3. Odontoma
• Odontoma, complex type
• Odontoma, compound type
Odontomas are hamartomas of aberrant tooth formation, which occur due to budding of extra-
odontogenic epithelial cells or detachment of odontogenic cells from the dental lamina [48].
These odontogenic cells may in turn differentiate and deposit enamel, dentine, cementum or
pulp in the form of multiple teeth like structures (compound odontoma), amorphous calcified
masses (complex odontoma) or a combination of both (composite odontoma and compound‐
complex odontoma). Trauma to the tooth bud during its early developmental stages has been
proposed as a possible predisposing factor for the origin of odontoma. [49,50].
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As a result, these tumors are mostly radiodense. In the compound odontoma, multiple small
and malformed tooth-like structures are formed creating a “bag of marbles” radiographic
appearance. In the complex odontoma, there is little or no tendency to form tooth-like
structures. The dentin and enamel are entwined in a mass that bears no resemblance to teeth.
Both types of odontoma are found in the early years, usually in the teens or early twenties.
Compound odontoma is more common in the anterior jaw segment whereas the complex type
is found more commonly in the posterior jaws (Figure 7). Many are associated with an
unerupted tooth. Odontomas behave more like developmental abnormalities (hamartomas)
than true neoplasms. Although they may reach a large size, they do eventually cease growing
in contrast to true neoplasms which show continuous growth. Treatment is elective surgery.
They have a limited growth potential and cause no pain or cosmetic deformity [46].

(a)

(b)

NOTE: We have skipped odontoameloblastoma, (c) calcifying cystic odontogenic tumor, denti‐
nogenic ghost cell tumor, malignant ameloblastoma,ameloblastic
carcinoma, clear cell
odontogenic carcinoma because they are exceedingly
(d) rare.

Figure 7. a): Compound odontoma associated with two mesiodens. Photograph and radiograph showing a 11-year-old
boy presenting an anterior maxillary radiolucency with (e)
impacted supernumerary teeth and radio-opaque mass. (b):
Macroscopic appearance of the supernumerary teeth and postoperative operation site
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5.3. Mesenchyme and/or odontogenic ectomesenchyme with or without odontogenic

epithelium
5.3.1. Odontogenic fibroma
Central odontogenic fibromas are encountered as unilocular radiolucencies that turn out to be
solid, rather than cystic, following enucleation. They are rare, far rarer for example than
ameloblastomas, and arise usually anterior to the molars, more commonly in the maxilla and
mainly in women, as a small, well-circumscribed radiolucency that may cause resorption and ⁄
or displacement of adjacent vital teeth (Figure 8). A wide age-range is noted among the
relatively few reported cases, and a scalloped radiographic margin may denote a more
aggressive behavior pattern. Following enucleation, most odontogenic fibromas do not recur,
although there have been occasional reports of some following a more aggressive course;
however, there seems to be little correlation with the histological pattern [40, 46]

(a)

(b)

Figure 8. (a): Odontogenic fibroma. Radiograph showing a 12-year-old boy presenting with a posterior mandibular
(c)
mass associated with an impacted left first molar tooth. (b): Orthodontic extrusion of the impacted first molar using the

zygomatic bone anchor and clinical appearance after the right first molar extrusion
(d)

5.3.2. Odontogenic myxoma/myxofibroma (e)
Despite the name similarity, the odontogenic myxoma is quite a different entity from the
odontogenic fibroma in almost all respects. Odontogenic myxoma (OM) of the jaws, first
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described by Thoma and Goldman in 1947, is believed to arise from odontogenic ectomesen‐
chyme [51, 52]. It is a rare benign tumor characterized grossly by mucoid or gelatinous grayish-
white tissue that replaces the cancellous bone and expands the cortex. OMs are locally invasive,
non-metastasizing neoplasms of the jaws, almost exclusively seen in tooth-bearing areas. It
accounts for 0.2-17.7% of odontogenic tumors. It predominantly involves the mandible and
maxillary tumors are known to be more aggressive than tumors involving the mandible [53].
Most frequently, OMs occur in the 2 nd and 3 rd decades of life. Cortical expansion and
perforation are common findings; however, maxillary myxomas often extend into the sinus
[54]. Radiographically, the tumor presents as a unilocular or multilocular radiolucent lesion
with fine, bony trabeculae within its interior structure expressing a honeycombed, soap bubble,
or tennis racket appearance [55]. A histologic characteristic of this tumor resembles the
mesenchymal portion of a tooth in development. The lesion is not encapsulated being
characterized by the proliferation of a few rounded cells, fusiforms and star cells, being
included in abundant myxomatous stroma with a few collagen fibers [56]. They are uncom‐
mon. Extragnathic skeletal lesions are a rarity. Since it does not produce a calcified matrix
material, it is purely radiolucent. If allowed to reach a large size, it takes a big operation to
remove it [40].
5.3.3. Cementoblastoma
Cementoblastoma in the current World Health Organization classification of odontogenic

tumors, is in the category of tumors of mesenchyme and/or odontogenic ectomesenchyme with
or without odontogenic epithelium [57]. The lesion was first recognized by Noeberg in 1930
[58]. The lesion is considered as the only true neoplasm of cementum origin. It generally occurs
in young persons, comprises <1-6.2% of all odontogenic tumors and is characterized as being
attached to the roots, most frequently associated with first permanent molars [59]. The
differential diagnosis for a periapical radiopacity include cementoma, osteoblastoma, periap‐
ical cemental dysplasia, condensing osteitis and hypercementosis. The majority of these
tumors are radiopaque, but a radiolucent tumor may occur in rare instances. Histologically, it
presents as a well-circumscribed tumor composed of cementum like tissue surrounded by a
fibrous capsule. Surgical enucleation of the cementoblastoma with the associated tooth is
usually curative, although recurrences have been reported following incomplete excision. The
recurrence rate is 21.7-37.1% [60, 61].
5.4. Bone-related (Fibro-osseous) lesions
5.4.1. Juvenile ossifying fibroma
Benign fibro-osseous lesions of the head and neck region are uncommon and constitute a
wide range of tumors sharing some histopathological features. This group includes
developmental, reactive or dysplastic lesions as well as neoplasm such as fibrous dyspla‐
sia (FD), ossifying fibroma (OF), and cemento-osseous dysplasia (COD) [62]. Ossifying
fibromas are rare benign, neoplasms arising from undifferentiated cells of the periodontal
ligament tissues (63). These have been described as demarcated or rarely encapsulated
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neoplasms consisting of fibrous tissue containing varying amounts of mineralized materi‐

al resembling bone and/or cementum which is one of its principal characteristics [64]. In
1872, Menzel first described ossifying fibroma, but in 1972, Montgomery assigned terminol‐
ogy to it. It accounts for 3.1% of all oral tumors and for 9.6% of all gingival lesions. There
are two types of ossifying fibroma, central and peripheral. The central type arises from the
endosteum or periodontal ligament adjacent to the root apex and expands from the
medullary cavity of the bone. The peripheral type occurs solely on the soft tissue overly‐
ing the alveolar process. Trauma or local irritants are known to precipitate the develop‐
ment of this lesion [65]. It is common in young adults (especially, 2nd and 3rd decades)
with a female predominance and is generally asymptomatic until the growth produces a
noticeable swelling most often found in interdental gingiva, located anterior to molars and
in the maxilla [66]. The suggested etiology although unknown has been associated with
inflammatory hyperplasia of the periodontal ligament [67]. When ossifying fibroma is
diagnosed in young people the term "juvenile" is used. The accurate nature and classifica‐
tion of JOF has undergone considerable debate among pathologists, resulting in a confus‐
ing evolution of competing nomenclatures [68] According to the WHO classification of
odontogenic tumors 2005, JOF is further subdivided into two distinct clinic-pathological
variant i.e., juvenile psammornatoid ossifying fibroma (JPOF) and juvenile trabecular
ossifying fibroma (JTOF) [69]. Juvenile psammornatoid ossifying fibroma (JPOF) is a rare
fibro-osseous neoplasm that arises within the craniofacial bones in individuals under 15
years of age, and these lesions are usually benign and tend to grow slowly. JPOF is rare
fibro-osseous neoplasm. Probability of malignancy makes this lesion worrysome. The lesion
is nonencapsulated but well demarcated from surrounding bone. JPOF mainly involves the
bones of the orbit and paranasal sinuses, whereas the trabecular type commonly involves
the jaws. JPOFs are rare, benign, potentially aggressive fibro-osseous tumors of the
craniofacial bones characterized by the presence of numerous calcified spherules within an
actively proliferating connective tissue stroma. They are mainly seen in the sino-naso-
orbital region of young individuals. Males and females are equally affected. The maxilla
and the mandible are the dominant sites of incidence. Occurrence in the maxilla is slightly
more frequent than in the mandible (Figure 9) The incidence of JPOF is still unknown
because of relatively few cases reported till date. The pathogenesis of JPOF jaw lesions are
related to the maldevelopment of basal generative mechanism that is essential for root
formation. The developing tooth can either be displaced, missing or remain unerupted. It
tends to occur at younger age group and is locally aggressive and these characteristics make
them different from conventional ossifying fibroma and other fibro-osseous lesions.
Moreover, this lesion may clinically manifest with rapid painless expansion of the affect‐
ed bone as an aggressive lesion mimicking malignancy such as osteosarcoma. JPOF can be
easily excluded from malignant bone tumors on the routine histological examination.
Additionally, it may be difficult to distinguish JPOF from other fibro-osseous lesions because
of the overlapping features. It is important to accurately recognize JPOF for reaching the
diagnosis and treatment planning. Because of this lesion's aggressive nature and high
recurrence rate, early detection and complete surgical excision are essential [40, 46].
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(a)

(b)

(c)

(d)
Figure 9. (a): JPOF. Photograph showing a 14-year-old boy presenting an anterior maxillary expansion associated with
impacted left canine tooth ; Preoperative facial view showing asymmetry of face (left); Preoperative radiograph show‐
ing large radiolucency, well-defined sclerotic border around the upper left impacted canine tooth (right). (b): Clinical
and radiographical appearance of buccal cortical expansion. (c): Clinical appearance after enucleation and the mass.
(d): Postoperative panoramic radiograph showing normal bone pattern
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5.4.2. Central giant cell granuloma

There are a number of lesions that occur in the jaws that contain giant cells within them. They
include cherubism, giant cell granuloma of the jaws, giant cell tumor, aneurysmal bone cyst,
traumatic bone cyst and brown tumor of hyperparathyroidism. Their relationship to each
other, however, is ill defined. The histological similarities with the finding of multinucleated
giant cells of osteoclastic origin and the lesions themselves greatly differ in their genetic origin,
etiopathogenesis and clinical behaviour. Central giant cell granuloma (CGCG) is fairly
common in the jaws and it is a nonneoplastic bone disease, probably reactive to some unknown
stimulus. CGCG constitutes approximately 7% of the benign jaw tumors. Usually, it occurs in
patients 30 years of age or younger with painless swelling and an asymmetry in facial
appearance. The clinical behavior of CGCG ranges from a slowly growing asymptomatic lesion
to an aggressive lesion manifesting with pain, local bone destruction, root resorption, or
displacement of teeth. The highest rate of occurrence is the mandible, and most mandibular
lesions occur anterior to the first molars.

(a)

(b)

(c)
Figure 10. (a). CGCG: Photograph showing a 13-year-old boy presenting a posterior mandibular lesion at premolar re‐
gion (a): Preoperative facial view showing ulcerative mass (left): Preoperative radiograph showing the lesion. (b): Ex‐
cised pathologic mass associated with tooth ; Postoperative
(d) panoramic radiograph showing normal bone pattern.
Clinical view taken 13 months post-operatively
(e)
Its etiology is still unknown and its biological behavior is poorly understood. This lesion occurs

almost exclusively within the jaw bones. It usually presents as a painless swelling of the
jawbone. Radiographically, CGCG presents as radiolucent defect, which may be unilocular or
multilocular. The defect usually is well-circumscribed and, in some cases, displacement of
teeth can be found (Figure 10). Conventional treatment for the CGCG has been local curettage
and this has been associated with a high success rate and low recurrence rate. The conservative
surgical treatment of CGCG usually involves curettage alone or along with peripheral
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ostectomy with no evidence of disease in a 2 year follow up perior. The margins of the CGCG
may also be thermally sterilized with a laser or a cryoprobes. Radical surgical techniques of
resection without continuity defect, peripheral ostectomy and en-bloc resection have some‐
times been justified for aggressive CGCG. Pediatric patients necessitate conservative manage‐
ment to prevent long term developmental defects. Steroids and calcitonin have been advocated
recently for inhibition of osteoclastic activity. Equal parts of triamcinolone acetonide (10mg/
ml) and 0.5% bupivacaine injected into the lesion for a period of 11 weeks has been shown to
be effective in a child patient. Relative contraindications do exist in certain medical conditions,
such as diabetes mellitus, peptic ulcer and generalized immunocompromised states. Calcito‐
nin nasal spray 200 U/spray once or twice daily was reported to be safe and effective for the
treatment of CGCG [40,46].
6. Conclusion
Literature reveals very few reported studies involving pediatric pathologies and there are
different treatment modalities for pediatric jaw tumors in the recent literatures. Many surgeons
find it difficult to decide which technique offers better results, and are also uncertain about
the factors which might influence their techniques of choice. The rapid growth and develop‐
ment process in childhood and adolescence affects the growth potential of tumors and tumor
like lesions and occasionally results in considerable morbidity. There are many rare odonto‐
genic tumors that may involve the head and neck in the pediatric population. Each of them
deserves careful attention by a multidisciplinary tumor board that includes pediatric oncolo‐
gists, radiation oncologists, dentists, and surgeons. Clinicians need to keep abreast of the
various intraosseous lesions with their presenting signs and symptoms, so that the patient can
be treated without any delay and avoiding unnecessary administration of antibiotics. Subse‐
quent to an unresponsive antibiotic therapy radiographs are taken to reveal a radiolucent or
radiodense lesion in the jaws. As a consequence the contribution of pathological examination
remains imperative in odontogenic cyst or tumor diagnosis. It is very important to consider
surgical and permanent dental concerns during jaw tumor treatment planning. Facial growth
and aesthetic results should be considered in the surgical planning.
Author details
Mehmet Cemal Akay1*, Mert Zeytinoğlu1, Birant Şimşek1 and Işıl Aras2
*Address all correspondence to: cemalakay@yahoo.com
1 Ege University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery,

Bornova, Izmir, Turkey
2 Ege University, Faculty of Dentistry, Department of Orthodontics, Izmir, Turkey

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Chapter 15
Tumor Markers
in Common Oral and Maxillofacial Lesions
Taghi Azizi
http://dx.doi.org/10.5772/59342
1. Introduction
Immunohistochemical (ihc) stains are widely used for diagnosis of tumors. In this chapter we
present modern immunohistochemical stains for diagnosing those tumors that cannot be
evaluated via common or routine stains such as hematoxylin and eosin.
2. Epithelial tumors
Squamous cell carcinoma (SCC) and malignant melanoma are common epithelial lesions that
require IHC.
2.1. Squamous cell carcinoma
2.1.1. Definition
SCC is a malignant neoplasm arising from the squamous epithelium of the oral cavity most
commonly from the lip, then tongue, floor of mouth, gingiva, palate, and buccal mucosa.
Premalignant changes present as white (leukoplakia) or red (erythroplakia) mucosal patches.
2.1.2. Immunohistochemical stains
Squamous carcinomas are nearly always positive for CK.

• Common CK expression in squamous carcinomas includes AE1/AE3 and CKs 5, 5/6, 14,
and 17.
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• Nuclear p63 expression is common in squamous cell carcinomas but is not specific
• Cytokeratin stains may help detect subtle metastatic foci especially in post-treatment lymph
nodes (Figure 1).
• Over expression of p53 may be linked to response to radiation and/or chemotherapy
• p16 positive: strong and diffuse nuclear and cytoplasmic expression in oropharyngeal
carcinoma (HPV associated). [1-5]
a) b)

Figure 1. a) Squamous cell carcinoma (H&E). b) Cytokeratin stains in SCC.
2.2. Mucosal melanoma
2.2.1. Definition
Malignant mucosal melanoma (MMM) is a neural crest–derived neoplasm originating from

melanocytes and demonstrating melanocytic differentiation.
S100 protein, Melan A, HMB45, tyrosinase, vimentin are positive, Keratin and muscle markers
are negative (Figure 2). [6-13]
a) b)
Figure 2. a) Mucosal melanoma (H&E) b) IHC staining for HMB-45

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Immunohistochemistry in Common Oral and Maxillofacial Lesions 311

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3. Salivary gland tumors
The common salivary gland tumors needing IHC are:
• PLEOMORPHIC ADENOMA
• BASAL CELL ADENOMA
• CANALICULAR ADENOMA
• ONCOCYTOMA
• PAPILLARY CYSTADENOMA LYMPHOMATOSUM (WARTHIN TUMOR(
• SEBACEOUS ADENOMA/LYMPHADENOMA
• MUCOEPIDERMOID CARCINOMA
• ADENOID CYSTIC CARCINOMA
• POLYMORPHOUS LOW-GRADE ADENOCARCINOMA
• EPITHELIAL-MYOEPITHELIAL CARCINOMA
• CLEAR CELL CARCINOMA
• ACINIC CELL CARCINOMA
3.1. Pleomorphic adenoma
3.1.1. Definition
A benign neoplasm composed of ductal epithelial and myoepithelial cells set within a
mesenchymal stroma.
Cytokeratin cocktail, S100 protein, SMA, p63, calponin, MSA, GFAP, and CD10 reactive the
cells are highlighted by a mixture of epithelial and myoepithelial markers that include AE1/
AE3, CK5/6, CK7, and CK14; S-100 protein; p63; SMA; calponin; and GFAP. (Figure 3). [14-16]
3.2. Basal cell adenoma
3.2.1. Definition
Basal cell adenoma is a benign salivary gland epithelial neoplasm composed of a proliferation
of small basaloid cells in solid, tubular, trabecular, or membranous patterns. (Figure 4).
Immunohistochemical Inner luminal cells: cytokeratin cocktail, CK7, and CD117 Peripheral
basaloid cellS_100 protein, p63, SMA, and MSA [17 -19]
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a) b)
Figure 3. a) Pleomorphic adenoma shows a mixture of myoepithelial cells and isolated duct-tubular structures b) S-100
protein in the myoepithelial cells.

a) b)

Figure 4. a) Basal cell adenoma, trabecular type b) p63 highlights the basal cells
3.3. Canalicular adenoma
3.3.1. Definition
Canalicular adenoma is a benign epithelial salivary gland neoplasm characterized by chains

of columnar cells and preference for the minor salivary glands.
Cytokeratin and S100 protein reactive GFAP is reactive at the tumor/connective tissue interface
(Figure 5.) [17-23].
3.4. Oncocytoma
3.4.1. Definition
Oncocytoma (oncocytic adenoma) is a putative neoplastic proliferation of oncocytically altered

cells.
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a) b)

Figure 5. a) Canalicular adenoma, b) GFAP staining is positive
3.4.2. Immunohistochemical stains)

Cytokeratin, p63, and PTAH reactive (Figure 6) [17- 19, 21, 22]
a) b)
Figure 6. a) Oncocytes are Cytokeratin, highly positive polygonal cells with abundant granular eosinophilic cytoplasm
and round, centrally placed nuclei, with or without nucleoli. b) p63 reactive.
3.5. Papillary cystadenoma lymphomatosum (Warthin’s tumor)
3.5.1. Definition
Warthin’s tumor is a relatively common lesion composed of a double layer of oncocytic and
cystic architectural pattern cells, and a dense lymphoid epithelium in a papillary stroma.
(Figure7)

Epithelial component keratin reactive Lymphoid component reactive with B- and T-cell
markers [17- 19]
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Figure 7. a) Papillary-cystic tumor associated with a dense lymphoid stroma. b) KI 67 positive B- cell component.
3.6. Sebaceous adenoma / lymphadenoma
3.6.1. Definition
Sebaceous adenoma is a benign epithelial neoplasm composed of proliferating, incompletely

differentiated sebaceous glands. Sebaceous lymph adenoma is a rare variant in which the
epithelial proliferation is supported by a dense lymphoid stroma and possibly arises from
entrapped salivary gland tissue within intraparotid or periparotid lymph nodes (Figure 8).
Immunohistochemistry can be used to confirm the sebaceous differentiation (such as with

CD15, androgen receptor, or EMA Epithelial component is cytokeratin and is EMA reactive)
[17-19]
a) b)

Figure 8. a) Sebaceous lymphadenoma b) EMA highlights the sebocytes
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3.7. Mucoepidermoid carcinoma
3.7.1. Definition
A malignant glandular epithelial neoplasm characterized by mucus, intermediate, and

epidermoid cells. This common salivary gland malignancy represents between 2% and 16% of
all salivary gland tumors and up to one third of malignant salivary gland tumors.
3.8. Immunohistochemical stains
Intermediate and epidermoid cells are immunoreactive for cytokeratin and frequently EMA
Three cell populations can generally be seen in MEC- epidermoid cells, mucous cells, and
intermediate cells— variably set within a cystic background (Figure 9).
CK5/6, Ki-67, and p63 nuclear expression may help in the differential diagnosis. [23, 24]
a) b)

Figure 9. a) Mucoepidermoid carcinoma(H&E) and b) CK5/6 highlight the epidermoid and intermediate cells.
3.9. Adenoid cystic carcinoma
3.9.1. Definition
Adenoid cystic carcinoma accounts for 10% of all malignant salivary gland tumors. ACC is
cribriform and has two prominent growth patterns: Tubular, and solid, and it is composed of
epithelial and myoepithelial cells (Figure 10).
Pseudocysts are positive for PAS, Alcian blue, laminin, and type IV collagen Epithelial cells
are positive for low-molecular-weight keratins, EMA, and CD117 Myoepithelial cells are
positive with calponin, SMA, S100 protein, and p63. [25 – 32].
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a) b)

Figure 10. a) Adenoid cystic carcinoma showing multiple patterns b) CD117 highlights the epithelial cells.
Polymorphous low-grade adenocarcinoma.
3.9.3. Definition
This is a malignant epithelial tumor characterized by an infiltrative growth of cytologically

uniform cells (“low-grade”) arranged in architecturally diverse patterns (polymorphous),
slowly growing tumor that exclusively affects the minor salivary glands, most often of the
palate (Figure 11).
Cytokeratin, vimentin, and S100 protein are positive. Variable results are seen with immuno‐
histochemistry and are rarely of diagnostic value. It reacts with EMA, S-100 protein, and Bcl-2;
these findings can help differentiate it from PA and ACC. [17-19, 33]

a) b)

Figure 11. a) polymorphous low-grade adenocarcinoma b) S-100 protein

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3.10. Epithelial-myoepithelial carcinoma
3.10.1. Definition
Epithelial-myoepithelial carcinoma is a low-grade, malignant, biphasic salivary tumor that

comprises 1% to 2% of all salivary neoplasms, the majority of which develop in the parotid
gland. It is a malignant neoplasm with biphasic duct-like structures composed of an inner
layer of duct lining, epithelium-type cells and an outer layer of clear, myoepithelial-type
cells (Figure 12).
Inner cells are positive for keratin; outer myoepithelial cells are calponin, SMA, p63, and, less
reliably, S100 protein positive; CD117 and bcl-2 are frequently positive. [17- 19, 34

a) b)

Figure 12. a) Epithelial-myoepithelial carcinoma b) smooth muscle actin strongly stains the myoepithelial cells
3.11. Clear cell Carcinoma
3.11.1. Definition
Many salivary and nonsalivary tumors contain clear cells. Among these are mucoepidermoid
carcinoma, acinic cell carcinoma, oncocytoma, renal cell carcinoma, myoepithelioma, and clear
cell odontogenic carcinoma.
The neoplastic cells are positive with AE1/AE3, CAM5. 2, CK7, EMA, and p63; cells are negative
with S-100 protein, calponin, actins, and GFAP (Figure 13). They are usually negative for
myoepithelial markers that include S-100 protein, MSA, SMA, SMMHC, calponin, and GFAP
and are also negative for CD10, CK20, vimentin, desmin, RCC, CA9, and Pax-2 see). [35-37]
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a) b)

Figure 13. a) Clear cell carcinoma b) Highlighted clear cells by S100
3.12. Acinic cell carcinoma
3.12.1. Definition
A malignant epithelial neoplasm demonstrating serous acinar cell differentiation with

cytoplasmic zymogen secretory granules (Figure 14).
PAS-positive, diastase-resistant zymogen granules. Acinic cells may stain positively for
amylase, transferrin, lactoferrin, CEA, VIP, and others. About 10% show some positivity for
S100 protein. [38, 39]
Figure 14. a) Serous acinar cells have abundant pale to basophilic, heavily granular cytoplasm (H&E). b) Trypsin is
detectable in acinar cells.
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4. Soft tissue tumors
The most common soft tissue tumors needing IHC are:
• Lobular capillary hemangioma
• Fibrosarcoma
• Angiosarcoma
• Kaposi Sarcoma
• Leiomyosarcoma
• Synovial Sarcoma
• Rhabdomyosarcoma
• Granular Cell Tumor
4.1. Lobular capillary hemangioma
4.1.1. Definition
Lobular capillary hemangioma previously commonly referred to as “pyogenic granuloma, ”

is a reactive soft tissue growth with a predilection for the oral cavity that is histologically
characterized by a lobular arrangement (Figure15).
Positive for endothelial markers including factor VIII–related antigen and CD31 of proliferat‐
ing small blood vessels. [17-19]
Figure 15. a) H&E capillary hemangioma b) CD31 highlights the endothelial cell C) Factor VIII noted in the endothelial
cells.
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4.2. Fibrosarcoma
4.2.1. Definition
Malignant neoplasm with only fibroblastic/myofibroblastic differentiation (Figure 16).
Vimentin, and rarely, focal actin positivity. [40, 41]
Figure 16. a) Hypercellular tumor, showing spindle cells. b) Vimentin is highly positive
4.3. Angiosarcoma
4.3.1. Definition
Uncommon, high-grade malignant vascular neoplasm, occasionally associated with radiation.
Positive with CD34, CD31, factor VIII–RAg, vimentin, podoplanin. ERG shows nuclear
positivity in nearly 100% of angiosarcomas. FLI1 expression is found in as many as 100% of
angiosarcomas, but utility is limited by poor specificity for vascular lesions. CD31 expression
is found in more than 90% of angiosarcomas (Figure 17).
VEGFR3 expression is found in approximately 50% of angiosarcomas, [42-50]
4.4. Kaposis sarcoma
4.4.1. Definition
Kaposi sarcoma is a malignant neoplasm of endothelial cells. Oral lesions are commonly
multifocal. Early lesions: are flat, red, and asymptomatic. Older lesions: larger, darker, nodular,
and ulcerated. KS is common in patients with AIDS.
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Figure 17. a) Richly vascularized tumor with open vascular channels and mitotic figures b) CD 31 is positive.
Human herpes virus 8 has variable expression for endothelial markers (CD31, CD34)[17, 18,
19, 48, 51] (Figure 18).

c)

a) b)

Figure 18. a) Nodular aggregates of spindle cells forming slit-like spaces (H&E). b) CD34 is positive.
4.5. Leiomyosarcoma
4.5.1. Definition
Malignant tumor of smooth muscle
Currently, IHC confirmation of smooth muscle differentiation in LMS is based on the dem‐
onstration of desmin, α–SMA, muscle actin (HHF-35), and h-Caldesmon PAS with diastase
will highlight intracellular glycogen. Tumor cells will be strongly and diffusely reactive with
vimentin and actins (smooth muscle, muscle-specific), while variably positive for desmin [49,
50, 51, 52, 53, 54] (Figure 19) [52-57].
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Figure 19. a) Spindle cell population. b) Desmin reactivity.
4.6. Synovial sarcoma
4.6.1. Definition
Synovial sarcoma is a malignant soft tissue tumor that shows epithelial and mesenchymal
differentiation and has distinct clinical, genetic, and morphologic features.
Although it was once thought that synovial sarcoma arose in association with synovium, it is
now well known that this is not the case and that these tumors may arise at any anatomic
location.

Morphologically, synovial sarcoma takes three main forms: 1) biphasic, 2) monophasic, and
3) poorly differentiated. Biphasic synovial sarcoma (BSS) consists of a fascicular spindle cell
component and an epithelial component that usually shows glandular differentiation, whereas
monophasic synovial sarcoma (MSS) lacks the epithelial component. The glandular compo‐
nent of synovial sarcoma expresses cytokeratins, including AE1/AE3. EMA expression is
typically observed in both BSS and MSS. however, unlike its biphasic counterpart, MSS tends
to be focally and inconsistently reactive for cytokeratins.
In particular, MSS may show reactivity for simple keratins: CK7, CK8, CK18, and CK19. S-100
protein expression is found in approximately 30% of synovial sarcomas. CD99 is commonly
observed in MSS, but expression of this marker is also shared by some other spindle cell
neoplasms. Strong positivity for BCL2 protein has also been noted in the spindle cell compo‐
nent of synovial sarcoma. [55-58]. TLE1 is positive in synovial sarcoma (Figure 20).
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Figure 20. a) Spindle or epithelioid cells show a predominantly nested growth pattern. b) TLE1 is positive
4.7. Rhabdomyosarcoma
4.7.1. Definition
A malignant neoplasm with skeletal muscle phenotype: Embryonal type (80%): Alveolar type
(20%)
4.7.2. Immunohistochemical stain
MYOD1, SMA positive A variety of myoid markers are positive (desmin, myogenin, MyoD1,
myoglobin, actins), but it is important to remember that AE1/AE3, CAM5. 2, and CD56, along
with synaptophysin, may be focally positive in some cases. [59, 60, 61] (Figure 21)
a) b)
Figure 21. a) Mesenchymal cells and rhabdomyoblasts b) Desmin

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4.8. Granular cell tumor
4.8.1. Definition
This is an uncommon tumor composed of poorly demarcated granular cells, thought to be

Schwann-cell derived, that frequently arise below a mucosa, the latter often showing pseu‐
doepitheliomatous hyperplasia. Granular cell tumor tends to affect the oral cavity (tongue
most commonly). Tumors are usually smooth surfaced, poorly demarcated, and are often
polypoid, and measure from1 to 2 cm.
The neoplastic cells yield a strong and diffuse nuclear and cytoplasmic S-100 protein reaction
and are also positive for CD68, NSE, α-1–antitrypsin [17-19, 62] (Figure 22).
a) b)
Figure 22. a) Polygonal granular cells H&E b) neoplastic ells with s-100
5. Hematologic disorders
The common hematologic disorders that need IHC stains are;

• Hodgkin's lymphoma
• Non – Hodgkin's lymphoma
• Extranodal NK/T-Cell lymphoma, (angiocentric T-cell lymphoma) Midline lethal granulo‐

ma
• Burkitt's lymphoma
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5.1. Hodgkins lymphoma
This almost always begins in the lymph nodes, and any lymph node group is susceptible.
The most common sites of initial presentation are the cervical and supraclavicular nodes (70%
to 75%). Hodgkin's lymphoma is currently classified in the following manner:
• Lymphocyte-rich
• Nodular sclerosis
• Mixed cellularity
• Lymphocyte depletion
The antibodies most commonly used for diagnosing HL are Ber-H2 (CD30), LeuM1 (CD15),
LCA (CD45), L26 (CD20), CD75 (LN1), CD74 (LN2), PAX5, CD3, UCHL1 (CD45RO), ALK,
fascin, and EBV-LMP1. EMA and CD57 can be used to recognize NLPHL.
Monoclonal antibody LN1 reacts with H/RSCs in approximately one third of HL cases, most
frequently in cases of NLPHL (>75% of cases)(Figure 23). [17-19]
Figure 23. a) Hodgkin/Reed-Sternberg cells b) antigenic Reed-Sternberg cells for CD15
5.2. Non- Hodgkins lymphoma
5.2.1. Definition
Non-Hodgkin's lymphoma most commonly develops in the lymph nodes, In the oral cavity.
Lymphoma usually appears as extranodal disease. The malignancy may develop in the oral
soft tissues or centrally within the jaws; they most commonly affect the buccal vestibule,
posterior hard palate, or gingiva.
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Small Cell Lymphoid Neoplasms
The lymphoma cells express pan–B-cell antigens (CD19, CD20, CD22, PAX-5). Mantle cell
lymphoma (MCL) expresses pan–B-cell antigens (CD19, CD20, CD22), CD5, CD43, Bcl-2, and
cyclin D1.
Nodal marginal zone lymphoma (NMZL) will typically express pan–B-cell antigens that
include CD19, CD20, PAX5, and CD79a;
Co-expression with Bcl-2 and CD43 is common and occurs in 50%. The vast majority of low-
grade follicular lymphoma (FL) are positive for Bcl-2 small lymphocytic lymphoma (CLL/SLL)
includes expression of CD5, CD23, CD19, CD43, and Bcl-2 and has a proliferation rate of less
than 10%. [17-19] (Figure 24).
Large B-Cell Lymphoid Neoplasms
CD15 expression +
CD30 +
CD45 expression +
PAX5 strong, uniform + CD20 strong, uniform +.
CD79a expression +.
p63 +
a) b)
Figure 24. a) B-cell lymphoma (H&E) b) CD 20 is positive
T-Cell Lymphoid Neoplasms
Almost all peripheral T-cell lymphomas express pan–T-cell antigens CD3, CD2, and CD43.
Anaplastic large-cell lymphoma (ALCL) is positive for CD30, and the expression should be
strong and in at least 75% of the cells.
The neoplastic cells of angioimmunoblastic T-cell lymphoma)AITL) are positive for pan–T-cell
antigens CD3, CD2, CD5, [17-19]
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5.3. Extranodal NK/T-cell lymphoma, (angiocentric T-cell lymphoma) midline lethal

granuloma
5.3.1. Definition
NK/T-cell lymphoma is the most common malignant nonepithelial neoplasm found in the
upper respiratory tract and most commonly involves the nasal cavity, the maxillary sinus,
nasopharynx, and salivary gland. This discussion will be limited to extranodal NK/T-cell
lymphoma, nasal type (NK/T LNT), which is more common in the sinonasal region.
NK cells express CD2, CD7, CD8, CD56, and CD57. They are positive for cytoplasmic CD3,
but not surface CD3, and do not typically express CD5. The neoplastic counterpart, extranodal
NK/T-cell lymphomas, express CD2, cytoplasmic CD3, CD56, and, in most cases, EBV. [17-19]
(Figure 25, 26).
Figure 25. a) Extranodal natural killer/T-cell lymphoma b) CD3 staining is positive
a) b)
Figure 26. a) Atypical lymphoid cells(NK/T-CELL LYMPHOMA) b) Diffusely immunoreactive with CD3C
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5.4. Burkitts lymphoma
5.4.1. Definition
Burkitt's lymphoma is a malignancy of B-lvmphocyte origin that represents an undifferenti‐

ated lymphoma. The tendency for jaw involvement seems to be age related: nearly 90% of 3-
year-old patients have jaw lesions.
There were statistically significant differences in the expression of CD10 (28/28 vs. 1/16), bcl-2
(3/28 vs. 11/16), MUM1 (5/28 vs. 15/16), a PI of 95. 0% or more (27/28 vs. 2/16), and combined
CD10+/bcl-2-/bcl-6+ (24/28 vs. 1/16) between BLs and DLBCL-HPSSs. Of the BLs, 7 (25%) of 28
and 26 (96%) of 27 were positive for EBER and c-myc rearrangement as compared with 0 of 16
and 1 (7%) of 15 DLBCL-HPSSs, respectively as compared with 0 of 16 and 1 (7%) of 15 DLBCL-
HPSSs, respectively. [17-19, 63]

a) b)

Figure 27. a) Burkitt's lymphoma. "starry-sky" appearance b) CD10 staining
6. Bone tumors
The common bone tumors needing IHC are:
• Osteosarcoma
• Chondrosarcoma
• Ewing sarcoma
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6.1. Osteosarcoma
6.1.1. Definition
Osteosarcoma is the most common nonhematopoietic primary malignant bone tumor ; it is a

malignant mesenchymal tumor producing osteoid from the tumor cells (Figure 28).
CD99 positive; rare cytokeratin and smooth muscle actin reaction. Overall, the reported
specificity of immunoreactivity for osteonectin and osteocalcin is approximately 40% and 95%,
respectively, for the diagnosis of a bone forming tumor. A recent promising marker for
identification of osteoblastic differentiation is SATB2, a nuclear matrix protein that plays a role
in osteoblast lineage commitment. α-SMA and desmin, which can lead to misdiagnosis. [63-69]
a) b)
Figure 28. a) Osteosarcoma demonstrates irregular trabeculae of tumor osteoid arising from sarcomatous stroma. b)
CD99 is positive
6.2. Chondrosarcoma
6.2.1. Definition
Chondrosarcoma is a malignant tumor of bone that shows pure cartilaginous differentiation.

Secondary changes that include myxoid features, ossification, and calcification may be present.
(Figure 29).
Cartilage stains S100 protein positive Mesenchymal chondrosarcoma: Sox9, CD99, and Leu7
positive Although the cartilaginous component of mesenchymal chondrosarcoma is S-100
protein positive, the small-cell component expresses CD99, CD57, and NSE therefore immu‐
nohistochemically, there may also be overlap with Ewing sarcoma. However, unlike Ewing
sarcoma, MCS is nonreactive for synaptophysin and also typically does not express desmin,
actin, cytokeratin, or EMA. In addition, MCS lacks EWSR1 gene rearrangements. However, a
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recent study has identified a novel HEY1-NCOA2 fusion in MCS which appears to be a
consistent finding. [70, 71]

c)

a) b)

Figure 29. a) High-grade chondrosarcoma b) with marked S100 PROTEN increase in cellularity and myxoid matrix
6.3. Ewing sarcoma
6.3.1. Definition
High-grade, primitive neuroectodermal neoplasm (Figure 30)
Positive: FLI1 (nuclear), CD99, vimentin; rarely keratin. May react with other neural markers
(NSE, synaptophysin, S100 protein, NFP, GFAP, chromogranin). [72-79]
a) b)
Figure 30. a) Small nucleoli scant cytoplasm with mitosis b) diffuse strong membranous expression of CD99
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Author details
Taghi Azizi*
Address all correspondence to: aziziarshia@yahoo.com
Department of Oral and Maxillofacial Pathology, Baqiyatallah University of Medical Sciences

Tehran, Iran
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Chapter 16
Considerations for the Spread of Odontogenic Infections

— Diagnosis and Treatment
Flaviana Soares Rocha, Jonas Dantas Batista,

Cláudia Jordão Silva, Roberto Bernardino Júnior and
Luis Henrique Araújo Raposo
http://dx.doi.org/10.5772/59161
1. Introduction
The goal of this chapter is to present the basis for correct diagnosis and management of severe
odontogenic infections. The knowledge of the anatomy of fascial spaces is essential for the
correct diagnosis and treatment of head and neck infections, because both facial and cervical
fasciae work as an effective barrier against the spread of infections in this region[1, 2]. Once
these infections occur, they are often difficult to assess accurately by clinical examinations and
conventional radiographic techniques, and the outcome may be serious and potentially life-
threatening[3]
The fasciae of the neck are glossy and divided into two separated layers: the superficial fascia
and the deep fascia. The superficial fascia is actually a component of the fatty subcutaneous
tissue while the deep cervical fascia is divided into three layers: the superficial layer, the
visceral or middle layer, and the pre vertebral or deep layer. The deep cervical fascia plays an
important role in determining the location and course of spread of infections within the soft
tissues of the neck. The infections that commonly affect head and cervical areas are frequently
from odontogenic origin and to a lesser frequency, proceeding from foreign bodies or trauma
to this region[4]. An impacted mandibular third molar is one of the most frequent causes of
odontogenic infection[5-7]. Moreover, an semi-impacted third molar results in odontogenic
infection more commonly than fully erupted or completely impacted molars [7].
Odontogenic infections occasionally spread beyond the barriers of the fascial spaces, which
are formed, as seen, by the deep cervical fascia of the suprahyoid regions of the neck[2]. Among
various spaces, the submandibular space is one of the first to be involved in odontogenic
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infections, similar to the masticatory space[2]. As infection may spread along deep cervical
facial planes and neck cavities, widespread cellulitis, necrosis, abscess formation, and sepsis
may occur in these cases[4]. Therefore, it is important to understand the anatomy, rate of
progression and potential for airway compromise of an infection[7].Spontaneous dissemina‐
tion of an odontogenic infection is however, very rare in immunocompetent patients[8, 9]. In
patients with anatomical abnormalities, systemic diseases or immunosuppression, bacteremia
caused by dental procedures may lead to generalized or metastatic systemic infection com‐
plications leading to hospital care[10, 11]. In particular, patients with poorly controlled
diabetes mellitus are more susceptible to bacterial infections[12-14]. However, death from
odontogenic infection is quite rare [9, 15, 16].
Despite being rare, facial and neck fasciae spaces involved by infections from odontogenic
origin may lead to a very morbid condition. The diagnosis delay and late or wrong therapeutic
approachs to deep infections in these areas are the main causes of high mortality rate in this
life-threatening situation.[4] Dentistry has made great progress in prevention and early
intervention of odontogenic infection. The introduction of antibiotics reduced significantly the
mortality and morbidity of these infections, however, even in this contemporary postantibiotic
era, serious infections such as a descending necrotizing mediastinitis still have a high mortality
rate with a fulminating course, leading frequently to death.[17-20]
2. Facial and cervical space anatomy
The knowledge of the relevant facial and cervical anatomy of the face is essential for todays
clinical practice, allowing precise and successful diagnosis. Figure 1 describes the principal
anatomic structures and spaces of the face.
Figure 1. Anatomy of the fascial spaces in axial (A) and coronal (B) images. SMS: submandibular space; SLS: sublin‐
gual space; PPS: parapharyngeal space; CS: carotid space; MS: masticatory space. SMG: submandibular gland; GGM:
genioglossus muscle; MHM: mylohyoid muscle; MM: masseter muscle; MPM: medial pterygoid muscle; LPM: lateral
pterygoid muscle; TM: temporal muscle.
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Considerations for the Spread of Odontogenic Infections — Diagnosis and Treatment 343
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The superficial fascia a component of the fatty subcutaneous tissue and the deep cervical fascia
is an important anatomic structure, determining the location and course of spread within the
soft tissues of the neck.
2.1. Deep cervical fascia
The deep cervical fascia is divided into three layers: the superficial layer, the visceral or middle
layer, and the pre-vertebral or deep layer.
The superficial layer of the deep cervical fascia encircles the neck, enveloping the sternoclei‐
domastoid and trapezius muscles and the muscles of mastication, along with the submandib‐
ular and parotid salivary glands. It extends from the nuchal line of the skull, mastoid processes,
and mandible inferiorly to the scapula, clavicle, and lower cervical vertebrae.
The middle layer of the deep cervical fascia encloses the anterior viscera of the neck (thyroid
gland, larynx, trachea, and pharynx) and the strap muscles. It attaches to the skull base and
extends into the mediastinum.
The deep layer of the deep cervical fascia is divided into the pre-vertebral and alar divisions.
The pre-vertebral division tightly encloses the spine and paraspinous muscles. Ventrally, it
lies immediately anterior to the vertebral bodies, forming the anterior wall of the pre-vertebral
space. It extends from the base of the skull to the coccyx.
The alar division of the deep layer of the deep cervical fascia lies between the pre-vertebral
division and the middle layer of the deep cervical fascia. It extends from the skull base to the
mediastinum. The carotid sheath is made of contributions from all three layers of the deep
cervical fascia and envelops the carotid artery, jugular vein, and vagus nerve.[21, 22]
2.2. Fascialspaces
The parapharyngeal space fascia is in an area of fatty areolar tissue with complex fascial
margins that lies in a central location in the deep face. It extends from the skull base to the
hyoid bone, containing only fat tissue, branches of the trigeminal nerve, and the pterygoid
venous plexus. Posterior to the parapharyngeal space is the carotid space. All three layers of
deep cervical fascia contribute to the carotid sheath that circumscribe this space.
The carotid space extends from the skull base to the aortic arch. Its suprahyoid contents include
the internal carotid artery, jugular vein, cranial nerves IX–XII, and deep cervical lymph node
chain.
The retropharyngeal space is a posterior midline space that has the middle layer of deep
cervical fascia as its anterior margin and the deep layer of deep cervical fascia as its posterior
and lateral margins. It extends from the skull base to the level of the T3 vertebral body.[21, 23]
The danger space lies posterior to the retropharyngeal space and is separated from the
retropharyngeal space by the alar fascia. The posterior margin of the danger space is the pre-
vertebral division of the deep layer of the deep cervical fascia. The importance of the danger
space, and the reason for its name, is that it extends from the skull base to the level of the
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diaphragm, providing a pathway into the posterior mediastinum and pleural spaces. Infec‐
tions of danger space most commonly occurs when an abscess in the retropharyngeal space
ruptures through the alar fascia.[21, 23-31]
3. Teeth involved in fascial infections
Invasive dental manipulation is known to cause bacteremia and generally considered high-
risk procedures for the spread of infection in susceptible patients.[31-48] Sato et al., has
shown that the main origin of maxillofacial infections were odontogenic (79.31%), fol‐
lowed by trauma (10.7%), immunosuppression (1.6%), pathologies (1.6%), and other causes
(8%).[49] Seppänen et al., also reiterated that the most common dental procedures that
precede odontogenic infection complications are: tooth extraction (60%), endodontic
treatment (20%), dental implant surgery (8%), restorative treatment (8%) and dental plaque
and calculus removal (4%).[50-52]
Lower third molars are more frequently involved in odontogenic infections when compared
with other teeth. Flynn et al., presented in their prospective study with 37 consecutive
hospitalized patients, a 68% prevalence rate of this group of teeth in association with odonto‐
genic infections, followed by other lower posterior teeth (premolars, first and second molars),
without anterior teeth involvement.[13] Third molar removal is one of the most regular
dentoalveolar surgical procedures.[10, 26, 52-65] With an 80% prevalence of retained third
molars in the adult population,[23] appropriate treatment, and especially prophylactic third
molar removal remains a key focus of interest in healthcare with both medical and economic
dimensions. It is generally accepted that substantial risks may arise both from third molar
removal,[6, 29, 37, 60, 66, 67] as well as from a “wait and see “policy.[4, 11, 14, 25, 33, 44, 65]
4. Microbiological involvement
The severe infections of odontogenic origin frequently involve a complex polymicrobial mix
of aerobes, facultative aerobes and strict anaerobes working together. Some species like
Peptostreptococcus, Staphylococcus, Lactobacillus, Prevotella, Treponema, Fusobacterium, Veillonella,
Actinomyces, Bacteroide ssp. and oral Streptococcus sp. are frequently associated with infections
of odontogenic origin.[13, 36, 43, 46, 48, 56] Sakamoto et al., reported 17 different species
collected from a single surgical site.[48] Flynn et al., isolated 90 different strains of microor‐
ganisms in 37 patients, and of these, 17 were penicillin-resistant.[13] Other species can be easily
found at the infection sites, but generally, they reflect the indigenous microflora of the oral
cavity. Routine culture and sensitivity testing for minor oral infections does not appear to be
justified, however, when an infection involves anatomic spaces of moderate or greater severity,
or when there is significant medical/immune compromise, the tests become important to the
outcome.
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5. Pathway of facial and cervical infections of odontogenic origins
5.1. Fascial infections derived from mandibular odontogenic origins
Infections originating in the facial planes of the head and neck spread downward along the
cervical fascia, facilitated by gravity, breathing, and negative intrathoracic pressure. Knowl‐
edge of the facial spaces and fascial planes is essential for understanding the propagation,
pathways, symptoms, and complications of cervical infections.[4, 47] Although the pattern of
spread varies among patients, a relatively constant trend in the distribution of infection into
the spaces seem to be evident. Some studies clearly demonstrated that the masticatory space
is the most prevalent site for odontogenic infection spread. Taken together with the finding
that the masticatory space encompasses the posterior mandibular body, ramus, and a part of
the alveolar bones of the maxilla, this suggests that the masticatory space may be the initial
site of spread of odontogenic infection. This contention was further supported by the finding
that mandibular infection more frequently involved the masseter and medial pterygoid
muscles (located in the lower compartment of the masticatory space where the mandible is
included) than the temporalis and lateral pterygoid muscles (located in the upper compart‐
ment of the space where part of the maxilla is included).[3]
The spaces adjacent to the masticatory space are the parotid space posteriorly, the paraphar‐
yngeal space medially, and the submandibular and sublingual spaces inferiorly (Figure 1).[48]
The parapharyngeal space occupies the central position among the masticatory, parotid, and
carotid vascular spaces. Therefore, infections in the parapharyngeal space may originate from
any adjacent space. A fascia extends from the posterior superior margin of the medial ptery‐
goid muscle to the base of the skull to separate the masticatory space from the parapharyngeal
space.[49] In this way, it is possible to believe that infection spreading from the masticatory
space into the parapharyngeal space may pass via the medial pterygoid muscle. Yonetsu et al.,
found that 100% of patients with parapharyngeal space involvement also had the medial
pterygoid muscle affected, and 79% of patients with infection in the medial pterygoid muscle
area had concomitant involvement of the parapharyngeal space. However, in none of their
cases spread from the submandibular into the pharyngeal spaces.[3]
The parotid space abuts the posterior masticatory space and is enveloped by a layer of the deep
cervical fascia.[50] Yonetsu et al., demonstrated that odontogenic infection may extend into
the parotid space, via the masticatory space.[3] The retropharyngeal space connects the skull
base to the upper mediastinum and contains loose fatty tissue in its infrahyoid portion. Thus,
the retropharyngeal space is considered to be important due to its proximity to the airway and
because infections in this space may cause mediastinitis, bronchial erosion, and septicemia.[3,
50] The vertebral and vascular spaces are thought to be rarely involved by head and neck
infection.[51]
The infection spread occurs when accumulated pus perforates bone at the weakest and thinnest
part. In the mandible, the lingual aspect of the molar region represents the easiest way.[4, 52]
If odontogenic infection perforates this portion of bone, it will spread into the sublingual or
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submandibular space. As these spaces are partially separated by a thin sheet of mylohyoid
muscle, infection in either space easily spreads into the other. It is generally believed that the
midline enables free communication from either the sublingual or submandibular space.[3, 50]
Delineating the maxillary spread pattern is quite difficult, because limited data is available
regarding its infections.[3] Nevertheless, it is plausible to consider that the observed difference
in the spread profile between maxillary and mandibular infections may be due to differences
in the distance between the original focal area in jaw bones and each of the spaces. For instance,
maxillary infection was associated with temporalis muscle involvement more often than
mandibular infection. Maxillary infection also spreads first to the masticatory space, but the
temporalis and lateral pterygoid muscles are predominant targets for the infection. Involve‐
ment of the sublingual and submandibular spaces is rare. Otherwise, odontogenic infection
arising in the mandible spreads first to the masticatory space. The masseter and medial
pterygoid muscles in the masticatory space are most frequently involved. Thereafter, the
infection spreads medially into the parapharyngeal space and posteriorly into the parotid
space. Involvement of the sublingual and submandibular spaces seems to occur directly from
the primary site of mandibular infection.[3]
There are complex pathways which allow infection to spread along the facial and neck
structures. Thus, it is important for dental practitioners to know more about the possibility of
a dental intervention to be a cause of severe infections.
The sequence of odontogenic infection spread that most commonly occurs is:
1. The masticatory space is the primary site of spread from mandibular infection.
2. The parotid and pharyngeal spaces are the secondary sites of spread from the masticatory
space.
3. Mandibular infection spreads directly to the sublingual and submandibular spaces, and
4. Maxillary infection spreads to the deep facial and neck spaces in a different way from that
of mandibular infection (Figure 2).
5.2. Fascial infections derived from maxillary odontogenic origins
The pattern of maxillary infection spread differs from that of the mandible. Generally, the main
maxillary spaces involved were found to be the buccal maxillary (19.05%) and canine (15.24%).
[49] According to Yonetsu et al., the temporalis muscle was involved in 100% of the patients
with maxillary infection. The involvement of the temporalis muscle in mandibular infections
occurred only in 26% of the patients. The downward spread into the sublingual and subman‐
dibular spaces from maxillary infections did not occur. The lateral pterygoid and masseter
muscles were frequently involved (86%) as in the cases of mandibular infection. Other spaces
were also involved, but less frequently. The buccal space was involved in 57% of the patients
with maxillary infection[66] (Figure 2).
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Figure 2. Different locations of odontogenic infections. (A) Submandibular and sublingual region. (B) Submandibular
region. (C) Cervical region. (D) Palate. (E) Orbital region. (F) Submandibular and buccal region.
6. Causes of infections
6.1. Pericoronitis
Pericoronitis is an infection of the gingiva of a partially erupted tooth. The most frequent form
of pericoronitis is caused by the partially erupted lower third molar, mainly due to the
favorable niche that is created once the mucous cap covering the molar becomes retentive and
deep enough to trap food particles and reduce the oxygen potential. These factors create the
perfect microenvironment for the onset and subsequent development of a recurrent infectious,
inflammatory condition caused by polymicrobial microorganisms, especially strict anaerobes.
[19] Third molar pericoronitis may appear in either of its two acute variations, namely serous
and suppurative, as well as in its chronic form; when either of the two acute forms previously
mentioned stays untreated.
6.2. Periapical lesions/Intra-oral abscess
The most significant clinical condition of all bacterial infections of periapical origin is the so-
called acute apical periodontitis.[16] It is usually the result of purulent pulpitis that spreads
into the periapical space, therefore, it appears in the course of pulpal disease. In acute apical
periodontitis there is an accumulation of pus inside the apical space of the tooth involved. This
condition is commonly underestimated by dental practitioners in terms of its morbidity and
mortality.[46] (Figure 3)
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Figure 3. Clinical (A) and radiographic(B) aspects of a periapical lesion.
6.3. Infection of sublingual, submental and submandibular spaces (Ludwig’s Angina)
Ludwig’s angina is a rapidly spreading cellulitis that may produce upper airway obstruction,
often leading to death. The most common source of Ludwig’s angina is an odontogenic
infection, from one or more grossly decayed, infected teeth, and is usually as a result of a native
oral mixed aerobic-anaerobic flora. The patient with Ludwig’s angina presents severe and
obvious extra oral swellings including bilateral submandibular, submental, and sublingual
spaces. Elevation and displacement of the tongue, trismus, drooling of saliva, airway obstruc‐
tion, sore throat, dysphagia and/or dyspnea are commonly present. With extensive use of
drainage and antibiotics, most facial infections have satisfactory outcome before they have a
chance to progress to Ludwig’s angina.[1] (Figure 4)
Figure 4. Clinical presentation of Ludwig’s angina.

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6.4. Cervical cellutis
Cervical cellulitis is most commonly from odontogenic origin and despite modern antibiotic
therapy, cases with an initial delay in diagnosis and treatment may still result in this life-
threatening situation.[17, 58-60] Odontogenic infections are usually locally confined, self-
limiting processes. However, under certain circumstances, like anatomical variations or
suppression of the immune system of some patients, these infections may pass through the
bony, muscular, and mucosal barriers and spread into contiguous and distant spaces, resulting
in severe fulminating infections in the body cavities.[60]
When cervical cellulitis involves the parapharyngeal, retropharyngeal, and viscerovascular

spaces, the purulent process has easy access to the mediastinum, pericardium, and thorax,
thereby increasing mortality rates.[13, 17, 58-60] Because of the fulminant nature of descending
cervical cellulitis with mediastinal complications, prompt recognition followed by broad-
spectrum antibiotic therapy, immediate surgical intervention, and intensive medical support
are required.[13, 61]
The second and third mandibular molars are the teeth most frequently implicated in the cause
of odontogenic deep neck infections.[17, 58, 60, 61] Because their roots lie below the mylohyoid
muscle, medial perforation of a periapical abscess has immediate access to the submandibular
space. Then, a collection of pus in the neck spreads along the cervical fascial planes, resulting
in complications.[13]
6.5. Descending Necrotizing Mediastinitis (DNM)
Acute purulent mediastinitis occasionally develops as a complication of odontogenic infection,

in which case it is denominated descending necrotizing mediastinitis.[17] This is a serious
infection involving the connective tissue that fills the interpleural spaces and surrounds the
median thoracic organs. It is one of the most dreaded and the most lethal form of mediastinitis,
which occurs as a complication of oropharyngeal abscesses or as a complication of cervical
trauma, with severe cervical infection spreading along the fascial planes into the mediastinum.
As infection spreads along deep cervical fascial planes into the mediastinum, widespread
cellulitis, necrosis, abscess formation, and sepsis may concomitantly occur. The delay of
diagnosis and late or incomplete drainage of the mediastinum are the main causes for high
mortality rates associated with this condition.[4]
Even with the use of computed tomography scanning or magnetic resonance examination,
aggressive drainage, and modern antibiotic treatment, the mortality rate of descending
necrotizing mediastinitis remains high. Surgical management, particularly the optimal form
of mediastinal drainage, remains controversial with support ranging from cervical drainage
alone to cervical drainage and routine thoracotomy.
6.6. Necrotizing fasciitis
Abscesses of the peritonsillar region are among the most common deep abscesses of the head
and neck. Although rare, complications resulting from this disease may be life threatening.
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One of the most dangerous complications is necrotizing fasciitis, which is a rare soft tissue
infection characterized by progressive destruction of fascia and adipose tissue that may not
involve the skin.[62, 63] Necrotizing fasciitis is characterized by its fulminating, devastating,
and rapid-progressing course.[64] Diabetes mellitus, burns and malnutrition are common
predisposing factors. Initially, cervical necrotizing fasciitis is predominantly characterized by
a “simple” infection in the upper aerodigestive tract like pharyngitis or even tonsillitis.
Typically, the general condition gets worse within a very short period of time with cardiovas‐
cular decompensation due to a toxic shock-like condition. Cervical necrotizing fasciitis initially
involves the superficial muscular system and superficial fascial planes of the head and neck
or it may result from a deep soft tissue infection, such as odontogenic infections or even
pharyngitis, which spreads along the deep fascial planes.
If the disease is not recognized in time the infection can rapidly involve the great vessels or
mediastinum, producing systemic toxicity and sepsis.[65, 66] The basis of successful treatment
comprises aggressive surgical debridement and drainage of the involved necrotic fascia and
tissue along with intensive broad-spectrum intravenous antibiotic coverage.[63]
7. Signs and symptoms
The current signs and symptoms presented by patients with severe infections from odonto‐
genic origin are crucial factors for the patient’s life maintenance. Sato et al., has shown in their
eight-year retrospective study that cases of odontogenic infections call for immediate thera‐
peutics, either clinical or surgical, with precise daily or long-term monitoring of patients until
complete resolution of the clinical infection status is reached. The most frequent signs and
symptoms found in these patients were trismus (43.33%), fever (28.10%), dysphagy (25.24%),
pain (24.76%), and swelling (20%), all of which are classic signs of a dire clinical situation.26
8. Imaging
Imaging plays an essential role in the diagnosis and management of head and neck infections
since, by clinical examination alone. It is often difficult to determine if a swollen neck is due
to cellulitis or an abscess; the location, extent or source of the infection, and whether the process
is self-limited or if it is potentially life-threatening is also clinically unclear.[21]
Radiographs of the cervical segment and the chest may be useful in the demonstration of
subcutaneous emphysema in the form of vertical, linear, clear bands of gas extending from the
cervical spaces into the mediastinum. The lateral radiograph of the neck can reveal a prever‐
tebral soft tissue opacity pushing the trachea anteriorly. Chest radiograph can demonstrate a
widened mediastinum and pleural effusion. However, the modest diagnostic sensibility of
cervical and chest plain film should call immediately for computed tomography scanning or
a magnetic resonance of the cervicothoracic areas.[2, 17, 67, 68]
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Any patient with neck swelling and/or pain from dental infection should have a comput‐
ed tomography exam of the neck and chest to evaluate the spread of infection. Comput‐
ed tomography examination and neck evaluation include: diffuse thickening of the cutis
and subcutis and reticular enhancement of the subcutaneous fat of the face and neck;
thickening and/or enhancement of cervical fasciae; asymmetric thickening or enhance‐
ment of cervical muscles, reactive lymphadenopathy; septic vascular thrombosis and fluid
collections with or without gas. Mediastinal computed tomography findings include: streaky
enhancement of mediastinal fat, fluid collections with or without gas, pericardial effusion
and pleural effusion.[21]
9. Treatment
Treatment of odontogenic infections includes diagnosis and management of the causative

factor, drainage when necessary (Figures 5-6) and, usually, prescription of appropriate
antibiotics. It is imperative that the source of infection be addressed immediately. In addition,
the patient’s medical status must be optimized. The patient’s fluid and nutrition status should
also be addressed, as many patients with odontogenic infections have decreased oral intake
due to pain and difficulty in chewing or swallowing. The clinician must be aware of the most
likely causative organisms and prescribe the narrowest spectrum of antibiotics that will cover
all possible offending organisms.
Figure 5. Sequence of drainage of odontogenic infection – case 1. Note that the most dependent part (under the swel‐
ling) must be incised not the thin most swollen part (to prevent scarring).
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Figure 6. Figure 6: Sequence of drainage of odontogenic infection – case 2.
10. Conclusions
A simple tooth infection, especially in diabetics, immunocompromised, or debilitated patients

should not be underestimated in its ability to cause severe infections. Furthermore, even non-
invasive dental manipulations may also precipitate systemic spread. Facial and cervical
infections are potentially lethal complications. However, with good knowledge of the anatomic
pathways of the infection, early diagnosis, attention to airway maintenance, aggressive
intravenous antibiotic therapy, surgical intervention and careful postoperative management,
the infectious process should have a satisfactory outcome. The practitioner must be alert to the
particularities of infections from odontogenic origin, as well as to the facial and cervical spaces
anatomy, because these structures are crucial for the patient’s life and play important roles
during the execution of treatment procedures.
Acknowledgements
The authors would like to thank Analice Giovani Pereira for the support during the writing of
the chapter and selection of clinical cases.
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Author details
Flaviana Soares Rocha1, Jonas Dantas Batista1*, Cláudia Jordão Silva1,

Roberto Bernardino Júnior2 and Luis Henrique Araújo Raposo3
*Address all correspondence to: jonasdantasbat@gmail.com
1 Department of Oral and Maxillofacial Surgery and Implantology – School of Dentistry -

Federal University of Uberlândia – UFU, Brazil
2 Department of Human Anatomy - Biomedical Science Institute - Federal University of

Uberlândia – UFU, Brazil
3 Department of Occlusion, Fixed Prostheses, and Dental Materials – School of Dentistry -

Federal University of Uberlândia – UFU., Brazil
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and maxillofacial surgery. J Oral MaxillofacSurg 2009: 67: 1092-1097.
[27] Flynn TR, Shanti RM, Levi MH, Adamo AK, Kraut RA, Trieger N. Severe odontogen‐
ic infections, part 1: prospective report. J Oral MaxillofacSurg 2006: 64: 1093-1103.
[28] Eklund SA, Pittman JL. Third-molar removal patterns in an insured population. J Am
Dent Assoc 2001: 132: 469-475.
[29] Kunkel M, Morbach T, Kleis W, Wagner W. Third molar complications requiring
hospitalization. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2006: 102:
300-306.
[30] Worrall SF, Riden K, Haskell R, Corrigan AM. UK National Third Molar project: the
initial report. Br J Oral MaxillofacSurg 1998: 36: 14-18.
[31] Hugoson A, Kugelberg CF. The prevalence of third molars in a Swedish population.
An epidemiological study. Community Dent Health 1988: 5: 121-138.
[32] Bui CH, Seldin EB, Dodson TB. Types, frequencies, and risk factors for complications
after third molar extraction. J Oral MaxillofacSurg 2003: 61: 1379-1389.
[33] Libersa P, Roze D, Cachart T, Libersa JC. Immediate and late mandibular fractures
after third molar removal. J Oral MaxillofacSurg 2002: 60: 163-165; discussion
165-166.
[34] Moghadam HG, Caminiti MF. Life-threatening hemorrhage after extraction of third
molars:case report and management protocol. J Can Dent Assoc 2002: 68: 670-674.
[35] Valmaseda-Castellon E, Berini-Aytes L, Gay-Escoda C. Inferior alveolar nerve dam‐

age after lower third molar surgical extraction: a prospective study of 1117 surgical
extractions. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 2001: 92: 377-383.
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[36] Yoshii T, Hamamoto Y, Muraoka S, Kohjitani A, Teranobu O, Furudoi S, et al. Inci‐

dence of deep fascial space infection after surgical removal of the mandibular third
molars. J Infect Chemother 2001: 7: 55-57.
[37] Blakey GH, Marciani RD, Haug RH, Phillips C, Offenbacher S, Pabla T, et al. Perio‐
dontal pathology associated with asymptomatic third molars. J Oral MaxillofacSurg
2002: 60: 1227- 1233.
[38] Eliasson S, Heimdahl A, Nordenram A. Pathological changes related to long-term

impaction of third molars. A radiographic study.Int J Oral MaxillofacSurg 1989: 18:
210-212.
[39] Fuselier JC, Ellis EE, 3rd, Dodson TB. Do mandibular third molars alter the risk of
angle fracture? J Oral MaxillofacSurg 2002: 60: 514-518.
[40] Knutsson K, Brehmer B, Lysell L, Rohlin M. Pathoses associated with mandibular

third molars subjected to removal. Oral Surg Oral Med Oral Pathol Oral RadiolEn‐
dod 1996: 82: 10- 17.
[41] Manganaro AM, Cross SE, Startzell JM. Carcinoma arising in a dentigerous cyst with
neckmetastasis. Head Neck 1997: 19: 436-439.
[42] Punwutikorn J, Waikakul A, Ochareon P. Symptoms of unerupted mandibular third

molars. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 1999: 87: 305-310.
[43] Yamaoka M, Furusawa K, Ikeda M, Hasegawa T. Root resorption of mandibular sec‐
ond molar teeth associated with the presence of the third molars. Aust Dent J 1999:
44: 112-116.
[44] Leone SA, Edenfield MJ, Cohen ME. Correlation of acute pericoronitis and the posi‐
tion of the mandibular third molar. Oral Surg Oral Med Oral Pathol 1986: 62:
245-250.
[45] Venta I, Turtola L, Murtomaa H, Ylipaavalniemi P. Third molars as an acute problem

in Finnish university students. Oral Surg Oral Med Oral Pathol 1993: 76: 135-140.
[46] Robertson D, Smith AJ. The microbiology of the acute dental abscess. J Med Micro‐
biol 2009: 58: 155-162.
[47] Zachariades N, Mezitis M, Stavrinidis P, Konsolaki-Agouridaki E. Mediastinitis,

thoracic empyema, and pericarditis as complications of a dental abscess: report of a
case. J Oral MaxillofacSurg 1988: 46: 493-495.
[48] Braun IF, Hoffman JC, Jr. Computed tomography of the buccomasseteric region: 1.
Anatomy. AJNR Am J Neuroradiol 1984: 5: 605-610.
[49] Curtin HD. Separation of the masticator space from the parapharyngeal space. Radi‐
ology 1987: 163: 195-204.
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[50] Paparella MM, Shumrick KA. Otolaryngology: Head and Neck. Philadelphia: WB Sa‐
unders, 1993: 2545-2563.
[51] Nyberg DA, Jeffrey RB, Brant-Zawadzki M, Federle M, Dillon W. Computed tomog‐
raphy of cervical infections. J Comput Assist Tomogr 1985: 9: 288-296.
[52] Lindner HH. The anatomy of the fasciae of the face and neck with particular refer‐
ence to the spread and treatment of intraoral infections (Ludwig's) that have pro‐
gressed into adjacent fascial spaces. Ann Surg 1986: 204: 705-714.
[53] Gutierrez-Perez JL. Third molar infections. Med Oral Patol Oral Cir Bucal 2004: 9
Suppl: 122-125; 120-122.
[54] Dogan N, Orhan K, Gunaydin Y, Koymen R, Okcu K, Ucok O. Unerupted mandibu‐

lar third molars: symptoms, associated pathologies, and indications for removal in a
Turkish population. Quintessence Int 2007: 38: e497-505.
[55] Peltroche-Llacsahuanga H, Reichhart E, Schmitt W, Lutticken R, Haase G. Investiga‐

tion of infectious organisms causing pericoronitis of the mandibular third molar. J
Oral MaxillofacSurg 2000: 58: 611-616.
[56] Gonzalez-Moles MA, Gonzalez NM. Bacterial infections of pulp and periodontal ori‐
gin. Med Oral Patol Oral Cir Bucal 2004: 9 Suppl: 34-36; 32-34.
[57] Marple BF. Ludwig angina: a review of current airway management. Arch Otolar‐
yngol Head Neck Surg 1999: 125: 596-599.
[58] Rubin MM, Cozzi GM. Fatal necrotizing mediastinitis as a complication of an odon‐
togenic infection. J Oral MaxillofacSurg 1987: 45: 529-533.
[59] Garatea-Crelgo J, Gay-Escoda C. Mediastinitis from odontogenic infection. Report of

three cases and review of the literature.Int J Oral MaxillofacSurg 1991: 20: 65-68.
[60] Zeitoun IM, Dhanarajani PJ. Cervical cellulitis and mediastinitis caused by odonto‐
genic infections: report of two cases and review of literature. J Oral MaxillofacSurg
1995: 53: 203- 208.
[61] Maisel RH, Karlen R. Cervical necrotizing fasciitis. Laryngoscope 1994: 104: 795-798.
[62] Sellers BJ, Woods ML, Morris SE, Saffle JR. Necrotizing group A streptococcal infec‐
tions associated with streptococcal toxic shock syndrome. Am J Surg 1996: 172:
523-527; discussion 527-528.
[63] Skitarelic N, Mladina R, Morovic M, Skitarelic N. Cervical necrotizing fasciitis: sour‐

ces and outcomes. Infection 2003: 31: 39-44.
[64] Tung-Yiu W, Jehn-Shyun H, Ching-Hung C, Hung-An C. Cervical necrotizing fascii‐

tis of odontogenic origin: a report of 11 cases. J Oral MaxillofacSurg 2000: 58:
1347-1352; discussion 1353.
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[65] Lalwani AK, Kaplan MJ. Mediastinal and thoracic complications of necrotizing fascii‐
tis of the head and neck. Head Neck 1991: 13: 531-539.
[66] Shindo ML, Nalbone VP, Dougherty WR. Necrotizing fasciitis of the face. Laryngo‐
scope 1997: 107: 1071-1079.
[67] Novellas S, Kechabtia K, Chevallier P, Sedat J, Bruneton JN. Descending necrotizing
mediastinitis: a rare pathology to keep in mind.Clin Imaging 2005: 29: 138-140.
[68] Schuknecht B, Stergiou G, Graetz K. Masticator space abscess derived from odonto‐
genic infection: imaging manifestation and pathways of extension depicted by CT
and MR in 30 patients. EurRadiol 2008: 18: 1972-1979.
[69] Tsunoda R, Suda S, Fukaya T, Saito K. Descending necrotizing mediastinitis caused

by an odontogenic infection: a case report. J Oral MaxillofacSurg 2000: 58: 240-242.
www.dentalbooks.co
Chapter 17
Combined Surgical and Orthodontic Management of

Maxillofacial Deformities
Sana Alami, Hakima Aghoutan, Samir Diouny,

Farid El Quars and Farid Bourzgui
http://dx.doi.org/10.5772/59164
1. Introduction
The development of orthognathic surgery techniques and materials has allowed surgeons and
orthodontists to standardize treatment of maxillomandibular deformities. Multidisciplinary
treatment of skeletal deformities by orthognathic surgery in addition to orthodontics has
become a routine strategy believed to result in functional and esthetic outcomes in adult
patients.
When malocclusion is caused by severe skeletal discrepancies, the orthodontist can propose
dentofacial orthopedics in growing children, dental compensation for skeletal deformity or
orthognathic surgery combined with orthodontic treatment (when the major growth potential
of the patient has been completed). The decision is based on clinical examination and cepha‐
lometric analysis, both of which aim to assess the amount of three dimensional discrepancy.
Patients with functional and esthetic issues require a multidisciplinary approach involving
orthodontic and orthognathic surgery to reposition the maxilla and/or the mandible in three
dimensions. Such a therapeutic approach is considered as the best treatment; it corrects
dentofacial deformities which cannot be treated by orthodontics alone [1].
The stability of results in addition to the functional well-being and aesthetic appearance
approach the level of excellence. The issue of skeletal, dento-alveolar and soft tissue relapse is
a matter of discussion, debate and controversy in the orthodontic literature. The aim of this
chapter is to define the criteria for stability that must be complied during both preparatory
orthodontic and surgery phases in orthognathic surgery, without over-timing the postopera‐
tive orthodontic phase.
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e management of dento‐skeletal dysmorphosis requires a team of specialists that
inly include orthodontists
134 A Textbook of Advanced Oral andand maxillofacial
Maxillofacial Surgery Volume 2 surgeons. The ultimate aim of
hodontists is both to meet the patients’ expectations, and make effective
tainable interventions.
1.1. Stability criteriaThree treatment
of ortho-surgical treatmentobjectives, which form the basis in
ating patients with dento‐facial deformities, are fundamental in orthognathic
The management of dento-skeletal dysmorphosis requires a team of specialists that mainly
gery namely includefunction,
orthodontistsesthetics,
and maxillofacial and stability.
surgeons. Skeletal
The ultimate relapse is
aim of orthodontists the to most
is both
meet the patients’ expectations, and make effective sustainable
mmon complication following orthognathic surgery. Optimal treatment planning interventions. Three treatment
objectives, which form the basis in treating patients with dento-facial deformities, are funda‐
maxillofacial
mental surgery requires
in orthognathic surgery namelyan function,
understanding
esthetics, and of postoperative
stability. skeletal
Skeletal relapse is the
most common complication following orthognathic surgery. Optimal treatment planning for
bility, dento‐alveolar position and the soft tissue response to skeletal movement.
maxillofacial surgery requires an understanding of postoperative skeletal stability, dento-
curate treatment planning
alveolar position and the and
soft careful orthodontic
tissue response and surgical
to skeletal movement. Accurateprotocols
treatment are
planning and careful orthodontic and surgical protocols are essential
ential to the achievement of treatment objectives; these have to be planned to the achievement of
treatment objectives; these have to be planned with collaborating partners upon initial
h collaborating partners upon initial consultation (Figure 1). [1]
consultation (Figure 1). [1]
Influencing Factors
- Preoperative age
- Soft tissue and muscles
- Presurgical skeletal pattern
- Dental decompensation
- Coordination of dental arcss
- Direction and amount of surgical
movement
- Type and material of fixation

Figure 1. Factors influencing stability in orthognthic surgery treatment.[1]
Figure 1 : Factors influencing stability in orthognthic surgery treatment.[1]
2. Preliminary patient evaluation
Preliminary patient evaluation
A systematic examination is necessary to adequately evaluate and treat patients with dento-

facial deformities. Treatment planning should start only when the orthodontist and surgeon
have agreed on a final treatment plan. It is mandatory that the patient be well informed about
ystematic examination is necessary to adequately evaluate and treat patients
the treatment plan and related possible disadvantages.
h dento‐facial deformities. Treatment planning should start only when the
Indeed, efficacy is guaranteed when there is clear and effective communication between the
hodontist and surgeon have agreed on a final treatment plan. It is mandatory
orthodontist and the maxillofacial surgeon from the outset.
t the patient be well informed about the treatment plan and related possible
Routine evaluation includes [1]:
advantages.
eed, efficacy is guaranteed when there is clear and effective communication
ween the orthodontist and the maxillofacial surgeon from the outset.
utine evaluation includes [1]:
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Combined Surgical and Orthodontic Management of Maxillofacial Deformities 135

http://dx.doi.org/10.5772/59164
• Evaluation of patient’s medical history
• Socio-psychological assessment of the patient’s motives and expectations
• Aesthetic facial evaluation involving frontal and profile analysis
• Dental and occlusal oral function evaluation
• Cephalometric radiographic evaluation which forms an important part of the database for
orthognathic surgical treatment planning. Soft tissue, skeletal and dental analysis are
helpful diagnostic guides.
• Occlusion and study cast evaluation which includes examination for intra and interarch
relationships.
The initial consultation aims to discuss the possible need for surgical procedure as part of the
treatment to achieve optimal results. However, before treatment, it is important to put
emphasis on those elements that are directly related to stability; some of these include
operative age, the soft tissue and muscles, and mandibular inclination. [2, 3]
2.1. Preoperative age
Growth following surgery may result in relapse; surgical osteotomy and osteosynthesis have
little influence on the mandibular jaw growth. The initial growth of the patient’s face and
continuous remodeling processes may lead to an advantageous or disadvantageous change of
position of the mandible after sagittal split osteotomy. [3] The inability to predict the potential
growth of the mandible can lead to failure or recurrence when the surgical indication is
established before the end of growth. This leads practitioners to adopt a cautious attitude. To
minimize the risks of relapse due to continuous growth, surgery should only be recommended
to patients when growth is complete.
2.2. Soft tissue and muscles
Although long-term studies of surgical orthodontic stability are sparse, many authors predict
the importance of active and /or passive contractions exerted by muscles and/or post surgical
skeletal recurrences due to soft tissue. [2] An examination of cervical soft tissues and orofacial
muscles (in particular the tongue) at rest and during function requires due attention. This is
illustrated in case 1 which was a 19-year-old female admitted for burn injuries following a
home accident at the age of 6 yrs. Aesthetic imbalance and significant dento-skeletal deformity
is due to post-burn contractures of the neck (Figures 2 and 3). Facial appearance is the patient’s
main concern. Radiographic evaluation and cephalometric analysis showed the patient
presented high values for mandibular length and plane angle (FMA= 38°). The Wits appraisal
indicated a large anteroposterior discrepancy between the maxilla and mandible (AO‐
BO=-6.5mm) (Figure 4). Only surgery can improve the aesthetics. The expected dental and soft
tissue changes to be affected by the preoperative orthodontic treatment are illustrates by
cephalometric tracing. The surgical plan consisted of two-jaw surgery (Figure 5).
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• Lefort I maxillary osteotomy is used to perform advancement and expansion of the maxilla
and a slight superiorly repositioning is needed to allow the mandible to auto-rotate and
close the openbite.
• Bilateral sagittal split osteotomy for setback of the mandible.
Preoperative orthodontic treatment planning included teeth alignment without extraction and
provision of good arch form assisted by maxillary expansion (Figure 6).
réparatrice des tissus cutanés du cou, seule garante d’une stabilité après chirurgie orthognathique. La frenectomie linguale
But the project initially
réeducation de la postureconceived
linguale etcan
de laonly succeed
déglutition after surgical
constituent également repair
un gageofdecervical
stabilité.skin tissue,
the only guarantee of stability after orthognathic surgery. Lingual Frenectomy, re-education
But the project initially conceived
du cou, can only succeed
d’uneafter surgical
aprèsrepair of cervical skin tissue, the only guarantee
linguale of stability
for tongue position
réparatrice
orthognathic during
des tissus
réeducation de surgery.
cutanés
la postureLingual
swallowingseule
Frenectomy,
linguale et
arere-education
garante
modalities
de la déglutition constituentof
that
stabilité
help
the tongue
également
stability.
chirurgie orthognathique.
as well
un gage
La frenectomie et la
as swallowing are modalities that help prom
de stabilité.
stability.
But the project initially conceived can only succeed after surgical repair of cervical skin tissue, the only guarantee of stability after
orthognathic surgery. Lingual Frenectomy, re-education of the tongue as well as swallowing are modalities that help prompte
stability.
Figure Figure 2: Frontal

2. Frontal view, and
view, profile profile andofsmile
smile of patient
the patient before
before treatment:
treatment: Female, 19 years of age,W, 19 years of age,
characteristics longhad characteristic
the long
face pattern,
Figure 2:face pattern,
prognathism
Frontal andwith
view, prognathism,
vertical
profile growth
and and vertical
pattern,
smile of patient scar growth
contracture
before pattern,
treatment: due to scare contracture
neck burn and due to
W, increased
19 years neck burncharacteristics
ofinterlabial
age, had and increased
gap. of interlab
gap.
the long face pattern, with prognathism, and vertical growth pattern, scare contracture due to neck burn and increased interlabial
gap.
Fig. 3: Pre-treatment intra-oral photographs: frontal lateral occlusion

Figure There
3. Pre-treatment intra-oralSo,photographs: frontal lateral occlusion shows severe open bite and–shaped
maxillary
lyre)antero‐
Fig. 3:isPre-treatment
serious open bite. maxillary
intra-oral anteroposterior
photographs: frontaland transverse
lateral deficiency
occlusion (maxillary arch explains
posterior and transverse
crowding deficiency.
in the anterior Constricted
maxillary arch maxillary arch explains the crowding in the anterior maxilla.
There is serious open bite. So, maxillary anteroposterior and transverse deficiency (maxillary arch –shaped lyre) explains
crowding in the anterior maxillary arch

Figure 3: Pre‐treatment intra‐oral photographs: frontal lateral occlusion
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Figure 3: Pre‐treatment intra‐oral photographs: frontal lateral occlusion
shows severe open bite and maxillary anteroposterior and transverse deficiency.
shows severe open bite and maxillary anteroposterior and transverse deficiency.
Constricted maxillary arch explains the crowding in the anterior maxilla.
Constricted maxillary arch explains the crowding in the anterior maxilla.
http://dx.doi.org/10.5772/59164

Figure 4: pre‐treatment orthopantomogram and lateral teleradiogram of skull.
Figure 4: pre‐treatment orthopantomogram and lateral teleradiogram of skull.
Figure 4. Pre-treatment orthopantomogram and lateral teleradiogram of skull.
Figure 5. Figure 5 : The orthodontic visual treatment objective
The orthodontic visual treatment objective illustrates the desired presurgical orthodontic tooth movement

and predicts the surgical repositioning of the jaws and subsequent soft tissue changes. It has a key role in choosing
illustrates the desired presurgical orthodontic tooth movement and predicts the
dental extractions, if needed.
Figure 5 : The orthodontic visual treatment objective
illustrates the desired presurgical orthodontic tooth movement and predicts the

Fig. 6 : Immediate preoperative intraoral photographs Treatment does not need dental teeth extraction and the aim of
Figure 6. Immediate preoperative intraoral photographs. Treatment did not need dental teeth extraction and the aim of
preparatory orthodontic stage was to establish a good arch form in the maxillary and mandibular archs.
preparatory orthodontic stage was to establish a good arch form in the maxillary and mandibular arches.
1.3- Presurgical skeletal pattern
The influence of the mandibular plane angle on horizontal and vertical skeletal stability has been shown in several studies. [3, 4]
High angle patients have a greater risk of relapse after receiving bilateral sagittal split ramus osteotomy than low and normal–angle
patients. Patients with a low mandibular plane angle, compared to high and normal angle patients, appear to have a more
predictable procedure. Then, patients with a low mandibular plane angle have increased vertical relapse when advancement surgery
is indicated; whereas patients with a high mandibular plane angle have more horizontal relapse. [3] Because the muscles of
mastication are lengthened in the ramus area, they tend to return to their original positions, rotate the mandible in a clockwise
movement, open the bite, and cause relapse. To minimize the risk of relapse, patients should be selected carefully ; isolated
mandibular advancement or setback should not be perfomed for patients with high mandibular plane angles. [3]
www.dentalbooks.co
2.3. Presurgical skeletal pattern

The influence of the mandibular plane angle on horizontal and vertical skeletal stability has
been shown in several studies. [3, 4] High angle patients have a greater risk of relapse after
receiving bilateral sagittal split ramus osteotomy than low and normal–angle patients. Patients
with a low mandibular plane angle, compared to high and normal angle patients, appear to
have a more predictable procedure. Then, patients with a low mandibular plane angle have
increased vertical relapse when advancement surgery is indicated; whereas patients with a
high mandibular plane angle have more horizontal relapse. [3] Because the muscles of
mastication are lengthened in the ramus area, they tend to return to their original positions,
rotate the mandible in a clockwise movement, open the bite, and cause relapse. To minimize
the risk of relapse, patients should be selected carefully; isolated mandibular advancement or
setback should not be performed for patients with high mandibular plane angles. [3]
3. Defining treatment objectives
Therapy planning should be clear and precise and the objectives need to be defined with
collaborative partners before a final treatment planning decision:
• Focus of the objective of surgery should center on osteotomy choice and its site;
• Orthodontic objective conditioned by the surgical objective, will consist of determining the
necessary strategies to reduce preliminary occlusal obstacles and the rebalancing of the
dentoalveolar system.
Starting cases orthodontically and then, if unsuccessful, referring them for surgery often
produces compromised results. [5] It is, therefore, important to prioritize problems and think
of potential solutions; this way one can define the objectives of each treatment step. The initial
treatment plan must be established following a discussion between the different parties
responsible for the smooth implementation of the various steps of the treatment plan.In fact,
cephalometric and occlusal simulation setup permits the practitioner to project the occlusal
dental and facial skeletal result, to ascertain and determine a suitable orthodontic surgical
protocol. Those set-up demonstrates the general reharmonization of the teeth, the jaw and the
face. It can then be used as a reference instrument in discussions with the surgeon and patient,
and can be modified at all times according to the particular needs. The set-up is, and remains,
an estimation which supplies simple quantitative proportional and comparative data. We can
record all the data in it (Figure 7). [6]
The use of information technology in dental studies and orthodontics in particular, has
contributed to the use of set-up scanning. A 3D simulation system has been developed for
orthognathic surgery ; it helps integrate the shape data of the teeth, jawbone and face into
the same coordinate system on a computer. The movement of bone associated with
mandibular osteotomy and the subsequent changes in the facial form can thus be estimat‐
ed preoperatively. [7]
The three-dimensional setups allow orthognathic surgery simulation through:
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• Integration of the dental arch using a three-dimensional digital model and accurate face
scan of the patient.
• Simulation of different possible osteotomies (Lefort, Obwegeser genioplasty), and removal

of bone fragments.
• Visualization of contact points.
• Realization of a morphing orthognathic surgery
Figure 7. Surgical visual treatment prediction The presurgical setup can assist surgical diagnosis accurate prediction
of the postoperative skeletal, dental and facial profile and has become an essential part of the diagnostic and treatment
planning procedure of combined surgical-orthodontic therapy.
4. Surgical treatment
The treatment protocol includes three distinct, but successive steps: Orthodontic phases of
preparation are enacted prior to surgical treatment. Generally speaking, the stability of
expected results depends on both meeting pre-defined objectives for each step as well as on
the smooth and proper course of treatment. Otherwise, it could also be compromised by
incomplete orthodontic treatment and yield unfavorable outcomes in orthognathic surgery or
functional occlusal imbalance following treatment (Figure 8). [8]
Successful surgical correction of dentoskeletal cases is determined by both presurgical-

orthodontic treatment (which eliminates dental compensation), correct surgical planning, and
postoperative orthodontic therapy applied to refine the patient's occlusion. Fixed appliances
are normally used in both of these orthodontic stages.
- Realization of a morphing Orthognathic surgery
www.dentalbooks.co
3- Surgical treatment
140 The treatment

A Textbook protocol includes
of Advanced Oral andthree distinct,Surgery
Maxillofacial but successive
Volume 2steps: Orthodontic phases of preparation are enacted prior to surgical
treatment. Generally speaking, the stability of expected results depends on both meeting pre-defined objectives for each step as well as
on the smooth and proper course of treatment. It could also be compromised by incomplete orthodontic treatment ; Unfavorable
outcomes in orthognathic surgery or functional occlusal imbalance following treatment [8]. (Figure 8)
Pre-orthodontic surgery
Decompensation of incisors;
Reforming the arches
Surgical Phase
Standardization Maxillofacial mdb

reports
Harmonization of facial contours
Postsurgical orthodontic phase
Parallelism of Dental axes
Figure 8. The aim of surgical correction is to achieve the right occlusal and skeletal relationships and correct esthetics
simultaneously.
4.1. Preoperative / pre-surgical orthodontic phase

In orthognathic surgery cases, orthodontic treatment objectives are for the most part different
from those used in conventional orthodontics. The purpose of pre-surgical orthodontics is to
position the teeth to the most desirable position in preparation for surgery, to restore the
anteroposterior and vertical positions in addition to coordinating incisors. Two main elements
must prevail during this first phase: Incisors decompensation and transverse and dental arch
coordination. [1, 9]
4.1.1. Anteroposterior dental decompensation

In the presence of a bone gap, teeth manage to maintain an occlusion with dental compensation
in three dimensions.
In the sagittal plane, overjet does not represent magnitudes of bone gap. However, during
surgery, bone bases are mobilized to allow dental occlusion [10] in this context, it is clear that
the relationship between anterior and posterior bases of incisors determines the magnitude of
anterior-posterior relocation of the bone base. [11]
Presurgical orthodontic treatment aims to decompensate incisor inclination toward normal
values. It is therefore necessary to define beforehand the objective of the "terminal incisor
position”. Therefore In the case of skeletal class II, the lower incisors are proclined while the
upper incisors are lingual retroclined (Figure 9). In Class III, the reverse pattern is observed;
upper incisors are proclined while the lower incisors are retroclined (Figure 13). Bone gap is
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compensated for by teeth inclination [10] presurgical intra-arch objectives include positioning
of the incisors in “ideal” positions, establishment of correct torque, and elimination of tooth-
size discrepancies so as to permit the establishment of Class I canine and molar relationships
after surgery. In orthognathic surgery cases, extraction patterns, and types of mechanics used
are frequently the reverse of those used in conventional orthodontics. [11] Very often in skeletal
Class II, the first premolars are extracted in order to cover mandibular incisors and obtain a
Class I canine relationship. Extraction of the second premolars allows in recovery of the upper
incisors and the mesial movement of upper molars. The ultimate goal is to achieve a Class I
molar relationship (Figures 10- 12).
Figure 9. Dental compensation in skeletal Class II malocclusion
Figure 10. Direction of incisor decompensation in Class II malocclusion: the lingual inclination of the lower incisors is
increased and in some cases (Class II.1 malocclusion), the upper incisors retroclined
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Figure 10: direction of incisor decompensation in Class II malocclusion: the lingual inclination of the lower incisors is increased
and in some cases (Class II.1 malocclusion), the upper incisors reduced
Figure 10: direction of incisor decompensation in Class II malocclusion: the lingual inclination of the lower incisors is increased
and in some cases (Class II.1 malocclusion), the upper incisors reduced
Figure 11: Classic pattern extraction of 15, 25, 34 and 44 in order to increase the overjet and presurgically decompensate for the
Figure malocclusion.
11. Classic pattern extraction
The presurgical of 15,of25,
position the 34 and
teeth 44 in the
dictates order
teethtoremoval
increase
andthe
theoverjet
surgicaland presurgically
movement decompen‐
of the jaws and ultimately
sate forthe
thesoft
malocclusion.
Figure 11: Classic
tissue The presurgical
facialpattern extraction of position
balance. 15, 25, 34of the44teeth
and dictates
in order the teeth
to increase removal
the overjet and and the surgical
presurgically movement
decompensate for of
the
malocclusion. The presurgical position of the teeth dictates the teeth removal and the surgical movement of the jaws and ultimately
the jaws and ultimately the soft tissue facial balance.
the soft tissue facial balance.
Figure 12: extraction of 34 and 44 only can be justified

Figure 12: extraction of 34 and 44 only can be justified
Figure As
12.for
Extraction of 34III,
skeletal Class and 44 onlyofcan
extraction be justified
upper first premolar is enacted to reposition upper incisors and obtain Class I canine. (Figure
14)for
As Extraction of theIII,
skeletal Class 2ndextraction
premolarsofisupper
not systematic given
first premolar that therapeutic
is enacted Classupper
to reposition II molar is tolerated
incisors fromClass
and obtain a anIocclusodontic
canine. (Figure
perspective.
14) (Figures
Extraction 15, premolars
of the 2nd 16) In fact,ispresurgical objectives
not systematic in the
given that sagittal plane
therapeutic Classfocus on removal
II molar of from
is tolerated dentala compensations.
an occlusodontic
As forperspective.
skeletal
However, Class 15, III,
surcompensation
(Figures Inextraction
16)represents securityof
fact, presurgical for upper in first
stable occlusion
objectives premolar
and improved
the sagittal plane focus isonenacted
aesthetics. to reposition
removal of dental compensations.upper
incisors
Thisand obtain the Class I canine relationship.
in Class II cases(Figure 14) Extraction ofmaximal
the 2nd premolars
correction is
However, surcompensation represents security for stable occlusion and improved aesthetics.
may require use of Class III elastics (and vice versa), thus allowing for surgical of the
not systematic
underlying
This given
skeletal
may require that
Class therapeutic
thedeformity.
use of III elastics in ClassClass II molar
II cases (and is thus
vice versa), tolerated
allowing forfrommaximalan occlusodontic
surgical correction of the
underlying skeletal deformity.
perspective. (Figures 15, 16) In fact, presurgical objectives in the sagittal plane focus on removal
of dental compensations. However, decompensation represents security for stable occlusion
and improved aesthetics.
Figure 13. Dental compensation seen in skeletal Class III malocclusion

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This may require the use of Class III elastics in Class II cases (and vice versa), thus allowing
for maximal surgical correction of the underlying skeletal deformity.
Figure 13: dental compensation in skeletal Class III malocclusion
Figure Figure
14. Direction of incisor
14: direction of incisordecompensation in Class
decompensation in Class III malocclusion:
III malocclusion: the labialthe labial inclination
inclination of the lower
of the lower incisors incisors is
is increased
increased
and and the upper
the upper incisorsincisors
reduced reduced
Figure 15: Classic pattern extraction of 14, 24, 35 and 45 in order to increase the negative overjet and presurgically
Figure decompensate
15. Classic pattern extraction Correct
for the malocclusion. of 14, 24, 35 and
planning 45orthodontic
of the in order to increase
tooth thebefore
positioning negative overjet
surgery and presurgically
will enhance the surgical de‐
compensate forand,
potential thehence,
malocclusion. Correct planning of the orthodontic tooth positioning before surgery will enhance
the esthetic result.
the surgical potential and, hence, the esthetic result.
Figure 16: extraction of 14 and 24 is often sufficient and molar Class II acceptable.
Figure 16. Extraction of 14 and 24 is often sufficient and molar Class II acceptable.
Transverse arch Coordination
One goal of presurgical orthodontics is that maxillary and mandibular transverse diameters coincide for a reasonable
intercuspidation after surgery. [10] It was clearly established that both vertical and horizontal recurrence correlates with dental
arches incoordination and the persistence of occlusal interferences. The resulting occlusal imbalance is closely related to
orthodontic preparation, sometimes without extraction [12] In the transverse plane, differentiation of skeletal from dental problems
as well as identification of relative and absolute discrepancies should be carried out presurgically. Orthodontic or surgical
expansion should be used, depending on individual circumstances. (Figure 17 ) [11]
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4.1.2. Transverse arch coordination
One goal of presurgical orthodontics is that maxillary and mandibular transverse diameters
coincide for a reasonable intercuspation after surgery. [10] It is clearly established that both
vertical and horizontal recurrence correlate with dental arches in coordination and the
persistence of occlusal interferences. The resulting occlusal imbalance is closely related to
orthodontic preparation, sometimes without extraction [12] in the transverse plane; differen‐
tiation of skeletal from dental problems as well as identification of relative and absolute
discrepancies should be carried out presurgically. Orthodontic or surgical expansion should
MEDICAL‐EDITED CHAPTER FOR AOMFS VOL

be used, depending on individual circumstances (Figure 17). [11]

Figure 17. Dental arch width must be assessed preoperatively by measuring and comparing the distance between the
Figure17: Dental arch width must be assessed preoperatively by measuring and
mesiolingual cusps of the maxillary first molars versus the central fossae of the mandibular first molars. In this case,
comparing the distance between the mesiolingual cusps of the maxillary first
there are skeletal transverse deficiencies which must be corrected by surgical maxillary expansion.
molars versus the central fossae of the mandibular first molars. In this case, ther
In the absence of a major transverse problem, arch compatibility is generally achieved by
are skeletal transverse deficiencies which must be corrected by surgical maxillary
coordination. [11] This is true for class II cases, where transverse shift goes unnoticed as
revealed by the manipulation in the corrected position. This is a favorable orthodontic work
expansion.
so that both arches engage properly when the surgical mandibular advancement is performed.
In the absence of a major transverse problem, arch compatibility is generally
Surgical disjunction or surgically assisted expansion can help to prevent transverse recurrence
relatedachieved by coordination. [11] This is true for class II cases, where transverse shi
to excessive teeth release. [10] Study casts carried out at the end of orthodontic
preparation are essential; they allow rectifying any condition that may potentially lead to
goes unnoticed as revealed by the manipulation in the corrected position. This is
complications, and thus affects the success and stability of the surgical procedure. [13]
favorable orthodontic work so that both arches engage properly when the surgic
mandibular advancement is performed.
4.2. Surgical phase
The order of importance begins with the direction and amount of skeletal movement, the type
Surgical disjunction or surgically assisted expansion can help to prevent transve
of fixation used, and finally, the surgical technique. [3, 14] Other factors were also stated,
recurrence related to excessive teeth release. [10] Study casts carried out at
namely, the maxillomandibular order or surgery-orthodontics[15- 17]
end of orthodontic preparation are essential; they allow rectifying any condi
4.2.1. Direction and amount
that may of surgicallead
potentially movement
to complications, and thus affects the success
In a report on the hierarchy of stability in orthognathic surgery, Proffit ranked isolated
stability of the surgical procedure. [13]
maxillary advancement as the second most stable orthognathic surgical procedure after
3.2‐ Surgical phase
The order of importance begins with the direction and amount of skeletal
movement, the type of fixation used, and finally, the surgical technique. [3, 14]
Other factors were also stated, namely, the maxillomandibular order or surgery‐
orthodontics[15‐ 17]
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maxillary upward positioning; the latter was performed more than maxillary advancement
with or without mandibular setback. [13, 14]
4.2.1.1. Maxillary upward
Maxillary impaction is recommended in the case of patients with dolichofacial condition and
vertical maxillary excess. Excellent skeletal stability is achieved in 90% of the cases, irrespective
of the type of osteosynthesis used. [14] Such stability is due to the physiological occlusal
adaptation related to mandible rotation. Interocclusal space is then maintained. [14, 18]
In asymmetry correction of the maxilla characterized by the inclination of the occlusal plane,
surgery combines maxillary impaction and mandibular surgery. The maxillary component of
this asymmetry correction is considered stable [19]
4.2.1.2. Mandibular advancement
Sagittal split ramus osteotomy (SSRO) is a well-established procedure for correcting mandib‐
ular retrognathism. [20] The literature contains a number of studies on postoperative changes
after SSRO. At retention phase, relapse occurred due to the increase in mandibular plane and
ANB angle, and an increase in overjet. [19, 21] The etiology of relapse is multifactorial,
involving the proper seating of the condyles, the amount of advancement, the soft tissue and
muscles, the mandibular plane angle, the remaining growth and the skill of the surgeon. [3, 8,
21] It is believed that orthosurgical treatment for the correction of Class II with mandibular
advancement could be stable, provided the amount of skeletal movements and the circumja‐
cent soft tissues are respected. Advancements over 10mm lead to horizontal relapse. [14, 21,
22] In systematic review that evaluate horizontal relapse in bilateral sagittal split advancement
osteotomy, it was shown that advancements in the range of 6 to 7 mm or more predispose to
horizontal relapse. [3]
4.2.1.3. Maxillary advancement
Maxillary advancement could be stable, provided that skeletal movements, as recommended

by some others, were under 6, 8 or 10mm. In fact, the use of rigid fixation and bone grafting
for good stability of maxillary advancement up to 6 mm showed no recurrence. [14, 19, 23-
25] For a maxillary advancement of less than 8mm, it was suggested that the maxillary maintain
its horizontal postsurgical position (less than 2 mm) in 80% of the cases; a risk of recurrence
between from 2 and 4 mm can be seen in 20% of the cases. [25]
4.2.1.4. Mandibular setback
The sagittal split ramus osteotomy (SSRO) and the intraoral vertical ramus osteotomy (IVRO)
are well-established procedures for correcting mandibular prognathism. Both techniques have
advantages and disadvantages; include bony contact between the distal and mesial segments
and application for both advancement and retraction and the duration of intermaxillary
fixation (IMF). Orthognathic surgeons must weigh up these advantages and disadvantages
when deciding which surgical treatment to use in cases of mandibular prognathism. Another
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important factor for surgeons to consider is postoperative stability. While the literature
contains a number of studies on postoperative changes after SSRO, a few reports concern post-
operative stability after IVRO.
IVRO is a relatively simple technique, which is applicable for only retraction of the mandible.
The postoperative changes and stability tend to be influenced by the surgical techniques
employed and the skills of the surgeons. In the short term after IVRO, clockwise rotation was
observed due a less bony contact between the proximal and distal segments during surgery.
After this period of adaptive rotation, the mandible showed a slight tendency to relapse with
forward movement up to 2 years after IVRO. [20] With bilateral sagittal split osteotomy setback
(BSSO), the relapse is more frequent than vertical osteotomy. However, it is an effective
treatment of skeletal class III and a stable procedure in the short and long term. Analyzing the
different relapse rates in systematic review showed that main relapse mostly takes place
immediate after surgery and in the short term. [2, 14] From the reviewed literature, it was
conclude that skeletal relapse is very frequent and was influenced by the magnitude of surgical
correction and the inclination of the ramus after surgery. But, compared with mandibular
advancement BSSO, the amount of setback was correlated less frequently with the amount of
relapse. Opinions differ and generally speaking, the father the distal segment is set back (more
than 10mm), the greater the tendency for the proximal segment to rotate. Furthermore,
maintaining the initial inclination of the ramus could therefore reduce the tendency to relapse.
[2, 14, 22, 26] Other research suggested that post-operative relapse in mandibular setback
surgery may relate to the pre-surgical skeletal pattern of each patient and the perimandibular
connective tissue action. Additionally, some vertical mandibular relapse after setback surgery
may be affected by the postural changes of the tongue and hyoid bone [26] However, it was
reported that the role of suprahyoid muscles is less important after a mandibular setback than
after advancement or a closing gap.[26,27] Correcting the open bite by orthognathic surgery
directed only at the mandible has a high risk of relapse because of mandibular up-repositioning
in a counter-clockwise rotation. A mandibular backward repositioning is equally performed
to prevent open bite relapse. [28]
4.2.1.5. Maxillary advancement combined with mandibular setback
The mandibular setback is frequently combined with Le Fort I osteotomy for maxillary
advancement when there is a greater discrepancy between the maxilla and mandible and
greater labial projection. Surgical correction of Class III malocclusion after combined maxillary
and mandibular procedures appears to be a fairly stable procedure for maxillary advance‐
ments up to 5 mm, independent of the type of fixation used to stabilize the mandible. Likewise,
no statistically significant differences have been observed between the procedures conducted
on both jaws versus the lower jaw only. [21, 29- 31] Over the past few years, the number of
patients with mandibular prognathism as a component of a skeletal Class III problem who
were treated with mandibular setback alone decreased remarkably, compared with outcomes
in patients with two- jaw surgery. A number of reasons to explain such a tendency are listed
below: [32, 33]
• Restricting the amount of mandibular setback by simultaneously advancing the maxilla
contributes to stability.
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• Facial appearance was better if simultaneous maxillary advancement allowed a smaller

mandibular setback;
• Large setbacks lead to airway reduction
• The outcomes of isolated mandibular setback surgery were shown to be less predictable and
less stable than desired.
• The better control of the ramus position when 2-jaw surgery is performed
4.2.1.6. Maxillary expansion
Transverse maxillomandibular discrepancies are a major component of several malocclusions.

The correction of skeletal transverse deficiency of the maxilla may be achieved surgically. [34]
The segmental maxillary osteotomy (SMO) is recommended when a moderate transverse

defect of the maxillary bone in the amount of 5 to 6mm require correction. To increase the
transverse diameter of the maxilla, maxillary expansion is simultaneously performed with
Lefort I planned to correct all maxilla-mandibular discrepancies (vertical and sagittal reposi‐
tioning). It consists at least to two osteotomy lines, one on either side of the palatine raphe,
performed after orthodontic preparatory stage. [34, 35] Maxillary expansion is relatively
simple, but treatment stability remains a common problem. Overcorrection and rigid osteo‐
synthesis are recommended. In addition, the corrected maxilla should be reinforced with
intraoral retention provided by a preformed palatal bar or splint. [14, 35]
The Surgically assisted rapid palatal expansion (SARPE) is used in cases of severe deficit
estimated at more than 6 to 7mm; surgically-assisted maxillary expansion, which depends on
osseous distraction osteogenesis the separating of segments of bone to create new bone and
the movement of whole groups of teeth and their periodontium. This technique works by
release of the maxilla bone resistances and assures excellent stability.
4.2.1.7. Genioplasty
The chin is subject to morphological anomalies in the sagittal (retrogenia or progenia), vertical
(excess or insufficient height), or transversal (laterogenia) axes. Genioplasty, used alone or in
conjunction with other maxillomandibular osteotomies, is an important and reliable technique
for the esthetic treatment of the lower facial skeleton. It can be a powerful procedure to improve
the facial profile by modifying the position of the chin bones in three planes. Genioplasty is a
stable surgical procedure when used in conjunction with rigid internal fixation. So there is no
significant relapse after genioplasty and bilateral sagittal split osteotomy or genioplasty alone
after 12 months. In fact, the changes are minimal and hard to detect clinically. [36]
4.2.2. Osteotomy fixation (type and materials)
Osteotomy fixation technique is one of the factors that determine the horizontal and vertical
postsurgical relapse potential. The short- and long-term outcomes of different fixation
techniques are a topic of interest in the orthodontic literature. [37] In earlier years, maxillary
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osteotomies were stabilized using intraosseous wires. In the 1980s, rigid internal fixation
of osteotomy segments using miniplates and/or screws were introduced in an attempt to
decrease postsurgical relapse and to allow earlier mobilization of the mandible. In fact,
miniplates were introduced for fixation in BSSO, and have several advantages compared
with bicortical screw osteosynthesis, because of the stretching of the musculature and
paramandibular tissues, the bilateral compound joints, the masticatory forces, and occlu‐
sion. [27, 37] A number of studies that addressed the value of rigid internal fixation reported
that 50% of the total forward relapse of mandible occurred during the 6 weeks after surgery.
In contrast, with wire fixation and maxillomandibular fixation, the mandible maintained its
position or moved posteriorly during MMF fixation. [33] On the other hand, in study which
investigates biomechanical stability of RIF, the relationship between screw placement
configurations and stability was demonstrated. It was concluded that bi-cortical screws with
a 2.3-mm diameter and triangular configuration were considered as a sufficient fixation tool
for BSSO than the linear configuration. [38] However, there is a trend toward increase in
relapse from short-term to long-term studies when bicortical screws are used. [3] Bicorti‐
cal screws of titanium, stainless steel, or bioresorbable material show little difference
regarding skeletal stability compared with miniplates in the short term. A greater num‐
ber of studies with larger skeletal long-term relapse rates were evident in patients treated
with bicortical screws instead of miniplates. [3] The use of bicortical screws or mono-
cortical screws, together with plates, is the most demanding fixation procedure of the
craniofacial skeleton when used in mandibular advancement patients. [8] It was also shown
that the use of BSSO of the mandible with or without counterclockwise rotation of the
occlusal plane for anterior open bite correction, increases stability in the vertical direc‐
tion. [39] Thus, some of the limitations of metal plates and screws used for the fixation of
bones have led to the development of plates made from titanium. Such a technique has
been in use in orthognathic surgery for about two decades, because of their high biocom‐
patibility and resistance to corrosion. In addition, titanium fixation produces stability for
the osteotomy site and allows patients to use their masticatory system functionally
immediately after surgery. [40] The development of bioresorbable osteosynthesis devices
made it possible to avoid second surgery to remove titanium plates linked sometimes to
palpability, infectious complications or allergies; although they are rare. However, con‐
cerns remain about the stability which was related to the movements in orthognathic
surgery. [26, 40] The systematic reviews of bioresorbable versus titanium fixation for
orthognathic surgery, have shown that bioresorbable fixation systems produce reliable
skeletal stability. [40] However, it suggested no statistically significant difference for plate
and screw fixation using either titanium or resorbable materials. There are a few studies
about the stability of biodegradable devices osteosynthesis and it was recommended that
these materials should be used with caution for bony movements of greater magnitude
until their usefulness is evaluated in studies with large maxillary advancements. [30]
4.3. Postsurgical orthodontics
Postsurgical orthodontic treatment involves finalization of the occlusion and retention.

Working wire and light up and down elastics or slightly Class II or Class III elastics ensures
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the refinement of the occlusion. This final stage is equally important to ensure stable results.
It is not enough to place orthodontic retainers at the end of treatment. It is appropriate to
finalize and fine-tune the occlusion with a view to achieve stability, function, and facial
balance. [1, 41]
4.3.1. Functional balance conditions
Neutralizing the functional matrix at the end of treatment contributes significantly to stability
of results. It is important to note that mastery of the neuromuscular environment is an
important element of skeletal and dentoalveolar modeling of each patient. The stability of the
result after treatment is therefore based on the diagnosis of muscle behavior, and functional
rehabilitation.
This final phase of treatment is the best time to prescribe exercises for normalizing orofacial
muscles and harmonizing skeletal relationships making rehabilitation more effective.
4.3.2. Occlusion balance conditions
The finishing and detailing phase, the last stage of active orthognathic surgery treatment,
makes it possible to improve the occlusion, by adopting a number of criteria as defined by
various authors; the ultimate goal is to improve the esthetic result, on the condition that
treatment objectives during the pre-planning phase have been met.
Dental balance should be considered both statically and dynamically. Indeed, intra-arch
condition inter-arch relationships, and balance provides functional comfort and lasting results.
Treatment stability depends in part on obtaining a "functional occlusion" consistent with the
physiology of TMA. The quality of finishing for some researchers (Tweed) is sufficient as a
natural retainer tool.
4.3.2.1. The sequence of ortho-surgical treatment
The sequence of steps of ortho-surgical treatment is illustrated through a clinical case: A 16-
year-old patient reported aesthetic and psychological discomfort related to severe skeletofacial
discrepancy. The patient also complained of functional difficulty during mastication and
expressed concern at his inability to bite using the anterior sector of the dentition. In face and
profile views, skeletal class III due to underdevelopment of the upper jaw and to mandibular
deformity in frontal, vertical and sagittal dimension was noticed (Figure 18).
Intraoral examination showed severe molar and canine Class III, the absence of overbite and
the marked negative overjet. The crowding of the superior incisors was confirmed in occlusal
view. The position of the incisors had evidently compensated for the skeletal malocclusion
(Figure 19).
The lateral teleradiogram and relative cephalometric values confirmed the diagnosis of serious
skeletal Class III (Figure 20).
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Figure 18 : Frontal view, profile and smile of patient before treatment

Figure 18. Frontal view, profile and smile of the patient before treatment showing long and narrow face, concave pro‐
A patient H. presented long and narrow face, concave profile, lack of upper lip support, with maxillary anteroposterior deficiency
file, lack of upper lip support, with maxillary anteroposterior deficiency and mandibular anteroposterior excess. Clini‐
and mandibular anteroposterior excess. Clinically significant asymmetry of mandible to the right is present.
cally significant
Figure 18 :deviation of the
Frontal view, mandible
profile to the
and smile right is
of patient present.
before treatment
A patient H. presented long and narrow face, concave profile, lack of upper lip support, with maxillary anteroposterior deficiency
and mandibular anteroposterior excess. Clinically significant asymmetry of mandible to the right is present.
Figure 19 : Pretreatment intraoral photographs: frontal, lateral and occlusion

The Class III malocclusion is characterized by an anterior and posterior crossbites . Crowding is present in both arches (palate-
Figure position
19. Pretreatment intraoral
of maxillary lateral photographs:
incisors) due tofrontal,
narrowlateral and dental
maxillary occlusion
archThe
andClass III malocclusion
compensated mandibularis characterized
incisors
by anposition
anteriorofand posterior
maxillary crossbites.
lateral Crowding
incisors) due to narrowismaxillary
present dental
in both arches
arch (palate-position
and compensated of maxillary
mandibular incisors lateral inci‐
sors) due to narrow maxillary dental arch and compensated mandibular incisors
Given the severe skeletal disharmony, the treatment plan suggested was orthognathic surgery
to improve both esthetic and functional problems. The surgery was followed by presurgical
preparation of dentition. The treatment plan consisted of extraction of the first maxillary
premolars to align the anterior arch, eliminate compensations and to establish ideal incisor,
and second mandibular premolars position (Figure 21). The outcome of this preparation is
evident in the postorthodontic presurgical intraoral and profile photographs and composite
cephalometric tracing. The patient felt his profile was getting worse (Figures 22, 23)
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position of maxillary lateral incisors) due to narrow maxillary dental arch and compensated mandibular incisors
Figure 20: Pretreatment orthopantomogram and laterolateral teleradiogram of skull.

orthopantomogram shows and impacted of 18 and 28 that must be removal. The maxillomandibular disharmony
compensations were evident. Both teleradiogram and cephalometric values showed lingual inclination of mandi
protrusion of maxillary incisors.
Figure 20: Pretreatment orthopantomogram and laterolateral teleradiogram of skull. The
orthopantomogram shows and impacted of 18 and 28 that must be removal. The maxillomandibular disharmony and incisors
Given the severe skeletal dysharmony, the treatment plan suggested was orthognathic surgery to improve both e
compensations were evident. Both teleradiogram and cephalometric values showed lingual inclination of mandibular incisors and
problems.
protrusion The
of maxillary surgery was followed by presurgical preparation of dentition. The treatment plan consisted of ext
incisors.
Figure 20. Pretreatment
maxillaryorthopantomogram
premolars to alignand thelateral teleradiogram
anterior of thecompensations
arch, eliminate skull. The orthopantomogram
and to establish shows and
ideal incisor position, an
Given
impacted 18 the
andsevere skeletal
28 that
mandibular must dysharmony,
be removed.
premolars. the The
treatment
(Figure plan suggested
outcomewas
maxillomandibular
21) The orthognathic
disharmony
of surgery
and
this preparation to evident
incisor
is improve both esthetic
compensations
in the and function
were evi‐
postorthodontic presurgical
problems. The surgery was followed by presurgical preparation of dentition. The treatment plan consisted of extraction of first
dent. Both teleradiogram
profile and cephalometric
photographs and values showed
composite lingual inclination
cephalometric tracing. of mandibular
The patient felt incisors
their and protrusion
profile was getting worse (Figure
maxillary premolars to align the anterior arch, eliminate compensations and to establish ideal incisor position, and second
of maxillary incisors.
mandibular premolars. (Figure 21) The outcome of this preparation is evident in the postorthodontic presurgical intraoral and
profile photographs and composite cephalometric tracing. The patient felt their profile was getting worse (Figures 22, 23)
Figure 21: intraoral views after presurgical orthodontic preparation: immediate preoperative views and radiogram of patient
Figure The
21. Intraoral
Figure
objective
views after treatment
of presurgical
presurgical
21: intraoral views orthodontic
after
should
preparation
presurgical
be to
The
orthodontic
create a harmonious
objective of presurgical
form ofpreparation: immediate
the maxillary and
treatment should be
mandibularpreoperative
dental arches views and radiog
to create a harmonious
independently form
The objective
of each of
ofthe
other. Themaxillary
use of classand
presurgical mandibular
treatment
III elastics isshoulddental
be toarches
nececessaru tocreateindependently.
athe
increase harmonious The use
form
labial inclination of
ofof class
thethe III elastics
maxillary
lower incisors and mandibular d
and
is necessary to increase
overjet the
and labial inclination of the lower incisors
the negative
independently presurgically
of each decompensate
other. The useforoftheclass III and
malocclusion. the negative overjet and presurgically decom‐
elastics is nececessaru to increase the labial inclination of the l
pensate for the malocclusion.
the negative overjet and presurgically decompensate for the malocclusion.
Figure 22: pretreatment and presurgical profile views: The worsening of the profile was due to dental decompensation, with the
incisors positioned on the bony bases as adequately as possible.
Figure 22. Pretreatment

Figure 22:andpretreatment
presurgical profile views: The worsening
and presurgical of the The
profile views: profile was due to
worsening ofdental decompensation,
the profile was due to dental decompe
with the incisors positioned
incisors on the bony
positioned bases
on the bonyas adequately as possible.as possible.
bases as adequately
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Figure 23. Pretreatment and presurgical

Figure 23: pretreatment lateral teleradiographies
and presurgical and composite
lateral teleradiographies cephalometric
and composite tracingtracing
cephalometric of theofpatient.
a patient. Note the
valuesillustrating
Note the values illustratingthe
thedecompensation
decompensation of
of incisors
incisorsand
andthe
theincrease
increaseofofa Witts.
witts.
Surgical visual treatment objectives are shown in figure 24. Two-jaw surgery was performed in this case. The maxilla was
Surgical visual
Figure
advanced treatment
23: pretreatment
and mandible objectives
and presurgical are
setbaccked of
with shown
lateral in Figure
teleradiographies
counterclockewise 24.composite
and
rotation Two-jaw
by surgery
cephalometric
means of Lefort was performed
tracing
I maxillary
of a patient. Note the
and sagittal split osteotomies.
values illustrating the decompensation incisors and the increase of a witts.
in this case. The maxilla was advanced and mandible setback with counterclockwise rotation
The postoperative views show the resolution of the main issues, the establishment of a bilateral molar and canine Class I
by means of visual
Surgical Leforttreatment
relationship I maxillary
and correct and
objectives
overjet andsagittal
are shown insplit
overbite.The osteotomies.
figure 24. Two-jaw
satisfactory surgery
aesthetic resultwas performed
in terms in this
of profile case. Theand
appearance maxilla
smile was
line is
advanced and
evident mandible
from setbaccked
the extraoral with counterclockewise
photographs, rotation
which also show byupper
correct meansincisor
of Lefort I maxillary
exposure and sagittal split
and normalization osteotomies.
of the position of the
The postoperative views
bony bases. The curveshow
in the the resolution
contour of harmonious
line is more the main issues, the advancement
after surgical establishment
of theof a bilateral
maxilla and mandibular setback.
The (Figures
postoperative views
27) show the resolution of the main issues, the establishment of a bilateral molar and canine Class I
molarrelationship
and canine 25, 26,Class I relationship and correct overjet and overbite. The satisfactory
and correct overjet and overbite.The satisfactory aesthetic result in terms of profile appearance and smile line is
aesthetic result
evident in extraoral
from the terms of profile appearance
photographs, which also showand smile
correct upperline is exposure
incisor evidentand
from the extraoral
normalization of the position of the
bony bases. The curve in the contour line is more harmonious after surgical advancement of the maxilla and mandibular setback.
photographs,
(Figures 25,which
26, 27) also show correct upper incisor exposure and normalization of the
position of the bony bases. The curve in the contour line is more harmonious after surgical
advancement of the maxilla and mandibular setback. (Figures 25- 27)
Figure 24: Lefort maxillary osteotomy to superiorly reposition and advancement the maxilla to allow the mandible to autorotate
and close the openbite.
Figure Figure 24: maxillary

24. Lefort Lefort maxillary osteotomy
osteotomy to superiorly
to superiorly reposition
reposition and and advancement
advance the maxilla
the maxilla to allowtothe
allow the mandible
mandible to autorotate
to auto-
and close
rotate and close the
the openbite.
openbite.
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Figure 25: Immediate postoperative intraoral views: the use of surgical arch wires along with controlled elastic therapy and
exercise programs after fixation,, greatly facilitate treatment.
Figure 25. Immediate postoperative intraoral views: the use of surgical arch wires along with controlled elastic therapy
and exercise programs after fixation, greatly facilitate treatment.
Figure 25: Immediate postoperative intraoral views: the use of surgical arch wires along with controlled elastic therapy and
exercise programs after fixation,, greatly facilitate treatment.
Figure 26: Clinical appearance and post surgical orthopantomogram and laterolateral teleradiogram of skull.
We can note the immediate postoperative changesand the steosynthesis of the maxilla and the mandible with titanium miniplates
and26:
Figure screws. Soappearance
Clinical the witts and
andthe
postANB values
surgical illustrate the reequilibation
orthopantomogram of maxillomandibular
and laterolateral relationschip. .
teleradiogram of skull.
We can note the immediate postoperative changesand the steosynthesis of the maxilla and the mandible with titanium miniplates
Figure 26. Clinical
and screws. So the appearance andvalues
witts and the ANB post surgical orthopantomogram
illustrate the and lateral teleradiogram
reequilibation of maxillomandibular relationschip. .of skull. Note the im‐
mediate postoperative changes and the osteosynthesis of the maxilla and the mandible with titanium miniplates and
screws. The Witts and the ANB values illustrate the re-harmonization of the maxillomandibular relationship..
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Figure 27. Pretreatment and post-surgery composite cephalometric tracing illustrating the soft tissue, skeletal and den‐
tal changes.
Figure 27: Pretreatment and post-surgery composite cephalometric tracing illustrating the soft tissue, skeletal and dental changes.
The end
Viewresults of treatment
the end results were28),gratifying
of treatment (Figure (Figure
we can conclude 28).
that benefit of repositioning incisive via Class II elastics, surgical
expansion and genioplasty would allow to much better occlusal relationships and aesthetic results.
Figure 28: The changing profile during treatment and intraoral views after debonding
Figure 28. The changing profile during treatment and intraoral views after debonding
Conclusion
5. Conclusion
Stability of results depends on overall treatment plan. Successful treatment depends on a rigorous diagnosis and a treatment plan, a
close collaboration between all the different actors involved; all of which are deal within predefined objetices using a highly
Stability of results
personalized approach.depends on overall treatment plan. Successful treatment depends on a
rigorous diagnosis and deformities
Moderate to severe skeletal a treatment, a close
often requires collaboration
a combined between
orthodontic and all the
surgical approach different
for optimal functionmembers
and best
esthetic results. Indeed, given the development of orthodontic and surgery techniques, this approach becomes a fully-fledged form
of treatment which belongs, quite naturally, in the arsenal of treatment we can offer our adult patients.
Orthognatic surgery has created new and exciting oppotunities in the treatment of patients with dentofacial deformities and has
relieved the orthodontist of having only compromised treatment to offer patients with skeletal disharmony.
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http://dx.doi.org/10.5772/59164
involved; all of which deal within predefined objectives using a highly personalized approach.
Moderate to severe skeletal deformities often require a combined orthodontic and surgical
approach for optimal function and best esthetic results. Indeed, given the development of
orthodontic and surgery techniques, this approach becomes a fully-fledged form of treatment
which belongs, quite naturally, in the arsenal of treatment we can offer our adult patients.
Orthognathic surgery has created new and exciting opportunities in the treatment of patients
with dentofacial deformities and has relieved the orthodontist of having only compromised
treatment to offer patients with skeletal disharmony.
One needs to be fully convinced that ortho-surgical treatments should be in no way viewed
as a game of chance. The main focus of orthodontic treatment should be on obtaining and
maintaining long-term clinically satisfactory stability results. Without stability, the achieve‐
ment of good function and satisfactory aesthetics is obviously not successful.
Author details
Sana Alami1, Hakima Aghoutan1, Samir Diouny2, Farid El Quars1 and Farid Bourzgui1*
*Address all correspondence to: faridbourzgui@gmail.com
1 Department of Dento-facial Orthopedics, Faculty of Dental Medicine, Hassan II Ain Chok

University in Casablanca, Morocco
2 Chouaib Doukkali University, Faculty of Letters & Human Sciences, El Jadida, Morocco
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[32] Proffit WR, Phillips C, Turvey TA. Stability after mandibular setback: mandible-only
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[33] Proffit WR, Phillips C, Dann Ct, Turvey TA. Stability after surgical-orthodontic cor‐
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[34] Suri L, Taneja P. Surgically assisted rapid palatal expansion: A literature review. Am
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Chapter 18
Telegnathic Surgery for Obstructive Sleep Apnea
Dina Ameen
http://dx.doi.org/10.5772/59276
1. Introduction
Obstructive sleep apnea (OSA) is a repetitive partial or complete upper airway collapse during
sleep. It is defined as reparative episodes of hypopnea or apnea for at least 10 seconds in
association with more than 2 % decrease in oxygen hemoglobin saturation. OSA along with
snoring and upper airway resistant syndrome fall into a broad category of sleep related
breathing disorder (SBD). The incidence of OSA is up to 9% of women and 24% of men aged
30–60y. Adverse consequences of OSA include: excessive daytime sleepiness (EDS), hyper‐
tension, ischemic heart disease, metabolic syndrome, stroke and death. There are many
modalities for OSA treatment; conservative approach includes weight reduction, positioning
devices, continuous airway pressure (CPAP), and oral appliances. Due to a large percentage
of noncompliance with the conservative approach, surgical treatment is a valid option of OSA
treatment.
Surgical options are tracheostomy, uvulopalatopharyngoplasty, palatal pillars, radiofrequen‐
cy ablation of soft palate or tongue, anterior mandibular osteotomy, hypoid suspension,
tongue reduction, tongue suspension and telegnathic surgery (maxillomandibular advance‐
ment). This chapter provides an overview in OSA surgical treatment.
2. Sleep stages
During normal sleep, the stages are:

1st stage is non-rapid eye movement (non-REM), lasting 70-90 minutes. The non-REM is the
quiet sleep, which is consists of 4 stages.45-50% of total sleep is stage 2. Delta sleep is stages 3
and 4, which are a deeper sleep marked by the increasing appearance of high-amplitude slow
waves. There is generalized slowness in all activities in non-REM sleep stage.
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2nd stage rapid eye movement (REM) stage will follow for 20 minutes. REM stage represents
the deep sleep stage; it follows the non-REM stage with 20-25% of total sleep. During average
night REM to non-REM ratio is 4:6 with intervals 60-90 minutes. Physiologic changes during
REM are generalized muscle atonia except for ocular muscles, increase temperature, blood
flow and oxygen use in the brain as well as increase in heart rate, blood pressure and respiration
with dramatic fluctuations. Respiration is controlled by 2-control systems; metabolic and
behavioral. Non-REM is predominantly controlled by the metabolic control system, which is
influenced by hypoxia and hypercapnia. On the other hand during the REM sleep, behavioral
control system is predominant. OSA usually occurs during stage 3, 4 and REM, which are the
deep sleep stages, and that is because of blunt responses to hypoxia and hypercapnia along
with the generalized muscle atonia; pharyngeal wall muscles may collapse [1] [2].
3. Anatomy
Upper airway obstructions can occur anywhere in the nasopharynx, oropharynx and hypo‐
pharynx. Nasopharyngeal obstruction examples are nasal septum deviation, nasal polyps and
rhinosinusitis; they can cause mild OSA [3]. Most common sites of airway collapse occur in
the hypopharynx [4]. It extends from the soft palate to the epiglottis; anteriorly it is formed by
the base of the tongue and soft palate, while pharyngeal constrictor muscles form the posterior
borders. Studies show that tongue volume and lateral walls of the pharynx are independent
risks to OSA. There are many craniofacial abnormalities that cause OSA. Even a minimal
change in maxillary or mandibular position can lead to upper airway collapse. OSA patients
could have one or more of the following anatomical variations:
A retro-position of the mandible or the maxilla, micrognathia, long soft palate, increased
thickness of the soft palate, macroglossia (large tongue) and differences in hyoid bone
position [5].
The success of surgical treatment is depending on the recognition of the level of obstruction.
There is a special surgical procedure for each site of obstruction.
4. Diagnosis
Many diagnostic tools can be used, yet physical examination is very important. A through
physical examination of the nose, oral cavity, pharynx and neck should be done. Endoscopy
gives clinicians visual assessment to the upper airway and may show possible sites of collapse.
Endoscopic Mullar maneuver is a useful procedure for OSA[6].The best results obtained by
instructing the patient to lie down in supine position then inspire maximally then with closed
nose and mouth, while placing the endoscope at the level of supraglottis, the examiner will be
able to visualize the degree of pharyngeal collapse. Increase in negative pressure in the
pharynx will demonstrate the point of collapse. Standardized performance and documentation
is advocated to prevent any inter-investigator variability [7]. There are many classifications
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for upper airway obstruction; Fujita’s classification system described patterns of upper airway
obstruction in OSA patients in 1985. Fujita classified airway obstruction into 3 types namely:
Type 1. Isolated palatal obstruction,
Type 2. Isolated retrolingual obstruction, and
Type 3. Palatal and retrolingual obstruction
Recently other modifications to Fujita classification were advocated by adding more details
for the base of the tongue [8].
Polysomnography (PSG) is still the golden standard to establish OSA diagnosis. It can be used
as a diagnostic tool as well as to assess therapeutic efficacy of a given treatment modality
including weight loss, CPAP, oral appliances and MMA. It is usually done in a sleep clinic, as
the patient should sleep at least for 4 hours, and the electroencephalogram (EEG), electroocu‐
logram (EOG), electromyogram (EMG), and electrocardiogram (ECG) will be monitored [9].
There are many imaging studies proposed to evaluate the upper airway such as CT, MRI,
dynamic scanning protocols e.g. ultrafast CT or MRI [7]. In oral and maxillofacial clinics
cephalometric x-ray is still one of the most common x-rays used to diagnose and to evaluate
treatment along with orthopantomogram (OPG). Both are a simple 2D image commonly used
by oral and maxillofacial surgeon. It helps to detect posterior airway obstruction caused by
skeletal disharmony. Examples of some important cephalometric measurements are:
• Sella nasion A point (SAN) 82 °
• Sella nasion B point (SAB) 80°
• Posterior airway space (PAS) 11mm
• Posterior nasal spine-palate (PNS-P) 35mm
• Mandibular plane-hyoid (MP-H) 15mm

OPG is used before any skeletal surgery to estimate the location of vital structures such as
inferior alveolar nerve, mental foramen and apices of anterior teeth [10].
5. Risk factors and systemic complications
The incidence of OSA is different between men and women; most epidemiological studies
reports male predominance with 5-8:1 ratio [11]. Male predominance is due to the sex related
differences in upper airway anatomy and function, plus the differences in ventilator response
to arousals from sleep [12]. But menopause women show a similar incidence to men because
hormonal influences which play an important role in pathogenesis of OSA [13]. The other
important risk factor is body mass index (BMI); the Wisconsin Sleep Cohort Study shows that
one standard deviation difference in body mass index (BMI) was associated with a four-fold
increase in disease prevalence [14] [15]. Partial or complete airway obstruction for more than
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10 seconds will lead to decrease oxygen supply to vital organs such as the heart and brain
which result in many sign and symptoms. Excessive daytime sleepiness, memory loss,
impaired concentration, morning headache, decreased manual dexterity, libido and decrease
sexual performance [16].
Systemic complications of OSA includes cardiovascular and neurocognitive disorders and

death. Periods of apnea, prevent effective gaseous exchange at the alveoli which lead to
hypoxia and hypercapnia. Apnea dependent hypoxia and hypercapnia increase sympathetic
neural tone, which in turn cause vasoconstriction and increase in sympathetic nerve activity.
Sympathetic nerve function rises progressively during apnea and is enhanced further by
arousal. Increase in the sympathetic tone is the major cause of cardiovascular complications.
OSA is associated with hypertension [16-18], arrhythmia, myocardial infarction [16, 19, 20],
and congestive heart failure [16]. During the obstruction episodes there are marked changes
in blood flow in cerebral arteries. Netzer et al reported 80% changes in cerebral blood flow in
cerebral arteries [21]. During periods of apnea there is rapid increase in cerebral blood flow
followed by rapid fall to below baseline levels after apnea periods. Fluctuation in cerebral
blood flow along with many physiologic changes may lead to stroke [16]. Mortality rate of
OSA can reach up to 30% in 15 years if left untreated [22]. Excessive daytime sleepiness could
contribute to high rates of road traffic accidents. Studies show RTA among OSA patients is 1.3
to 7 times higher than the general population [23, 24].
6. Orthognathic surgery vs. telegnathic surgery
Maxillomandibular advancement is considered a telegnathic surgery, which involves maxil‐

lary and mandibular osteotomies to enlarge posterior airway space. Telegnathic surgery is
derived from the Greek words tele, which means “over a distance,” and gnathis, which relates
to the jaws, whereas orthognathic surgery is derived from the Greek words, ortho, which
means, “to straighten,” and gnathis meaning “jaw”. OSA patients are usually middle age, obese,
mostly males with significant comorbid medical conditions; on the other hand patients with
dentofacial abnormalities are young with no sex prevalence (male or female) and usually in a
good health.
There are no major differences in the surgical techniques although the goals of therapy are
different. In orthognathic surgery the goal is to correct the occlusion and improve esthet‐
ics while in telegnathic surgery the optimal goal is to relieve upper airway obstruction.
Orthodontic treatment is a must for all patients with dentofacial deformities who are going
for orthognathic surgery. In OSA patients accepting the existing bite can be used if the
patient does not want to go through the lengthy orthodontic treatment. Surgical move‐
ment in the orthognathic surgery patient are dependent upon the esthetic requirement as
well as occlusion correction, whereas in OSA patients a larger surgical movement of the
maxilla and mandible should be done (up to 10mm) with the main concern being open‐
ing the posterior airway space [25, 26].
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7. Classification
Respiratory disturbance index (RDI) represents the number of obstructive respiratory events
per hour of sleep. An RDI of 5 is the upper limit of normal.
RDI= (apnea+hypopnea ÷ total sleep time) × 60 [27].
OSA is classified into mild, moderate and severe depending on the respiratory disturbance
index (RDI) and oxyhemoglobin desaturation (SaO2).
Mild OSA is when RDI 10-30 and SaO2 >90%,
Moderate OSA is when RDI 30-50 and SaO2 >85%, and
Severe OSA is when RDI >50 and SaO2 <60% [28].
8. Treatment options
8.1. Conservative treatment
After diagnosis of OSA, conservative treatment is indicated. It includes weight reduction,

positional treatment, CPAP and oral appliances. Increase in BMI is a risk factor for OSA.
Although high BMI is a risk factor for OSA, 30% of OSA patients are not obese. BMI is defined
as the weight in kilograms divided by the height in meters squared (kg/m2). Overweight is
considered when BMI of more than 25 kg/m2 while obese is a BMI of more than 30 kg/m2.
Constriction of the hypopharynx and oropharynx are due to increase in neck circumference
and increased fatty deposits in the peripharyngeal area [29]. In the Wisconsin Sleep Cohort
Study, a 10% weight gain predicted a 32% increase in AHI, whereas a 10% weight loss predicted
a 26% decrease in AHI [14].
Continuous positive airway pressure (CPAP) or nasal Continuous Positive Airway Pressures
(nCPAP) are effective treatments for OSA. They are the 1st line treatment strategies when the
patient is diagnosed with OSA. CPAP/ nCPAP work as a pneumatic splint to open the airway
via tight fitting facemask or nasal mask and oxygen pump. There are many studies reporting
the success of CPAP treatment. CPAP can stop and reverse all OSA complications. Treatments
with CPAP result in decreased sympathetic tone, which will lead to decrease in blood pressure,
AHI, oxygen desaturation and improve sleep efficiency, [30-32]. CPAP compliance however
is only 65-80%, with 8% to 15% of patients stopping the treatment after the first night. This low
compliance rate is due to many associated complications such as nasal dryness and congestion,
sinus discomfort, massive epistaxis, skin rash and conjunctivitis from air leak. These compli‐
cations plus the physical discomfort, noise and difficult transporting the unit lowers the CPAP
tolerance [33,34].
OSA patients should be advised not to sleep in supine position; gravity is a factor that can
cause upper airway collapse. Positional behavioral therapy is to educate the patient to alter
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their sleep position by using a pillow or body belt; patients can alter their sleeping to a more
lateral position that could open the airway and reduce collapsibility [35].
Mild to moderate OSA patients who are unable to tolerate CPAP can be treated with oral
appliances. It simply prevents the mandible and associated muscles from going backward
during sleep; some appliances actually advance the mandible from centric occlusion. Oral
appliances should be adjusted on a periodic basis to prevent occlusal disturbances and
temporomandibular joint dysfunction [36].
8.2. Surgical options
1969 Kuhlo et al was the first to recommend tracheostomy for OSA treatment [37]. Although
tracheostomy is the most effective surgical procedure to treat OSA, it has morbidity and many
adverse effects on the quality of life namely wound infection, stenosis and bleeding. Because
of this many surgical techniques have developed to treat OSA. Based on the level of obstruction
there are many surgical options; for example nasal surgeries such as septoplasty, turbinoplasty,
polypectomy, adenectomy and tonsillectomy will address nasal obstruction. There are several
palatal surgeries to address retropalatal obstruction for example: uvulopalatopharyngoplasty
(UPPP), uvulopalatopharyngoplasty laser assisted (UPPP-LA), palatal pillar implants,
radiofrequency ablation of the soft palate, and many others. Tongue operations like tongue
suspension, radiofrequency ablation of the tongue, genial tubercle advancement with or
without hyoid suspension are used for retrolingual obstruction. On the other hand maxillo‐
mandibular advancement with or without combined procedures address retropalatal and
retrolingual levels of obstruction [26] [38].
The following section of this chapter will address some surgical techniques.
8.3. OSA treatment protocols
Successful OSA treatments depend on the recognition of the level of obstruction. Stanford
University Sleep Disorders and Research Center proposed a protocol for OSA based on the
site of obstruction.
Phase I protocol includes: UPPP, genioglossus advancement, and/or hyoid suspension then
Phase II protocol maxillomandibular advancement if the patient fails phase I treatment.

MMA can be used to treat OSA as a primary or secondary procedure. MMA is consid‐
ered primary when it is the 1st surgical procedure done to address multi-level of obstruc‐
tion, when MMA done after phase one treatment it is called secondary MMA. Recently
some surgeons prefer MMA advancement as the 1st surgical procedure especially if the
patient has maxillary or mandibular deficiencies [26,39]. MMA is indicated if the diagno‐
sis is confirmed severe OSA with RDI >50 and SaO2 <60%, non-compliance or tolerance to
CPAP, retroglossal obstruction, failure to respond to other surgical treatment such as UPPP
and maxillomandibular hypoplasia [1].
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8.4. Uvulopalatopharyngoplasty
Historically UPPP was an available option instead of tracheostomy until the recent expansion
in surgical treatment of OSA. In 1981 Fujita et al introduced the concept of uvulopalatophar‐
yngoplasty (UPPP) to enlarge retropalatal airway. UPPP involves partial excision of the uvula
and redundant pharyngeal and palatal tissues, with primary closure of the anterior and
posterior pillars under general anesthesia [40]. In 1991 O’Leary and Millman modify Fujita
UPPP by excising the palatopharyngeus muscle [41]. Uvulopalatal flap is another modification
published in 1996 by Powell et al [42]. UPPP complications range from velopharyngeal
insufficiency, dysphagia (difficulty swallowing), voice changes, and death from general
anesthesia [43]. With the advances in laser surgery uvulopalatopharyngoplasty–laser assisted
(UPPP-LA) was developed using the same principle of scalpel UPPP [44]. Variable success
rates reported in the literature is up to 70% and 78% respectively [45, 46]. Other studies show
only 40 % success in eliminating snoring [47].
Today UPPP or UPPP-LA is rarely used as a single treatment modality; this is primarily due
to the understanding of multilevel obstruction in most OSA patients. It is usually part of a
staged protocol for OSA treatment [48]. UPPP can be performed with genioglossus advance‐
ment or with MMA. Hendler and Barry in 2001 published their data about 41 OSA patients;
33 of them treated with combined UPPP and modified mortised genioglossus advancement
while the others had MMA combined procedures. All patients had pre-operative and post-
operative polysomnography to evaluate treatment success. They reported comparable success
rate of 86% in both groups concluding that UPPP/mortised genioglossus advancement is
effective for the treatment of obstructive sleep apnea. Maxillomandibular advancement is
effective for treating severe sleep apnea, and MMA can be done combined with UPPP/mortised
genioglossus advancement in some cases as long as it is indicated in order to avoid multiple
procedures [49].
8.5. Genioglossus advancement
Genioglossus muscle is a major pharyngeal dilator that plays an important role in OSA
pathophysiology. In 1984 Riley et al. first reported advancing the genial tubercle with its
genioglossus muscle attachment. The procedure was called inferior sagittal osteotomy [50].
If hyoid suspension to the inferior mandible is done at the same time it is called genioglos‐
sus advancement-hyoid myotomy [51]; the later was modified by suspending the hyoid to
the thyroid cartilage. By advancing the genioglossus muscle the tension will increase at the
tongue base thereby stabilize the hypopharyngeal airway [52]. In 1991 Riley et al modi‐
fied the technique by limiting the osteotomy to a rectangular window and called it anterior
mandibular osteotomy; this modification decreased anterior mandibular fracture [53]. In
2000, Lee and Woodson introduced a circular osteotomy of the genial tubercle [54]. All
these modifications were done to address postoperative complications such as bone necrosis
and anterior teeth pulp necrosis. Inferior sagittal osteotomy is indicated for patients with
a deficient mandible in anteroposterior dimension, it involves genial tubercle advance‐
ment with the inferior border of the mandible while the occlusal relations ship is un‐
changed. On the other hand anterior mandibular osteotomy is indicated for patients with
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normal mandibular anteroposterior dimension [52]; it requires careful assessment of the

genial tubercle, based on a study done by Mintz et al [55] on 14 human skulls, the superior
border of the genial tubercle is 6.45 mm inferior to the apices of central incisors with 35.4%
of the genial tubercle were located less than 5mm inferiorly. After estimating genial tubercle
location a rectangular window osteotomy is performed leaving the inferior border of the
mandible intact then advancing the segment to stabilize the hypopharyngeal airway. It will
require a 90 degree rotation of the osteotomized segment and placing the lingual cortical
plate anterior to the buccal/labial cortical plate [52]. Trephine osteotomy approach is another
technique using the same concept but with trephine burr in an attempt to decrease post-
operative complications (anterior teeth roots amputation) [54]. Foltán and René [56]
published a follow-up of 31 patients who had genioglossus advancement by the modified
genioplasty with hyoid myotomy. They reported 74% success rate showed by significant
dropping in RDI and oxygen desaturation index. Genioglossus advancement with or
without hyoid suspension is a valid technique to treat OSA; it could be performed alone
or as an adjunct to UPPP [57]. Another technique to address retrolingual obstruction is
tongue base surgeries. Tongue suspension is a revisable minimally invasive surgery
performed via submental incision. By introducing a large suture into the base of the tongue
and suspending the tongue to the mandibular lingual surface. Omur et al reported high
success (81.81%)of tongue base surgery with UPPP. They conclude that tongue base
suspension combined with UPPP has been shown to reduce RDI better than UPPP alone [58].
8.6. Maxillomandibular advancement
It is well recognized that patients with maxillomandibular deficiencies will ultimately

develop OSA; from this observation MMA is advocated for OSA treatment even in patients
with normal skeletal proportion [59]. MMA will increase the posterior airway dimension
by physically expanding the skeletal structure. The forward movement of the maxilloman‐
dibular complex improves the tension and collapsibility of the velopharyngeal and
suprahyoid muscles [60] [61]. Since the majority of OSA patients are middle age with a
saggy and droopy soft tissue; forwarded movement of the mandibulomaxillary complex
will not only bypass the obstruction; it will also provide facial rejuvenation by augment‐
ing soft tissue support [62]. MMA has many advantages such as decrease number of
surgeries needed by utilizing one surgery to bypass several sites of obstructions (by
performing Le Fort I advancement; it will open the nasal valve and consequently im‐
prove air flow, tighten the soft palate and pharyngeal muscles at the same time while
mandibular advancement will tighten genioglossus and suprahyoid muscles), avoid the
need for tracheostomy in the postoperative period and ultimately decrease medical costs
by decreasing hospital stay. If the patient will undergo simultaneous MMA and soft tissue
procedure such as UPPP or tongue reduction surgeries; temporary tracheostomy may be
indicated to ensure patent airway. Other indications for temporary tracheostomy are
difficult airway, RDI >60 and Sao2 <60, morbid obesity and significant craniofacial
abnormality [1] [59]. MMA is considered one of the most successful treatment modalities
for OSA after tracheostomy and CPAP [63] [64]. MMA success rate is very high compar‐
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http://dx.doi.org/10.5772/59276
ing to other surgical treatment. Riley et al [65] reported the largest MMA series with success
rate of 98%. In 2004 Dattilo and Drooger [66] reported 93% success rate in 14 of 15 cases,
whereas Hochban et al in 1997 reported 97% success rate in 37 of 38 cases [67].
MMA as a surgical techniques per se is the same as classical orthognathic surgery it involve
maxillary Le Fort I advancement and mandibular advancement simultaneously. The amount
of advancement is usually 10mm - the maximum amount of possible advancement. There
are some differences that should be considered with MMA e.g. vascular supply, bone
healing and the need of adjunctive surgical procedures. Most of MMA candidate patients
had unsuccessful UPPP; palatal scar may cause difficulty in advancing the maxilla or
compromise its blood supply. Patients treated with UPPP may have or be at risk for
velopharyngeal insufficiency (VPI). Advancing the maxilla may theoretically cause VPI or
worsen existing VPI. During MMA surgery, based on cephalometrics and model surgery,
the mandible is advanced first; this is because the amount of advancement is arbitrary and
without any considerations of the maxillary incisors esthetic position or functional occlusion.
[1,59,68]
Holty and Guilleminault published a meta-analysis of 53 reports describing 627 OSA patients
with maxillomandibular advancement for the treatment of obstructive sleep apnea; they
concluded that major and minor complication rates for MMA were 1.0% and 3.1%, respectively
with cardiac complications as the most major complications. Facial paresthesia is the most
common complication after MMA with 86% of cases resolved by 12 months after surgery. No
postoperative deaths were reported. Most subjects reported satisfaction after MMA with
improvements in quality of life measures [69]. Patients with poor response to MMA often have
had UPPP. The possible cause is failure of the airway to stretch laterally in the retropalatal area
caused by soft palate scarring from the previous surgery, making the tissues of the lateral
pharyngeal walls stiffer and thus less responsive to advancement [1,59].
9. Distraction osteogenesis and OSA
Recently, many surgeons suggest distraction osteogenesis for treating OSA. Distraction
osteogenesis has many advantages over the traditional MMA surgical technique; better soft
tissue adaptation, elimination of the need of a bone graft, less soft tissue dissection and better
stability. On the other hand, lengthy treatment and the need of postoperative orthodontic
treatment are the disadvantages of this kind of treatment [70] [71].
10. Summary
OSA surgical treatment success is primarily dependent on careful diagnosis and recognition
of levels of obstruction. Many surgical protocols are there in the literature. MMA along with
tracheostomy are the most successful surgical procedures to treat OSA.
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Orthognathic surgery Telegnathic surgery
Sex Male or female Male
Age Young Middle age or older
Health Usually healthy Many medical comorbidities
Surgical goal Correct the occlusion and improve Relive upper airway obstruction.
esthetics
Type of movement Depend on the dentofacial deformity Maxillomandibular advancement
Amount of movement Depend of the esthetic position of Up to 10mm advancement

maxillary central incisors and facial
esthetic
Orthodontic treatment Must Might accept the existing bite
Table 1. Differences between Orthognathic and Telegnathic surgery
RDI=(apnea+hypopnea ÷ total sleep time) × 60 SaO2
Mild 10-30 >90%
Moderate 30-50 >85%
Severe >50 <60%
Table 2. OSA classification
Conservative / medical treatment Surgical treatment
Weight reduction Tracheostomy
CPAP, nCPAP Nasal surgeries
Positional device Palatal surgeries
Oral appliances Tongue surgeries
Skeletal surgeries
Table 3. OSA Treatment
Author details
Dina Ameen*
Address all correspondence to: dr.dinaameen@gmail.com
Clinical Fellow at the University of Alabama at Birmingham, USA

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http://dx.doi.org/10.5772/59276
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Chapter 19
Comprehensive Management of Temporomandibular

Joint Ankylosis — State of the Art
Hossein Behnia, Azita Tehranchi and

Farnaz Younessian
http://dx.doi.org/10.5772/59165
1. Introduction
Temporomandibular joint (TMJ) ankylosis is one of the most challenging TMJ disorders that
can negatively affect oral related daily functions like mastication, speech and hygiene [1,2].
The accepted definition of ankylosis is the bony or fibrous tissue fusion between articular
surfaces including the meniscus, glenoid fossa and condylar heads [3]. Consequently, jaw
functions like the maximal incisal opening (MIO) and lateral excursive movements progres‐
sively decrease. This chapter describes the most important issues of early and late management
of TMJ ankylosis in both children and adults.
2. Etiology and pathogenesis of TMJ ankylosis
Trauma to the TMJ has been cited as the most common underlying reason responsible for
ankylosis; however, local infections (e.g. otitis media) and systemic disorders (e.g. rheumatoid
arthritis) also can also cause unilateral or bilateral TMJ ankylosis in some cases [4-7]. By
improving the immediate management protocol of condylar fracture and proper application
of antibiotics to fully address ear infections, the prevalence of ankylosis has decreased
significantly in recent years. In addition to the common etiologic factors of TMJ condylar
ankylosis, some affected infants with unknown etiological factors have been reported in the
literature (Figure 1 a-c) [8].
The pathogenesis of the TMJ ankylosis is described by a sequence of events. The increased
intra-articular vascular supply at the traumatized joint develops fibrosis and ultimately
management protocol of condylar fracture and proper application of antibiotics to fully address ear
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infections, the prevalence of ankylosis has decreased significantly in recent years. In addition to the
common etiologic factors of TMJ condylar ankylosis, some affected infants with unknown etiological
412 factors have been reported in the literature (Figure 1 a‐c) (8).
A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

a b c
Figure 1. 1.
Figure A 5-year-old girl with
A 5‐year‐old bilateral
girl with condylar ankylosis
bilateral of unknown
condylar etiologyof
ankylosis (nounknown
history of trauma or infection).
etiology a)
(no history of
Extraoral facial photograph of the patient demonstrate the upper occlusal canting with the help of a tongue depressor,
trauma or infection). a) Extraoral facial photograph of the patient demonstrate the upper occlusal
b) Intraoral photograph shows midline deviation, mandibular shift and increased overjet of the patient, c) three dimen‐
sional conewith
canting beam the
computer
help reconstruction of the
of a tongue patient demonstrates
depressor, the facial
b) Intraoral asymmetry. shows midline deviation,
photograph
mandibular shift and increased overjet of the patient, c) three dimensional cone beam computer
excessive localized bone formation [4]. Most of the animal studies consider intra-capsular
reconstruction of the patient demonstrates the facial asymmetry.
hematoma as the main underlying reason for development of the ankylotic mass following
trauma.
The Observedof hemorrhage
pathogenesis contains
the TMJ ankylosis different by
is described cellular pathways
a sequence activated
of events. by bone intra‐
The increased
morphogenic proteins (BMPs) and tumoral growth factors (TGFs) [9]. However, a study on
articular vascular supply at the traumatized joint develops fibrosis and ultimately excessive localized
human
bone subjects, (4).
formation revealed
Most that hematoma
of the animal in the joint
studies space intra‐capsular
consider does not always result in as
hematoma bony
the main
ankylosis [2]. This excessive bone mass does not have a neoplastic nature, but has the potential
of continual growth [10]. The presence of abnormal bony mass may restrict mandibular
movement, which subsequently may lead in loss of the functional matrix of bone and muscle
1
interaction, and consequently result in growth failure [11]. Inadequately treated or excessive
treatment of condylar fractures may lead to growth retardation or growth excess, respectively
[3]. Therefore, the best treatment steps for post-traumatic ankylosis and resulting growth
abnormality is prevention.
3. Diagnosis and clinical features of TMJ ankylosis
Maximum mouth opening in the presence of pain or without it is a clinical indicator of

traumatized condyles [12]. In addition to routine extra and intraoral photographs, supple‐
mental diagnostic records may be needed for complete diagnosis of each case. Towne’s
projection, posteroanterior and cone beam CT (3D) radiographs are commonly used for this
purpose (Figure 2 a, b).
Due to the flexibility of bone, it is possible to open the mandible to some extent, particularly
in unilateral ankylotic cases [13]. Long-standing TMJ ankylosis can result in functional loss
and facial deformity of affected individuals. In growing patients (mostly under 15 years) lack
of adequate growth at the condyles, which are the main growth centers of the mandible,
forward and downward movement of the mandible does not occur [13]. This growth retarda‐
tion can result in a distorted mandibular structure in all three dimensions, highlighted mostly
on sagittal views. Furthermore, deepening of the antegonial notch following continuous
subperiosteal bone formation at the angles may be seen in most of the affected. However,
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Comprehensive Management of Temporomandibular Joint Ankylosis — State of the Art 413

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concomitant with significant functional loss. Depending on the type of ankylosis (unilateral
or bilateral) clinical features can vary.
In the case of unilateral ankylosis, the patient also develops a mandibular asymmetry and
subdivision malocclusion (14). Furthermore, in unilateral cases canting of the upper occlusal surface
a b
thought to be caused by compensatory vertical eruption of the posterior maxillary teeth ipsilateral to
the restricted condyle is seen (Figure 3 a‐c). On the other hand, in bilateral ankylosis, more limited
Figure 2. a) Posteroanterior view of a condylar neck fracture, b) Coronal section of computer tomography scan of an‐
other range of interincisal
adult patient opening
with unilateral and fracture
condylar absence of maxillary
on the right side. occlusal canting is observed. Patients with
bilateral ankylosis develop retrognathia, short posterior facial height and openbite with possible
ankylosis in patientsview
older thanof 15
a years of age experience mild facial deformities
upper airway obstruction and severely convex facial profile (Figure 4 a, b) (15).
e 2. a) Posteroanterior condylar neck fracture, b) Coronal concomitant
section of comp
with significant functional loss. Depending on the type of ankylosis (unilateral or bilateral)
graphy scan of another adult patient with unilateral condylar fracture on the right side.
clinical features can vary.
In the case of unilateral ankylosis, the patient also develops a mandibular asymmetry and
Due to the flexibility of bone, it is possible to open the mandible to some extent, particu
subdivision malocclusion [14]. Furthermore, in unilateral cases canting of the upper occlusal
in unilateral ankylotic cases (13). Long‐standing TMJ ankylosis can result in functional
surface thought to be caused by compensatory vertical eruption of the posterior maxillary teeth
ipsilateral to the restricted condyle is seen (Figure 3 a-c) . On the other hand, in bilateral ankylosis,
and facial deformity of affected individuals. In growing patients (mostly under 15 years)
more limited range of interincisal opening and absence of maxillary occlusal canting is observed.
of adequate growth at the condyles, which are the main growth centers of the mand
Patients with bilateral ankylosis develop retrognathia, short posterior facial height and openbite
forward withand possible upper airway
downward obstruction and
movement of severely convex facialdoes
the mandible profile (Figure 4 a, b) [15].
not occur (13). This gro

retardation can result in a distorted mandibular structure in all three dimensions, highlig
mostly on sagittal views. Furthermore, deepening of the antegonial notch follo
continuous subperiosteal bone formation at the angles may be seen in most of the affec
However, ankylosis in patients older than 15 years of age experience mild facial deform

a b c
Figure 3. A 3-year-old girl with unilateral condylar ankylosis following trauma at birth, a) on facial examination, the
patient presented with facial asymmetry, shortened ramus height, jaw deviation and the chin was noticeably deviated
Figure 3. A 3‐year‐old girl with unilateral condylar ankylosis following trauma at birth, a) on facial
to the left and the maxilla was canted downward on the right side. b) The mandibular border became flat and elongat‐
ed onexamination, the patient presented with facial asymmetry, shortened ramus height, jaw deviation
the unaffected side and round on the affected side. The asymmetry is usually the least at the cranial base area
and becomes
and the worse
chin atwas
the lower parts including
noticeably theto
deviated chin.
the left and the maxilla was canted downward on the
right side. b) The mandibular border became flat and elongated on the unaffected side and round
on the affected side. The asymmetry is usually the least at the cranial base area and becomes
worse at the lower parts including the chin.
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a b c
Figure 4. An 18-year-old girl with bilateral condylar ankylosis. a) Long term effect of bilateral condylar ankylosis in a
Figure 4. An 18‐year‐old girl with bilateral condylar ankylosis. a) Long term effect of bi
growing adolescent, which result in limited mouth opening, micrognathia and absent neck chin angle. b) The profile
view is helpful to assess anteroposterior and vertical facial imbalance as well as aid in the determination of etiology of
condylar ankylosis in a growing adolescent, which result in limited mouth opening, microg
the asymmetry. C) 3D CT scan.
and absent neck chin angle. b) The profile view is helpful to assess anteroposterior and v
Prevention of TMJ ankylosis following trauma:
facial imbalance as well as aid in the determination of etiology of the asymmetry. C) 3D CT sc
Regaining normal range of mandibular movement should begin as soon as possible after
Prevention of TMJ ankylosis following trauma:
trauma. Many clinicians recommended a few days [5-7] of no-intervention immediately after
the injury. This
Regaining phaserange
normal allowsof
resolution of painmovement
mandibular and swellingshould
of the TMJ before
begin as reestablishment
soon as possible after tr
of normal range of movement [16]. However, care must be taken not to overextend this phase
Many clinicians recommended a few days (5‐7) of no‐intervention immediately after the injur
regarding ankylosis development. Excellent compliance of the affected individuals with
phase allows resolution of pain and swelling of the TMJ before reestablishment of normal ra
physiotherapy and functional appliances immediately after trauma is an essential part of
future growth
movement and development.
(16). However, care Failure to achieve
must a highnot
be taken levelto
of compliance
overextend to physiotherapy
this phase regarding an
and application of intraoral appliances, increase the risk of future ankylosis, which
development. Excellent compliance of the affected individuals with physiotherapy would be and func
more problematic for patients as time passes.
appliances immediately after trauma is an essential part of future growth and development. F
to
3.1.achieve a high level
Early management of compliance to physiotherapy and application of intraoral appli
in childhood
increase the risk of future ankylosis, which would be more problematic for patients as time pas
Prevention of the ankylosis of the traumatized condyles requires maintenance of the normal
range ofa.movement. In most cases, if the normal range of movement can be achieved, the TMJ
Early management in childhood
will heal without any functional complication. When the patient is able to reach maximal
Prevention of the ankylosis of the traumatized condyles requires maintenance of the normal ra
opening, even in the presence of pain, the simplest prevention regimen would be insertion of
a removable appliance,
movement. which guides
In most cases, if the thenormal
mandible into its
range of correct positioncan
movement during
be closure. The the TMJ wi
achieved,
design and fabrication of different types of removable appliances depends on the clinical
without any functional complication. When the patient is able to reach maximal opening, even
situation of each patient, but commonly all are fabricated from a construction bite in which
presence
advances theof pain, the on
mandible simplest prevention
the affected side moreregimen
than the would be insertion
contralateral of a removable
side in addition to app
conciseguides
which maxillary and
the mandibular
mandible midlines.
into The major
its correct difficulty
position with construction
during bite
closure. The is that and fabricat
design
the clinician must be able to guide the mandible to the proper position, rapidly and accurately.
different types of removable appliances depends on the clinical situation of each patien
Different types of appliances and various combinations of components can be incorporated in
commonly all are fabricated from a construction bite in which advances the mandible on the af
side more than the contralateral side in addition to concise maxillary and mandibular midline
4
compliance and age of the affected child, we use four different techniques:
compliance and age of the affected child, we use four different techniques:
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1‐ Two
1‐ Two simple
simple removable
removable Hawley
Hawley appliances
appliances attached
attached together
together while
while the
the patient
patient is is in
in centric
centric
occlusion (CO) guiding the lower jaw to symmetric position (Figure 5).
Comprehensive Management of Temporomandibular Joint Ankylosis
occlusion (CO) guiding the lower jaw to symmetric position (Figure 5). — State of the Art 415
http://dx.doi.org/10.5772/59165
2‐ Fixed functional appliance with the aid of cement luting agent on the primary molars bands
2‐ Fixed functional appliance with the aid of cement luting agent on the primary molars bands
for more secure retention (Figure 6‐a).
for more secure retention (Figure 6‐a).
these appliances to meet individual requirements. Depending on compliance and age of the
affected
3‐ child, of
3‐ Usage
Usage we use four different
of bi‐zygomatic
bi‐zygomatic techniques:
suspension
suspension wires in
wires in more
more severe
severe cases
cases in
in the
the absence
absence of
of patient
patient
1. Two simple removable Hawley appliances attached together while the patient is in centric
compliance and inadequate intraoral retention of the appliance.
occlusion (CO) guiding the lower jaw to symmetric position (Figure 5).
4‐ Interdental
4‐ Interdental Kobayashi
Kobayashi wires
wires with
with guiding
guiding interarch
interarch elastics,
elastics, in
in cases
cases of
of excessive
excessive restricted
restricted
2. Fixed functional appliance with the aid of cement luting agent on the primary molars
mandibular movement, which do not permit the clinician to take an impression (Figure 6‐b).
mandibular movement, which do not permit the clinician to take an impression (Figure 6‐b).
bands for more secure retention (Figure 6-a).

3. Usage of bi-zygomatic suspension wires in more severe cases in the absence of patient
4. Interdental Kobayashi wires with guiding interarch elastics, in cases of excessive restricted
mandibular movement, which do not permit the clinician to take an impression (Figure
6-b).

a b c
Figure 5. Two simple removable Hawley appliances attached together is the most common
appliance used to guide the patient into symmetric position.

a b c
Figure 5. Two simple removable Hawley appliances attached together is the most common appliance used to guide the
Figure 5. Two simple removable Hawley appliances attached together is the most common
patient into symmetric position.
appliance used to guide the patient into symmetric position.

a b c
c
a b
Figure 6. a) Fixed functional appliance with molar bands that can hold the mandible in its correct
Figure 6. a) Fixed functional appliance with molar bands that can hold the mandible in its correct position full-time, b
Figure 6. a) Fixed functional appliance with molar bands that can hold the mandible in its correct
and c) Interdental Kobayashi wires and guiding interarch orthodontic elastics.
position full‐time, b and c) Interdental Kobayashi wires and guiding interarch orthodontic elastics.
position full‐time, b and c) Interdental Kobayashi wires and guiding interarch orthodontic elastics.
Despite the
Despite the
Despite improvements, removable
the improvements,
improvements, removable appliances
removable appliances are
appliances are not
are not a
not aa practical
practical way
practical way to
way to manage
to manage more
manage more severe
more severe
severe situations that require extra manipulation of the TMJ fracture. A closed reduction
situations that require extra manipulation of the TMJ fracture. A closed reduction often is useful to
situations that require extra manipulation of the TMJ fracture. A closed reduction often is useful to often
is useful to re-establish normal jaw function as a next step [17]. In fact, if the fractured condyle
is still within the articular fossa, there is an opportunity to heal in a quite adequate functional
5
5
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position, only by maintaining the occlusion. This technique is preferred over open reduction
due to high success rate, less complications and technical problems and also less remnant facial
scars [18]. However, clinical decision on the most appropriate type of treatment must be made
considering different individualized factors like patient age, medical history, risk of infection,
of
andscarring or nerve
risk of chronic injury,
pain, risk ofand also or
scarring presence of other
nerve injury, concomitant
and also facial,
presence of othermandibular
concomitantor cranial
facial, mandibular or cranial fractures [19]. Conservative management of condylar fractures is
fractures (19). Conservative management of condylar fractures is still the preferred option, however,
stillrare
in the cases
preferred option, however,
of condylar in rare into
displacement casesthe
of condylar displacement
middle cranial fossa, into the middle
or lateral extracapsular
cranial fossa, or lateral extracapsular displacement of the fractured segment, open reduction of open
displacement of the fractured segment, open reduction is selected (17). The advantages
is selected [17]. The advantages of open treatment for condylar fractures would be the
treatment for condylar fractures would be the possibility of restoring the anatomical position of the
possibility of restoring the anatomical position of the fragments and disc, and subsequently
fragments and disc, and subsequently immediate functional movement of the jaw, which greatly
immediate functional movement of the jaw, which greatly avoids the development of ankylosis
avoids the development of ankylosis of the traumatized joint (20).
of the traumatized joint [20].
Treatment
3.1.1. Treatment
Unilateral condylar fracture
3.1.1.1. Unilateral condylar fracture
A 4‐year‐old boy was brought in approximately five hours after being hit on the left side of the face.
He complained of pain on the left side (Figure 7 a). The impressions of upper and lower arch with
A 4-year-old boy was brought in approximately five hours after being hit on the left side of
limited
the face.jaw
He opening
complained were performed
of pain and side
on the left an (Figure
attached upper
7 a). and lower Hawley
The impressions of upperappliance
and was
lower arch with
fabricated limited
to guide the jaw opening
patient were
into performed
correct and
closure an attached
(Figure 7 b). upper and lower
The condyle of Hawley
the affected side
appliance was fabricated to guide the patient into correct closure (Figure 7 b). The condyle of
healed and positive outcomes were maintained during a 1‐year follow‐up (Figure 7 c and Figure 8 a,
b). affected side healed and positive outcomes were maintained during a 1-year follow-up
the
(Figure 7 c and Figure 8 a, b).

a b c
Figure 7. a) Pretreatment intraoral photograph shows inability of the patient to open the mouth.
Figure 7. a) Pretreatment intraoral photograph shows inability of the patient to open the mouth. b) Removable appli‐
ance inserted for further guidance of the lower arch. c) Frontal facial view at the end of active treatment.
b) Removable appliance inserted for further guidance of the lower arch. c) Frontal facial view at
the end of active treatment.
3.2. Early management in adulthood
Sometimes adult patients suffer severe trauma to the condyles, particularly as a part of a
catastrophic event [21]. Although, because of absence of required growth in later stages of life,
this restricted condylar growth might not result in severe facial deformities, but it may result
in limited mandibular function. Recent improvements in treatment techniques including advent

a b
b) Removable appliance inserted for further guidance of the lower arch. c) F
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the end of active treatment.
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Follow‐up radiograph of the patient which reveals adequate alignment of the fractured bony
segment after 1‐year.
a b
b. Early management in adulthood
Figure 8. Same patient shown in Figure 7. a) Note the presence of condylar neck fracture at posteroanterior projection
Sometimes adult patients suffer severe trauma to the condyles, particularly as a part of a
immediately
radiograph before treatment with removable appliance. b) Follow-up radiograph of the patient which re‐
catastrophic event (21). Although, because of absence of required growth in later stages of life, this
veals adequate alignment of the fractured bony segment after 1-year.
Figure 8. Same patient shown in Figure 7. a) Note the presence of condy
restricted condylar growth might not result in severe facial deformities, but it may result in limited
of temporary anchorage devices (TAD) can help clinicians manage the other jaw fractures
mandibular function. Recent improvements in treatment techniques including advent of temporary
posteroanterior projection radiograph immediately before treatment with rem
presentingdevices
anchorage with the
(TAD) traumatized condyles.
can help clinicians In contrast
manage tojaw
the other thefractures
traditional techniques
presenting like
with the
intermaxillary
traumatized wire fixations,
condyles. In contrast application of TADs
to the traditional does not
techniques like restrict the range
intermaxillary wire of normal
fixations,
functional movements.
application of TADs does Innot addition,
restrict comparing their
the range of application
normal functional in movements.
growing patients, TADs
In addition,
could be inserted in mature bony structures of the jaws without any additional risk regarding
comparing their application in growing patients, TADs could be inserted in mature bony structures of
6
possible
the damageany
jaws without to un-erupted dental
additional risk crypts.
regarding This approach
possible damage to removes
un‐erupted thedental
necessity of This
crypts. pres‐
ence of enough remaining dentition to be used as guidance of jaw movements (Figure 9 a-c).
approach removes the necessity of presence of enough remaining dentition to be used as guidance
With the help of these TADs and temporary light interarch elastics one can guide directional
of jaw movements (Figure 9 a‐c). With the help of these TADs and temporary light interarch elastics
one can guide
remodeling directional remodeling
of traumatized of traumatized
condylar segments, condylar
in a manner segments,
similar in a manner
to removable similar [21].
appliances to
removable appliances (21).

a b c
Figure 9. a) Settling of the occlusion and guidance of proper healing procedure by means of TADs and light intermax‐
Figure 9. a) Settling of the occlusion and guidance of proper healing procedure by means of TADs
illary elastics in an adult patient, b) orthodontic brackets were bonded on teeth to correct the remaining dental malpo‐
and light intermaxillary elastics in an adult patient, b) orthodontic brackets were bonded on teeth
sition, c) final treatment result (From Tehranchi A: Rapid, conservative, multidisciplinary miniscrew-assisted approach
for correct
to treatmentthe
of mandibular
remaining fractures
dental following plane crash
malposition, Denttreatment
c) final Res J. 2013 Sep-Oct; 10: 678–684).
result (From Tehranchi A: Rapid,
conservative, multidisciplinary miniscrew‐assisted approach for treatment of mandibular fractures
following plane crash Dent Res J. 2013 Sep‐Oct; 10: 678–684).
4. Management of TMJ ankylosis
Treatment of TMJ ankylosis is an excellent example of an important principle in the timing of the
treatment: because of devastating effects on future growth, presence of condylar ankylosis in
growing patients is an indication for early treatment; in contrast, condylar ankylosis in adult patients
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4. Management of TMJ ankylosis
Treatment of TMJ ankylosis is an excellent example of an important principle in the timing

of the treatment: because of devastating effects on future growth, presence of condylar
ankylosis in growing patients is an indication for early treatment; in contrast, condylar
ankylosis in adult patients must be treated considering the extent of functional limitation
of mandibular movement. In many clinical situations pain is uncommon and limited range
of opening is the first sign of condylar ankylosis, usually noticed by dental practitioners [22].
4.1. Management of TMJ ankylosis without severe dentofacial deformity
To date, various treatment approaches have been described to achieve successful manage‐
ment of ankylosis [23-24]; however no single treatment with uniformly successful results
has been assigned for all cases [4, 25-26]. The optimum selection of an adequate techni‐
que depends directly on the details of clinical situation of the patients and is highlighted
particularly in patients’ growing phase, since their consequent facial deformity could be
significantly worsened during growth [27]. In the aforementioned patients, orthopedic
treatment with functional appliances following surgical release of ankylosis is highly
recommended.
Possible treatment modalities for cases without severe facial deformities include surgical
excision of an ankylotic mass, gap arthroplasty and interpositional arthroplasty [16, 24].
These techniques may be supplemented by application of different autogenous or alloplas‐
tic materials to reconstruct the ramus and affected condylar segments [28-29].
The first treatment option is gap arthroplasty, which increases the gap between the articular
cavity and ramus by means of a simple bone division (Figure 10). The modifications of this
technique including increasing the gap alone to reduce the re-ankylosis may not be clinically
effective [30].
The second category, interpositional arthroplasty addresses the main drawbacks of the first
method, which is high recurrence rate [31]. In this technique, surgeons try to fill the gap with
autogenous graft materials including skin, dermis, flap of temporal muscle, cartilage or even
alloplastic materials like silastic (Figure 11 a-c). The placement of these materials prevents the
recurrence possibility. TMJ reconstruction is the third treatment option commonly done by
means of a costochondral graft. However, other autogenous graft sources like clavicular
osteochondral graft, coronoid process graft or alloplastic condylar implants can be used to
reconstruct the lost segments. Autogenous sources present donor site morbidity; however
alloplastic grafts are procedures with significant disadvantages of implant fracture of foreign
body reaction. Between autogenous sources, costochondral grafts represent the most variable
growth behavior, particularly in growing children, as compared to coronoid process graft,
which demonstrate more predictable growth behavior.
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Figure 10. Intra-operative view demonstrating gap arthroplasty technique.

a b c
Figure 11. Interpositional arthroplasty of an ankylotic condyle by means of square‐shaped silastic
Figure 11. Interpositional arthroplasty of an ankylotic condyle by means of square-shaped silastic graft material, a) Se‐
lected material,
graft alloplastic silastic-based graft
a) Selected material, b) Insertion
alloplastic of the alloplastic
silastic‐based silastic material,
graft material, c) final position
b) Insertion of the
of the allo‐
alloplastic
plastic material filling up the entire space created by the gap arthroplasty.
silastic material, c) final position of the alloplastic material filling up the entire space created by
the gap arthroplasty.
An approved international surgical protocol consists of 9‐steps to take before and after surgery.
1) Aggressive total resection of the ankylotic segment in the condylar TMJ region. Recently,
complete excision of the bony mass has been questioned regarding the increasing probability of
the recurrence rate (10). The underlying postulation was that leaving the opposing bony cut
surface of the condyles after complete excision increase the amount of clot formation on dead
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An approved international surgical protocol consists of 9-steps to take before and after
surgery.
1. Aggressive total resection of the ankylotic segment in the condylar TMJ region. Recently,
complete excision of the bony mass has been questioned regarding the increasing
probability of the recurrence rate [10]. The underlying postulation was that leaving the
opposing bony cut surface of the condyles after complete excision increase the amount of
clot formation on dead space, which ultimately results in the formation of dense fibrous
bridges that impede future mandibular movement [32]. Partial osteotomy of the region
with minimal clot formation has been cited as a more potent surgical approach [32].
2. Coronoidectomy on the affected side (ipsilateral) which usually elongates in long-

standing ankylosis and prevents intra-operative maximal opening because of the restric‐
tion. The autogenous bone achieved by this step can be used as a source of graft material
to re-establish the ramus height of the affected side.
3. If the above-mentioned procedures do not result in normal maximum opening (more than
35 mm) without excessive force, the opposite coronoid (contralateral) must also be
removed.
4. Lining of the joint with temporalis fascia or the remaining disk [16]
Remnants of the meniscus can serve as a barrier to prevent direct bony contacts and further
fusion between condylar heads and glenoid fossa. However, there is controversy in the
literature regarding the main role of the disc on the development of ankylosis [7]. In many
traumatized cases, it has been shown that the ankylosis can occur even in the presence of an
intact meniscus in the joint space [33-34].
5. Reconstruction of the ramus segment with costochondral grafts in growing patients if

possible using rigid fixation (Figure 12 a-c),

a b c

Figure 12. Intraoperative photographs of a patient with TMJ reconstruction treatment plan, a) extraoral access to the
Figure 12. Intraoperative
TMJ ankylotic mass through aphotographs of a patient
preauricular excision, with TMJ
b) submandibular reconstruction
incision for placementtreatment
of fixationplan,
plates a)
over
the costochondral
extraoral access graft, c) after
to the TMJ aggressive excision
ankylotic mass ofthrough
the ankylotic mass and fixation
a preauricular of theb)
excision, costochondral graft by
submandibular
means of fixation screws.
incision for placement of fixation plates over the costochondral graft, c) after aggressive excision of
the ankylotic mass and fixation of the costochondral graft by means of fixation screws.

6) Intra‐operative open bite creation on the affected side to permit settling of the bone graft, which
should be maintained by a hybrid orthodontic appliance for 3‐6 months (Figure 13 a) (35). Simple
removable functional appliance (Hybrid) with lingual and buccal shields on the affected side to
encourage dental eruption and a bite block on the contralateral side to impede the eruption (Figure
the ankylotic mass and fixation of the costochondral graft by means of fixation screw
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6) Intra‐operative open bite creation on the affected side to permit settling of the bo
http://dx.doi.org/10.5772/59165
should be maintained by a hybrid orthodontic appliance for 3‐6 months (Figure 13
removable functional
6. Intra-operative open biteappliance (Hybrid)
creation on the with
affected side to lingual and ofbuccal
permit settling the boneshields
graft, on the a
which should be maintained by a hybrid orthodontic appliance for 3-6 months
encourage dental eruption and a bite block on the contralateral side to impede the e (Figure 13
a) [35]. Simple removable functional appliance (Hybrid) with lingual and buccal shields
13 b). In adult cases, however, considering the absence of passive dental eruption
on the affected side to encourage dental eruption and a bite block on the contralateral side
should be managed by means of orthodontic brackets and light intermaxillary elastic
to impede the eruption (Figure 13 b). In adult cases, however, considering the absence of
b). passive dental eruption, the open bite should be managed by means of orthodontic
brackets and light intermaxillary elastics (Figure 14 a, b).

a b
Figure 13. a) A hybrid functional appliance consist of two set of shields (lingual
Figure 13. a) A hybrid functional appliance consist of two set of shields (lingual and buccal) to facilitate dental erup‐

tion on the affected side and acrylic bite block to impede dental eruption on the opposite site, b) A hybrid functional
facilitate dental eruption on the affected side and acrylic bite block to impede den
appliance in place
the opposite site, b) A hybrid functional appliance in place

a b
10
Figure 14. a) Bonding of orthodontic brackets on the upper and lower arch to correct the openbite on the affected side;
Figure 14. a) Bonding of orthodontic brackets on the upper and lower arch
note the degree of anterior open bite, b) Intraoral photograph of the final occlusion (From Behnia H: A Textbook of
Advanced Oral and Maxillofacial Surgery ISBN 978-953-51-1146-7. chapter 16, Distraction Osteogenesis; 2013).
on the affected side; note the degree of anterior open bite, b) Intraoral
occlusion (From Behnia H: A Textbook of Advanced Oral and Maxillofacia
51‐1146‐7. chapter 16, Distraction Osteogenesis; 2013).
7) Early mobilization with a short period of intermaxillary fixation (not more
Figure 14. a) Bonding of orthodontic brackets on the upper and lower arch to correct the openbite
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on the affected side; note the degree of anterior open bite, b) Intraoral photograph of the final
occlusion (From Behnia H: A Textbook of Advanced Oral and Maxillofacial Surgery ISBN 978‐953‐
51‐1146‐7. chapter 16, Distraction Osteogenesis; 2013).
7) Early mobilization with a short period of intermaxillary fixation (not more than 3 weeks),
7. Early mobilization with a short period of intermaxillary fixation (not more than 3 weeks),
8) Supportive adjunctive therapy including physiotherapy with strict follow up to prevent the re‐
8. Supportive
ankylosis adjunctive
phenomena. therapy
This therapy including
disrupts physiotherapy
and prevents withand
adhesions strict
soft follow
tissue up to prevent
contraction in
the re-ankylosis phenomena. This therapy disrupts and prevents adhesions and soft tissue
the healing stage (Figure 15 a‐c).
contraction in the healing stage (Figure 15 a-c).

a b c
Figure 15. a‐c) Adjunctive physiotherapy appliances that are used as aiding appliances during the
Figure 15. a-c) Adjunctive physiotherapy appliances that are used as aiding appliances during the physiotherapy
physiotherapy phase.
phase.
9. Additional corrective surgery at the later stages when growth is completed

9) Additional corrective surgery at the later stages when growth is completed
Recurrence of ankylosis and restricted mandibular movement are the most common complications
Recurrence of ankylosis and restricted mandibular movement are the most common compli‐
after
cationssurgical management
after surgical of the ankylotic
management mass. Following
of the ankylotic surgical protocol
mass. Following surgicaland also adequate
protocol and also
adequate compliance with postoperative adjunctive therapy might prevent these complica‐
compliance with postoperative adjunctive therapy might prevent these complications (31). The final
tions [31]. The final postoperative result is dependent directly on the selected surgical proce‐
postoperative result is dependent directly on the selected surgical procedure, surgical technique, and
dure, surgical technique, and attention to postsurgical physiotherapy.
attention to postsurgical physiotherapy.
Treatment
4.1.1. Treatment
Unilateral condylar ankylosis
4.1.1.1. Unilateral
A 5‐year‐old condylar ankylosis
girl with a history of left condylar trauma at age 2, with progressive facial asymmetry
and deviation of the dental midlines due to left condylar ankylosis (Figure 16 a). There was no
A 5-year-old girl with a history of left condylar trauma at age 2, with progressive facial
asymmetry and deviation of the dental midlines due to left condylar ankylosis (Figure 16 a).
There was no history of any other congenital malformation or childhood illness. On clinical
11
examination her jaw deviated slightly to the left on closure and showed limited right lateral
excursion. The ankylotic mass of the left condyle was demonstrated clearly on the MRI (Figure
16 b). An autogenous costochondral graft to reconstruct the left condyle had been done at age
5, which left an intraoperative open bite on the left side (Figure 16 c, d). A removable functional
hybrid appliance was provided for the patient immediately after surgery to maintain the graft
in a suitable position and let the posterior teeth on contralateral side erupt. This appliance
opened the bite on the left side and brought the chin to the midline (Figure 16 e). The patient
cooperated very well in the postsurgical phase with removable appliance and functional
exercises of the jaws. One year after the orthodontic phase, the patient demonstrated an
acceptable occlusion and facial symmetry (Figure 16 f).
teeth on contralateral side erupt. This appliance opened the bite on the left side and brought the
chin to the midline (Figure 16 e). www.dentalbooks.co
The patient cooperated very well in the postsurgical phase with
removable appliance and functional exercises of the jaws. One year after the orthodontic phase, the
patient demonstrated an acceptable occlusion and facial symmetry (Figure 16 f).
http://dx.doi.org/10.5772/59165

a b c

d e f
Figure 16.
Figure a) Facial
16. view ofview
a) Facial a 5 year-old
of a boy, b) MRI before
5 year‐old anyb)
boy, orthodontic intervention,
MRI before c) postoperative openbite
any orthodontic intervention, c)
immediately after surgery to free the ankylotic condyle, d) Insertion of a hybrid functional appliance for differential
postoperative openbite immediately after surgery to free the ankylotic condyle, d) Insertion of a
dental eruption, e) occlusion of the patient. The remarkable improvement from unilateral condylar ankylosis and sub‐
sequent normal
hybrid symmetric
functional growth of facial
appliance structure was achieved.
for differential dental The functional appliance
eruption, was alsoof
e) occlusion worn at night
the patient. The
during the growth period. f) Final facial view
remarkable improvement from unilateral condylar ankylosis and subsequent normal symmetric
growth of facial structure was achieved. The functional appliance was also worn at night during
4.2. Management of temporomandibular joint ankylosis combined with severe dentofacial
the growth period. f) Final facial view
deformity
b) Management of temporomandibular joint ankylosis combined with severe dentofacial
Patients with a history of persistent ankylosis usually demonstrate significant facial asymme‐
deformity.
try. In addition to previously described surgery to release the ankylotic mass, these patients
usually should
Patients with a undergo a second
history of procedure
persistent to compensate
ankylosis developed facial
usually demonstrate asymmetries.
significant This
facial asymmetry. In
second procedure can range from a conservative genioplasty to orthognathic surgery of both
addition to previously described surgery to release the ankylotic mass, these patients usually should
jaws. Recently,
undergo distraction
a second procedure osteogenesis has become
to compensate popular
developed facial asasymmetries.
another possible
This treatment
second procedure
option for the second phase [36]. However, precise monitoring of the distraction direction is
can range from a conservative genioplasty to orthognathic surgery of both jaws. Recently, distraction
an important consideration during this procedure. The final result of the distraction osteo‐
osteogenesis has become popular as another possible treatment option for the second phase (36).
genesis must
However, be maintained
precise monitoring via of help of other functional
the distraction appliances
direction in growing
is an important patients [37].
consideration during this
Other adjunctive cosmetic surgical techniques like fat injection also can be applied to com‐
pensate the remaining asymmetry of the face [30].
12
Surgical treatment with costochondral graft (CCG) and distraction osteogenesis (DO) in cases
with temporomandibular joint ankylosis associated with severe dentofacial deformities is
procedure. The final result of the distraction osteogenesis must be maintained via help of other
www.dentalbooks.co
functional appliances in growing patients (37). Other adjunctive cosmetic surgical techniques like fat
injection also can be applied to compensate the remaining asymmetry of the face (30).
Surgical treatment with costochondral graft (CCG) and distraction osteogenesis (DO) in cases with
temporomandibular joint ankylosis associated with severe dentofacial deformities is usually effective
usually effective and quite reliable (Figure 17 a,b). Most of the assigned patients had significant
mandibular
and quite reliable retrognathia
(Figure 17 and asymmetry.
a,b). Most of Distraction usuallypatients
the assigned started onhad
day 7significant
after surgery.
mandibular
retrognathia and asymmetry. Distraction usually started on day 7 after surgery.

Figure 17. A case with unilateral distraction osteogenesis after receiving costochondral graft.
Figure 17. A case with unilateral distraction osteogenesis after receiving costochondral graft. Lateral cephalometry of
the patient before (left) and after (right) distractor insertion.
Lateral cephalometry of the patient before (left) and after (right) distractor insertion.
Treatment
4.2.1. Treatment
Bilateral condylar ankylosis
4.2.1.1. Bilateral condylar ankylosis
A 21‐year‐old male with a history of trauma at age 9, presented severe mandibular deficiency,
A 21-year-old male with a history of trauma at age 9, presented severe mandibular deficiency,
micrognathia with restricted excursive and protrusive mandibular movement secondary to bilateral
micrognathia with restricted excursive and protrusive mandibular movement secondary to
condylar ankylosis (Figure 18 a). The dental history of the patient revealed that, he had previously
bilateral condylar ankylosis (Figure 18 a). The dental history of the patient revealed that, he
undergone had previously
an undergone
autogenous an autogenous
costochondral graft costochondral graft
after bilateral after bilateralone
condylectomy condylectomy
year later, but re‐
one year later, but re-ankylosis occurred. This whole procedure was repeated again one year
ankylosis occurred. This whole procedure was repeated again one year after failure; however it did
after failure; however it did not fully address the patient’s problem.
not fully address the patient’s problem.
The treatment plan was to lengthen the mandible with bilateral distraction osteogenesis,
which could
The treatment plan advance
was to the soft tissue
lengthen volume
the simultaneously.
mandible Orthodontic
with bilateral treatment
distraction including
osteogenesis, which
extraction of first premolars on both sides due to preparation of adequate overjet
could advance the soft tissue volume simultaneously. Orthodontic treatment including extraction of was con‐
ducted on both sides. The extraction space was subsequently closed with moderate anchorage
first premolars on both sides due to preparation of adequate overjet was conducted on both sides.
on both sides. Circumferential osteotomies were done on both side of the ramus and unilateral
extraoral space
The extraction distractors (multiguided
was Leibinger)
subsequently and were
closed with fixed in place (Figure
moderate 18 b). Consider‐
anchorage on both sides.
ing the asymmetric representation of mandibular retrusion, the amount of mandibular
Circumferential osteotomies were done on both side of the ramus and unilateral extraoral distractors
advancement in the distraction phase was not equal on the right and left sides. During
(multiguided Leibinger) and were fixed in place (Figure 18 b). Considering the asymmetric
distraction phase, posterior open bite developed on the right side which was corrected by
representation of mandibular retrusion, the amount of mandibular advancement in the distraction
continuous application of cross elastic traction via fixed orthodontics (Figure 18 c). Upper and
phase was not Hawley
lower equal retainers
on the with
right embedded
and left wire on During
sides. the occlusal surface ofphase,
distraction the upper posterioropen bite
posterior
teeth were provided for the patient after finishing orthodontic treatment.
developed on the right side which was corrected by continuous application of cross elastic traction
via fixed orthodontics (Figure 18 c). Upper and lower Hawley retainers with embedded wire on the
occlusal surface of the upper posterior teeth were provided for the patient after finishing
orthodontic treatment.
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Figure 18. a) Pre-distraction facial and intraoral appearance. Significant mandibular deficiency is apparent. b) Circum‐
ferential osteotomies were made at the body of the right and left ramus and then custom-made unidirectional extraoral
distractors were fixed in place. The mandible was advanced by 7 mm. The posterior open bite was created at the right
side as a result of mandibular lengthening. Orthodontic triangle elastics were used concomitant with fixed orthodontic
appliance to manage the posterior right open bite. c) Frontal facial view after debonding.
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5. Complications after surgery
Although significant complications in the postoperative phase subsequent to surgery are not
dramatic, it varies from mild pain to more serious persisting pain with restricted jaw move‐
ment and re-ankylosis. These unexpected adverse events and complications after surgery are

mostly divided into two broad categories; those related to re-ankylosis and those related to

the overgrowth of the cartilaginous
Although significant autograft
complications in [38]. phase subsequent to surgery are not
the postoperative
dramatic, it varies from mild pain to more serious persisting pain with restricted jaw movement and
In the literature,
re‐ankylosis. there
These are two main
unexpected adverse reasons forcomplications
events and re-ankylosis after
after surgical
surgery release
are mostly divided including
inadequate resection of the ankylotic mass intraoperatively and also,
into two broad categories; those related to re‐ankylosis and those related to the overgrowth of the absence of patient
compliance regarding post-operative jaw exercises [39-40]. The higher rate of reported re-
cartilaginous autograft (38).
ankylosisIn in children
the literature, comparing
there are two tomain
adults mayfor
reasons bere‐ankylosis
due to poor after compliance to including
surgical release aggressive post-
operative physiotherapy [4]. Complete diagnostic assessment of the ankylotic area, based on
inadequate resection of the ankylotic mass intraoperatively and also, absence of patient compliance
preoperative imaging examinations,
regarding post‐operative jaw exercises is(39‐40).
necessary to determine
The higher the extent ofin bony
rate of reported re‐ankylosis fusion and
children
the length of the coronoid process on both sides [38]. The extent of bony fusion in both sagittal
comparing to adults may be due to poor compliance to aggressive post‐operative physiotherapy (4).
Complete diagnostic assessment of the ankylotic area, based on preoperative imaging examinations,
and coronal planes should be studied carefully to prevent any serious complication of facial
is necessary to determine the extent of bony fusion and the length of the coronoid process on both
nerve and maxillary artery injuries. Adequate mouth opening must be checked intraopera‐
sides (38). The extent of bony fusion in both sagittal and coronal planes should be studied carefully
tively asto
a prevent
clinicalany indicator of successful
serious complication surgery.
of facial nerve and Further
maxillary ipsilateral orAdequate
artery injuries. contralateral
mouth coronoi‐
dectomyopening
with or without
must softintraoperatively
be checked tissue release may
as a need
clinical to beof performed
indicator to achieve
successful surgery. Further required
mouth opening
ipsilateral [38]. Growth behavior
or contralateral coronoidectomy of inserted grafts including
with or without undermay
soft tissue release and overgrowth
need to be may
also present someto complications
performed in later
achieve required mouth stages
opening of Growth
(38). treatment. Theof role
behavior of jaw
inserted mobility
grafts including exercises
under and overgrowth may also present some complications in later stages of treatment. The role of
at home and at physiotherapy in prevention of re-ankylosis cannot be over-emphasized in
jaw mobility exercises at home and at physiotherapy in prevention of re‐ankylosis cannot be over‐
childrenemphasized
or adults.in The preventive
children or adults. approach should
The preventive be strict
approach should adhesion to surgical
be strict adhesion protocol and
to surgical
post-operative
protocol and post‐operative physiotherapy requirements, monitored by both the orthodontist and
physiotherapy requirements, monitored by both the orthodontist and surgeon
(Figure 19).
surgeon (Figure 19).

a b
Figure 19. a) Panoramic radiograph of re‐ankylosis after previous costochondral grafting b) 3D CT
Figure 19. a) Panoramic radiograph of re-ankylosis after previous costochondral grafting b) 3D CT showing complete
showing complete bony ankylosis of the right condyle.
bony ankylosis of the right condyle.
However, if the re‐ankylosis occurs, the best option for its management depends directly on the type
However, if the re-ankylosis
of ankylosis. occurs,
Bony re‐ankylosis needs the best option
additional for its management
surgical procedures. depends
Fibrosis re‐ankylosis directly on
may be
the typemanaged
of ankylosis.
by means Bony re-ankylosis
of progressive needs
jaw mobility additional
exercises that can surgical procedures.
be delivered Fibrosis re-
through different
approaches. Some removable appliances may help clinicians overcome this problem (Figure 20 a‐d).
ankylosis may be managed by means of progressive jaw mobility exercises that can be
If the patient cannot comply with these techniques, the surgeon should help them by initiating
delivered through different approaches. Some removable appliances may help clinicians
physiotherapy under local anesthesia.
15
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overcome this problem (Figure 20 a-d). If the patient cannot comply with these techniques, the
surgeon should help them by initiating physiotherapy under local anesthesia.

a b
c d
Figure 20. A 5-year-old with bilateral condylar ankylosis following

a traumatic event. He underwent a surgical proce‐
dure to release the ankylotic condyles, which involved bilateral coronoidectomy also, a) Restricted opening secondary
to re-ankylosis,
Figure 20. b) Intraoral
A 5‐year‐old appliance
with consistingcondylar
bilateral of labial pads, and acrylic posterior
ankylosis bite plates
following that incorporate
a traumatic two
event. He
vertical-direction screws, c) The patient was asked to open the screw once a day, d) Because of the fibrosis type of an‐
underwent a the
kylosis, surgical
patient wasprocedure to
able to open his release
mouth the more
significantly ankylotic condyles, which involved bilateral
after treatment.
coronoidectomy also, a) Restricted opening secondary to re‐ankylosis, b) Intraoral appliance
5.1.of
consisting Treatment
labial pads, and acrylic posterior bite plates that incorporate two vertical‐direction
screws, c) The patient was asked to open the screw once a day, d) Because of the fibrosis type of
5.1.1. Unilateral condylar overgrowth
ankylosis, the patient was able to open his mouth significantly more after treatment.
A 29-year-old man was seen for treatment of severe facial asymmetry secondary to right
Treatment
condylar overgrowth (Figure 21 a-e). There was a history of TMJ ankylosis of the right condyle
at age 3. Three years later, the patient underwent an autogenous costochondral graft to
Unilateral condylar overgrowth
reconstruct the right mandibular condyle. The condylar structure was composed of the
cartilage part
A 29‐year‐old man of seen
was rib graft. As reported
for treatment of by the patient,
severe the condylar
facial asymmetry overgrowth
secondary initiated
to right condylar
approximately four years after graft surgery, when he was 10 years old, which lead to a
overgrowth (Figure 21 a‐e). There was a history of TMJ ankylosis of the right condyle at age 3. Three marked
facial asymmetry. On clinical examination there was chin deviation and midline divergence
years later, the patient underwent an autogenous costochondral graft to reconstruct the right
(mandibular dental midline shift). On functional evaluation of the patient, there was a
mandibular condyle. The condylar structure was composed of the cartilage part of rib graft. As
reported by the patient, the condylar overgrowth initiated approximately four years after graft
surgery, when he was 10 years old, which lead to a marked facial asymmetry. On clinical examination
there was chin deviation and midline divergence (mandibular dental midline shift). On functional
evaluation of the patient, there was a significant restriction on full range of anterior and transverse
jaw motion, with deviation upon opening. The treatment plan was to remove the condylar
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significant restriction on full range of anterior and transverse jaw motion, with deviation upon
opening. The treatment plan was to remove the condylar overgrowth through a preauricular
incision (Figure 21 f, g). Postoperative facial photography and panoramic view showed
significant improvement in facial symmetry at 18 month follow up (Figure 21 h-k).

a b

c d e

f g h i
j k

Figure 21. Male aged 29 years, a,b) severe facial asymmetry secondary to right condylar overgrowth is apparent, c-e)
Figure 21. Male aged 29 years, a,b) severe facial asymmetry secondary to right condylar overgrowth
3D computed tomography,
is apparent, posteroanterior
c‐e) 3D and panoramic
computed tomography, radiographs ofand
posteroanterior the patient before
panoramic surgical procedure,
radiographs of the f) in‐
tra-operative view of the right condylar overgrowth mass, g) excess part of overgrowth of the condyle. h,i) postopera‐
patient before surgical procedure, f) intra‐operative view of the right condylar overgrowth mass, g)
tive clinical appearance of the patient after surgical removal of condylar overgrowth mass, j,k) Final posteroanterior
excess part of overgrowth of the condyle. h,i) postoperative clinical appearance of the patient after
and panoramic radiographs of the patient following 18 months follow up.
surgical removal of condylar overgrowth mass, j,k) Final posteroanterior and panoramic radiographs
of the patient following 18 months follow up.
Acknowledgment:
17
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http://dx.doi.org/10.5772/59165
Acknowledgements
The authors thank staff of Orthodontic, Pediatric and Oral and Maxillofacial Surgery depart‐
ments for general support and treatment procedures of the presented cases.
Author details
Hossein Behnia1*, Azita Tehranchi2 and Farnaz Younessian3
*Address all correspondence to: behnia_h@hotmail.com
1 Dentofacial Deformity Research Center, Research Institute of Dental Sciences, Department

of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Beheshti University of Medi‐
cal Sciences, Tehran, Iran
2 Dental Research Center, Research Institute of Dental Sciences, Department of Orthodon‐

tics, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Dentofacial Deformity Research Center, Research Institute of Dental Sciences, School of

Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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www.dentalbooks.co
Chapter 20
Contemporary Management of Frontal Sinus Injuries

and Frontal Bone Fractures
Petr Schütz, Hussein Hassan Hamed Ibrahim and

Bashar Rajab
http://dx.doi.org/10.5772/59096
1. Introduction
Frontal bone (FB) fractures are found in about 12% of craniomaxillofacial trauma patients. [1,
2] They are more strongly associated with concomitant brain injuries than other facial fractures,
which is the reflection of the amount of energy required to produce a fracture in this region.
Recently, increase in the incidence of FB fractures was reported, while the incidence of fractures
of other facial sites decreased. [3] This increase in frontal bone fractures (FBFs) incidence may
be related to the emergence of causes other than road traffic accidents (RTAs), especially all
terrain vehicle (ATV) accidents. The aims of FBF treatment are restoration of facial appearance,
restoration of skull integrity and protection of brain, and prevention of late complications. The
most important factor in management of FBF is involvement of frontal sinus (FS). Despite the
relative frequency of FS injuries, there is no general consensus about their optimal management
and numerous treatment algorithms were published during the recent years. The purpose of
this chapter is to provide an overview of advances in surgical management of traumatized FS
and to share our experience with this type of injury.
2. Development and growth of the frontal bone
Ossification of the intra-membranous calvarial bones depends on the presence of the brain; in
its absence (anencephaly), no bony calvarium forms. A pair of FBs appears from single primary
ossification centers, forming in the region of each superciliary arch at the 8th week post-
conception. Three pairs of secondary centers appear later in the zygomatic processes, nasal
spine and trochlear fossae. Fusion between these centers is complete at 6 to 7 months post-
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conception. At birth, the frontal bones are separated by the metopic suture. Synostotic fusion
of this suture usually starts about the 2nd year and unites the frontal bones into a single bone
by 7 years of age. The metopic suture persists into adulthood in 10 to 15% of skulls. In such
cases, the frontal sinuses are absent or hypoplastic. [4]
The cranial and facial bones are first made of fibrous connective tissue. In the third month of
fetal development, fibroblasts become more specialized and differentiate into osteoblasts,
which produce bone matrix. From each center of ossification, bone growth radiates outward
as calcium salts are deposited in the collagen model of the bone. This process is not complete
at birth; a baby has areas of fibrous connective tissue remaining between the bones of the skull.
These are called fontanels, which permit compression of the baby’s head during birth without
breaking the still thin cranial bones. The fontanels also permit the growth of the brain after
birth. By the age of 2 years, all the fontanels have become ossified. [5]
Growth of the calvarial bones is a combination of suture growth, surface apposition and
resorption (remodeling), and centrifugal displacement by the expanding brain. The propor‐
tions attributable to the various growth mechanisms vary by age. Accretion to the calvarial
bones is predominantly sutural until about the 4th year of life, after which surface apposition
and remodeling become increasingly important.
The bones of the newborn calvarium are unilaminar and lack diploë. From about 4 years
of age, lamellar compaction of cancellous trabeculae forms the inner and outer tables of the
cranial bones. The tables become continuously more distinct into adulthood. This differen‐
tial bone structure creates a high stiffness - to - weight ratio, with no relative increase in
the mineral content of cranial bone from birth to adulthood. Whereas the behavior of the
inner table is related primarily to the brain and intracranial pressures, the outer table is
more responsive to extracranial muscular and buttressing forces. The internal plate becomes
stable at 6 to 7 years of age, reflecting the near cessation of cerebral growth. The thicken‐
ing of the frontal bone in the midline at the glabella results from separation of the inner
and outer tables with invasion of the FS between the cortical plates. Growth of the external
plate during childhood produces the superciliary arches and other bony landmarks that are
all absent in the neonatal skull. [4]
FS is a small out-pouching at birth and undergoes almost all of its development thereafter. The
FS may develop from one or several different sites (primary pneumatization): as a rudiment
of the ethmoid air cells, as a mucosal pocket in or near the frontal recess, as an invagination of
the frontal recess, or from the superior middle meatus. The process starts 3 to 4 months post
conception, but they do not yet invade the frontal bone. Secondary pneumatization takes place
between the ages of 6 months to 2 years postnatally and it develops laterally and vertically. FS
itself cannot be identified radiographically until approximately the age of 6 to 8 years, and
most pneumatization is completed by the time the child is 12 to 16 years- old, but it continues
until the age of 40. [4,6] In 10% of persons, FS develops unilaterally, in 5% it is a rudimentary
structure, and in 4% it is absent altogether, so that almost one-fifth of individuals have aberrant
sinus development (Figure 1).[7]
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Figure 1. Postnatal development of the frontal sinus.
3. Frontal bone anatomy
The frontal bone forms the forehead and the anterior part of the top of the skull, the anterior
cranial fossa and the roofs of the orbits. It consists of two parts, vertical called the squamous
part and horizontal called the orbital part. From the nasion FB extends approximately 12.5 cm
superiorly, 8.0 cm laterally, and 5.5 cm posteriorly. [8]
The squamous part has a convex outer surface which forms the main substance of the forehead
and the anterior part of the vault of the skull. The squamous part of FB has the nasal notch
which articulates with the nasal bone on either side of the middle line and more laterally with
the frontal process of maxilla and with the lacrimal bone. The squamous part of the frontal
bone consists of two layers of compact bone separated by a layer of cancellous bone (the diploë)
which contains red bone marrow and a number of diploic veins.
Its outer surface shows the following features:
Frontal eminences are the most prominent parts of FB.
Superciliary arches, thick curved ridges lie little above the medial portions of the supraorbital
margins. They are well developed in males and less marked or even totally absent in females.
Supraorbital margins, which form the upper boundaries of the orbits, end laterally at each
side in the zygomatic processes of the FB. They have the supraorbital notches at the junctions
of the middle and intermediate thirds. In some cases there may be foramina instead of notches.
Supratrochlear foramina are located medially to the supraorbital foramina or notches and
laterally to the nasal bones. The smooth area of the frontal bone just above the root of the nose
is called the glabella. Temporal line, a well-marked ridge, runs from the zygomatic process of
FB upward and backward (Figure 2).
The inner surface of the squamous part is concave and forms the anterior cranial fossa.
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The sagittal groove lies in the upper part of the middle line. The two edges of this groove unite
below to form a ridge - the frontal crest. The sagittal groove accommodates the anterior part
of the venous superior sagittal sinus.
The frontal crest gives attachment to the falx cerebri, a fold of dura matter. The frontal crest
ends below in a small hole called the foramen caecum between the frontal and the ethmoid
bone. The foramen caecum does not usually transmit any structure but may transmit a vein
from the nose to the superior sagittal sinus. [5, 8, 9]
The orbital parts of the FB extend laterally from the nasal notch, become concave and form
the orbital roofs. A spine or concavity exists along the medial anterior orbital roof, where the
trochlea of the superior oblique muscle is attached. The arched roofs of the orbits are separated
from one another by a median gap called the ethmoid notch. In the intact skull the ethmoid
notch is filled by the cribriform plate of ethmoid bone. The margins of the ethmoid notch of
the frontal bone contain many half cells which unite with corresponding half cells on the upper
surface of the ethmoid bone to form together the ethmoid air cells (Figure 2).
The frontal bone articulates with 12 other cranial bones: two parietals, two nasals, two maxillae,
two lacrimal, two zygomatic, the sphenoid and the ethmoid. The bones are separated by
sutures which hold the bones firmly together in the mature skull. Occasionally the squamous
part of FB may be separated into two halves by a midline metopic suture persistent from early
childhood. Normally, two halves of the frontal bone unite completely by the 8th year.
The arterial blood supply to the frontal bone is by the supraorbital, anterior superficial
temporal, anterior cerebral and middle meningeal arteries. The venous drainage is transoss‐
eous through the anastomosis of vessels of the subcutaneous, orbital, and intracranial struc‐
tures. The primary venous drainage is through the supratrochlear, supraorbital, superficial
temporal, frontal diploic (veins of Breschet), superior ophthalmic, and superior sagittal
sinuses. [4, 10, 11]
The frontal sinus may consist of one or more compartments, depending on the source of
pneumatization. The inter-sinus septum, which separates the left and right cavities of the sinus,
is continuous with the crista galli and cribriform plate inferiorly. The septum is usually
deviating from the midline sagittal plane. FSs vary in size in different people. The average
height of the sinuses is 32 mm, and their average width is 26 mm. The surface area is approx‐
imately 720 mm . [6-8, 12] The FS is in critical approximation to anatomical structures, which
2
underscores the importance of its management in injury. Posteriorly, the cribriform plate, dura
mater, and frontal lobes of brain are in close apposition to one another and to the posterior
wall of the sinus. The dura is densely adherent to the deep surface of the posterior table and
becomes more adherent and thinner along the caudal edge, where it turns to cover the fovea
ethmoidalis. [13] The lateral floor of the FS is the roof of the orbit, whereas the medial floor of
the frontal sinus contains the opening of the nasofrontal duct. Each sinus opens into the anterior
part of the corresponding nasal middle meatus by the ethmoidal infundibulum or nasofrontal
duct (NFD), traversing the anterior part of the ethmoid labyrinth. Anatomically significant
variations exist in the width, length, and shape of the NFD. The duct opening usually lies in
the posteromedial floor of the sinus. It is a funnel shaped constriction that passes between the
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Figure 2. Frontal bone (Gray’s Anatomy)
cancellous part of the anterior wall underlying the glabella and the anterior ethmoidal cells.
Its course is highly variable, running caudally from a few millimeters to up to 2 cm. The NFD
terminates at the uncinate process in the nasal cavity, which is a thin bone plate that is covered
on either side by mucosa. When the uncinate process is attached to the lamina papyracea, the
drainage is medial to the uncinate process through the middle meatus. This type of drainage
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pattern is seen in 66-88 % of cases. When the uncinate process attaches superiorly to more
medial structures (middle turbinate, cribriform, or skull base), the drainage of the sinus is
lateral to the uncinate process. This type of drainage pattern is seen in 12-34% of cases. A true
identifiable duct may be absent in up to 85% of FSs. In this situation, the FS drains indirectly
through ethmoid air cells to the middle meatus. Therefore, some investigators chose the term
nasofrontal outflow tract (NFOT) or frontal sinus outflow tract (FSOT) for the drainage path of the
FS (Figure 3). [7, 12-18]
Figure 3. Opposite extremes of frontal sinus development; aplasia (left) versus hypertrophy (right).
4. Frontal sinus physiology
The mucosa of the frontal sinus consists of pseudostratified ciliated epithelium, mucus
producing goblet cells, a thin basement membrane, and a thin lamina propria that contains
seromucous glands. It covers the entire surface of the sinus and ranges in thickness from 0.07
to 2.0 mm. When the mucosa is healthy, a blanket of mucin overlies the epithelium. The cilia
beat at 250 cycles/min. The mucin blanket flows in a spiral fashion in a medial-to-lateral
direction; the flow is slowest at the roof and fastest at the NFD. The mucin empties at the NFD
at a daily rate of 5.0 g/cm2. [14, 19, 20,]
The frontal sinus is unique in that it is the only sinus that has a recirculation phenomenon. The
mucus travels along the lateral side of the sinus and turns medially over the sinus floor and
down the lateral frontal recess wall. Of the secretion, 60% is directed back into the sinus cavity
as it reaches the frontal recess. [13] Clinically significant anatomical structures of the mucosa
of the frontal sinus are the foramina of Breschet, first described over 60 years ago. These
foramina are sites of venous drainage of the mucosa and can serve as the route of intracranial
spread of infection. The mucosa is found deeply penetrating these foramina. If mucosa is not
completely removed microscopically from these foramina in obliteration or cranialization
procedures, there is a high risk of mucocele formation. [13]
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5. Frontal sinus pathology and concept of “safe sinus”
Pathology of FS is rare but most commonly is associated with trauma, which causes fracture
of the frontal sinus walls.
Fractures of FS have many forms and a variety of classifications. Basically, they can be classified
as anterior or posterior wall fractures. These fractures can be simple with no displacement, or
complex displaced and comminuted with or without brain injury. Displaced anterior wall
fracture usually leads to a simple aesthetic deformity. Posterior wall fracture usually results
from high impact injury and bears a risk of placing the intracranial content in direct commu‐
nication with the nasal cavity. A complicating factor is involvement of the NFOT. Its obstruc‐
tion can lead to mucus retention and late infectious complications. [21]
A more detailed classification of the frontal sinus fractures which is suggested by many authors
[22-25] and can be as follows:
Anterior wall fractures:
Anterior wall fractures with no displacement
Anterior wall fractures with displacement and intact FSOT.
Anterior wall fracture with displacement and FSOT injury.
Posterior wall fractures:
Posterior wall fracture without displacement and no cerebro-spinal fluid (CSF) leak.
Posterior wall fractures without displacement and positive CSF leak.
Posterior wall fracture with displacement and no CSF leak.
Posterior wall fracture with displacement and positive CSF leak.
Infection of the sinus, which causes sinusitis, may give rise to serious complications due to the
proximity of FS to the cranial cavity, orbit, and nasal cavity. Complications can develop into
orbital cellulitis, epidural abscess, subdural abscess, meningitis, and in long-term into muco‐
pyocele.
Mucocele formation is a complication, which can develop years after trauma and the symptoms
may go unnoticed for a long period of time. [26] Therefore it is desirable to treat injured FS in
such way as to make it “safe”. This means either to obliterate it completely including all mucosa
lining, or to restore it to the functional state with unobstructed NFOT.
6. Diagnosis of frontal bone fracture
6.1. Physical examination
Findings suggestive of FBF include tenderness, paresthesia, forehead abrasions, lacerations,

contour irregularities and hematoma. Forehead lacerations should be examined under sterile
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conditions to assess the integrity of the underlying bone. Through-and-through injuries of the
frontal sinus have high morbidity, and prompt surgical treatment is indicated. Conscious
patients should be questioned regarding the presence of watery rhinorrhea or salty-tasting
postnasal dripping suspicious for CSF leak. Suspicious fluid can be grossly evaluated bedside
with a “halo test”. The bloody fluid is allowed to drip onto filter paper. If CSF is present, it
will diffuse faster than blood and result in a clear halo around the blood. Glucose or β2-
transferrin are the laboratory tests to confirm a CSF leak. [27]
6.2. Radiological examination
Plain radiographs do not adequately characterize FS fractures. Computed tomography (CT)

is the gold standard for the assessment of FS injuries. Advances in the equipment used for CT
imaging can now produce reformatted images of a very high quality. Patients are scanned in
one axial plane, in a supine position with thin cut spiral CT, creating data set allowing
generation of reformatted and reconstructed diagnostic images. Sagittal reconstructions can
be made to evaluate the posterior wall defect. Special importance belongs to evaluation of the
involvement and severity FSOT. [28]
Gross outflow tract obstruction (fracture fragments lying in the tract) can be observed in some
cases. FSOT injury is strongly suggested when the CT scan demonstrates the involvement of
the base of FS, the anterior ethmoid complex, or both. Fracture in the floor of the sinus can be
seen best with sagittal and coronal views, anterior ethmoid cell injury with coronal more than
axial views, and obstruction best with the coronal view (occasionally axial).Thus, the naso‐
frontal tract complex should be evaluated in the axial, coronal and sagittal planes. Unfortu‐
nately, the involvement of the FSOT is not always easily discernible with CT imaging. [16]
Three-dimensional (3D) reconstructions may help to visualize the external contour deformity
as well as associated facial skeleton injuries.
7. Historic development of operative methods
The evolvement of surgical methods dealing with diseased or injured FS is described in several
publications. The following summary is based on synopsis of two of them [1, 13]. In the
preantibiotic era frontal sinusitis and its complications were fearsome, with high morbidity
and mortality secondary to intracranial spread. The first reported procedure on FS for a
mucopyocele was performed by Wells in 1870. Operations of limited extent involved punc‐
turing the anterior table, some with limited removal of the mucosa, packing of the sinus or
creation of an external draining sinus tract.
In 1898 Reidel first described ablation of the anterior sinus wall. This radical, disfiguring
operation involved removal of the frontal bone and supraorbital bar to the posterior table of
the frontal sinus. Killian modified this approach in 1904 by preserving the supraorbital rims to
improve the patient’s appearance but still removing the anterior table and contents of FS and
then collapsing the skin to the posterior table of FS. The Killian procedure produced less
disfigurement but had significant rates of failure because of persistent disease at the naso‐
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frontal ducts and incomplete removal of all FS mucosa. The next significant advance was the
Lynch operation, described in 1921. The floor of FS and ethmoids were removed and the mucosa
extirpated through a medial periorbital incision in an effort to re-establish drainage. Complete
removal of the mucosa via this approach proved difficult. Disappointing results were also due
to re-stenosis of NFD, either by scarring or by herniation of the orbital tissues into the created
communication with the nasal cavity. Several modifications using stents and mucoperiosteal
flaps were devised later in an attempt to maintain patency of this artificial conduit.
In 1955, Bergara and Itoiz described the osteoplastic approach, which consisted of first defining
the extent of FS and then elevating the anterior sinus wall on an inferior pedicle of periosteum.
This provided adequate surgical access to allow for visualization and complete removal of the
sinus mucosa and obliteration of the remaining sinus with autologous free fat grafts. It also
improved forehead cosmesis. The osteoplastic flap operation has been subsequently modified
for use in trauma of the frontal sinus by elevating the pericranium with the scalp flap and
exploring the frontal sinus by removal of the free bone fragments.
Later studies published by Goodale (1958) and Montgomery (1964) recognized the importance
of NFD injury and popularized obliteration of FS with autologous fat. A variety of materials
such as bone, muscle, fascia, and hydroxyapatite have been successfully used to obliterate the
sinus cavity by later authors. In 1974, Nadell and Kline described a procedure to primarily
reconstruct depressed frontal skull fractures involving the sinus and cribriform plates.
Donald and Bernstein (1982) described a cranialization, procedure in which the intracranial
contents were isolated from the nose and the sinus was completely ablated. They validated
this approach in a cat model by demonstrating respiratory mucosa regrowth and an infection
rate of 44% with untreated posterior table defects.
8. Surgical approaches to frontal bone
8.1. Traumatic wounds
Only in exceptional cases an existing traumatic wound can be used to address an isolated
fracture of the anterior FS wall. It can be considered in limited injuries without involvement
of the FSOT and/or the medial orbital rim, in the absence of other associated regional cranio‐
facial injuries (Figure 4). [13]
8.2. Coronal incision
The main purpose of coronal approach is to avoid visible facial scars. Coronal incision more
or less follows the course of the coronal suture of the neurocranium, which joins FB to the
parietal bones. Therefore in the literature frequently encountered term bicoronal incision is a
misnomer, because there is just one coronal suture on the skull. Acceptable alternative term is
bitemporal incision. The extent and design of the incision depends on the targeted anatomic area
and intended surgical procedure. A fully developed coronal flap with preauricular or post‐
auricular extensions provides access to FB, zygomatic arches, bodies of the zygomatic bones,
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Figure 4. Industrial accident; re-opening of traumatic wound for fracture exposure
medial, superior and lateral orbital margins and much of the corresponding orbital walls, as
well as nasal bones. Via preauricular extension it is possible to address the temporomandibular
joint and the upper neck of the condylar process of the mandible. Coronal incision also allows
harvesting of calvarial bone grafts. There is general agreement that it is not necessary to shave
the hair, however shaving facilitates wound closure. In female patients with long hair, who
are understandably more distressed by prospect of hair shaving, the hair can be divided by a
comb and braided. Alternatively, 2 cm wide strip of shaven skin is sufficient. In consenting
male patients there is no harm in a complete hair shave, which makes suturing of the flap much
more comfortable and subsequent wound care easier and more hygienic (Figure 5).
Figure 5. Scalp preparation for coronal incision: hair braiding, strip shaving and full head shave.
After proper skin disinfection and draping the planned line of incision is marked with a
surgical pen. The incision line runs from ear to ear across the top of the head in either straight,
anteriorly curved, sinusoid or zigzag fashion. There is always some hair loss in the incision
line and the scar is much less prominent if it is not straight, especially in a patient with a short
hair-cut and when the hair is wet (Figure 6).
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Figure 6. Straight incision is more prominent in closely cropped hair, while zigzag incision gives good results even in
bald scalps.
The inferior extent of the incision depends on the target region. When desired exposure is
limited FB, it is sufficient to confine the incision to the level of upper ear attachment. The
placement of the incision line should take into consideration future balding patterns in men,
and anterior migration of the scar due to growth of the cranium in young children. There is
no advantage in placing the incision more ventrally, because the extent of exposure is given
by the caudal extent of the incision: the lowest points define the axis around which the flap
will rotate. Sufficient dorsal extension will also preserve the deep branch of the supraorbital
nerve and avoid sensory loss behind a too-anteriorly placed incision. It is desirable to make
the incision of the scalp parallel to the hair follicles. Avoiding the transection of hair follicles
avoids alopecia at the edges of the wound. [13]
Vascularization of the scalp is very rich and due to the presence of subcutaneous fibrous septa
the vessels gape and bleed profusely when cut. To reduce the initial bleeding and make
establishment of the proper dissection level easier, the sub-galeal layer is infiltrated with saline
or diluted local anesthetic with vasoconstrictor (e.g. adrenalin 1:200 000). The incision starts
on the top of the head and progresses step by step latero-caudally to both sides, while arresting
bleeding after each step. Hemostasis is mainly achieved by compression of wound margins
by Raney clips, Tessier scalp clamps, or running interlocking silk sutures. Use of electrocautery
should be minimized and only bipolar coagulation should be employed to protect hair follicles.
The three superficial layers of the scalp (skin, subcutaneous layer and galeal aponeurotica)
make up one functional unit. [29] The incision penetrates through these layers and stops just
above the pericranium inside the fourth layer of loose areolar tissue (subgalea fascia). Dissec‐
tion inside this level is initially facilitated by undermining the incision line with a spreading
hemostat. Below the superior temporal line the galea continues as temporoparietal fascia. The
dissection should be kept below this fascia, just on the top of temporalis fascia, which can be
identified as a tough white glistening layer. Branches of superficial temporal artery and vein
are usually transected here and need to be ligated or cauterized. After the whole length of the
incision has been developed to the proper depth, the scalp is pulled forward with a pair of cat
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paw retractors and the flap is dissected further by reverse cutting with a large blade until it
can be turned inside out (Figure 7).
Figure 7. Dissection of coronal flap: subperiosteal dissection over top of skull, dissection under temporalis fascia below
the level of the temporal line. In this case pericranial flap is not developed.
Anterior dissection progresses to the point where the base of the flap dissected so far reaches
a 45º angle with the zygomatic arches. The temporal and zygomatic branches of the facial nerve
leave the parotid gland and cross close to the periosteum of the zygomatic arch into the
temporoparietal fascia, 15–28 mm ventral to the external acoustic meatus. [30] To protect them,
further dissection in the temporal areas must continue under the temporalis fascia. The
temporalis fascia is incised over the root of the zygoma and the incision progresses firstly
through the external leaflet of fascia, just over the temporal fat pad. Above the line of fusion
of external and deep layer of temporalis fascia the dissection progressed just above the
temporalis muscle fibers, alongside the base of the developing flap, to the superior temporal
line. At this point it is necessary to consider if a pericranial flap will be needed for anterior
cranial fossa repair or sinus obliteration. If this is the case, its design must be incorporated into
the periosteal dissection instead of cutting the periosteum straight across the frontal bone. If
pericranial flap is not needed, right and left incisions in the temporalis fascia are connected by
incising the pericranium between them. The forward dissection of the coronal flap continues
in the subpericranial level, then subfascial level over the temporalis muscles and temporalis
fat pads. The connection between the periosteum and temporalis fascia at the superior
temporal line is firmly adherent to the underlying bone and requires sharp dissection, which
is best done by diathermy in cutting mode (Figure 8).
When the dissection reaches the orbital margins, careful attention is paid to identification and
freeing of the supraorbital neurovascular bundles. This is easy if only supraorbital notches are
present. If the bundles pass through supraorbital foramina, these must be converted into
notches by resecting the foramina’s inferior margins with a fine chisel. The periosteum must
be subsequently elevated beyond the orbital margin and inside the orbital cavity to allow free
retraction of the flap. [31] The contentious point of the above described technique is the
dissection in the temporal area. If the dissection proceeds as described, it jeopardizes inner‐
vation and vascularization of the temporal fat pad. It can lead to postoperative temporal
hollowing as a consequence of a fat atrophy. [13] For this reason some authors prefer to keep
the dissection completely above temporalis fascia, but “maintaining the integrity of tempor‐
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Figure 8. Elevation of pericranial flap and release of supraorbital nerve.
oparietal fascia” to protect the facial nerve branches. [32] To overcome this dilemma between
jeopardizing either the facial nerve or temporal fat pad, Luo et al. recently described an
alternative dissection technique: the supratemporalis approach. The temporal fascia was
incised 5-6 cm up the zygomatic arch. The flap was composed of skin, subcutaneous fat,
temporoparietal fascia, temporal fascia, and temporal fat pad on the surface of the temporalis
muscle. The authors operated 40 cases with no temporal fossa depression observed in any of
them. [33]
8.3. Alternative skin incisions
The coronal scalp approach provides excellent operative field exposure and results in a hidden
scar. However, it is also associated with certain disadvantages and complications. These
include longer operating times, increased blood loss, scalp hematoma, postoperative infection,
a large scar with related alopecia, potential injury to the branches of the facial nerve with
frontalis muscle paresis and brow ptosis, injury to auriculotemporal, supraorbital and
supratrochlear nerves with numbness and paresthesia, parietal scalp pain, temporal fossa
depression, scar irregularities and ptosis of facial soft tissues. [13, 34, 35] In attempts to avoid
these problems different simplified methods of surgical access were reported for management
of uncomplicated anterior table FS fractures. If the posterior table is involved then the
technique is contraindicated. Also FSOT must be intact. Careful selection of patients is vital.
A small skin incision can be made parallel to the margin of the eyebrow to approach the
fracture. It is often possible to introduce a small periosteal elevator through the inferior edge
of the fracture. If this is not possible, a 5 mm burr hole is created near or on the fracture site.
A narrow periosteal elevator is introduced into FS and fracture is reduced with careful
pressure. The bony opening may be used to confirm adequate reduction endoscopically. [34]
A similar technique with wider exposure of fracture utilizes an upper blepharoplasty incision.
[44] Another alternative approach is incision through the frontalis rhytid crease. [36]
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9. Current operative methods of frontal sinus management
According to the clinical presentation of the fractures, treatment can range from reconstruction
of the sinus walls to obliteration or cranialization. The degree of the displacement of the facture
and the involvement of FSOT and/or the brain will determine the type of management of the
fracture.
9.1. Reconstruction of frontal sinus
Common treatment for simple FS fracture without FSOT involvement requires adequate
surgical exposure, an anatomic reduction and plating. Frontal sinus function and anatomy can
be preserved this way in the majority of cases. [1]
9.1.1. Open methods
The surgical approach is usually through coronal incision or alternatively through existing
lacerations if access is adequate. [37] After complete exposure of the fracture it is necessary to
remove fragments of the anterior sinus wall to gain unobstructed access and to be able to
evaluate integrity of posterior sinus wall, FSOT and sinus mucosa. In case of comminuted
fracture with multiple fragments these can be lifted using periosteal elevator or small bone
hook. Reduction of noncomminuted, compressed fractures can be challenging. When the
convex surface of the frontal bone is fractured, it goes through a compression phase before it
becomes concave. Fracture reduction requires enough force to pull the bone fragments back
through the compression phase. [38] It may be necessary to remove bone from fracture line
using cutting burr and widen it to gain enough space and relieve pressure for lifting of
impacted fragment. It can be helpful to place a screw in the depressed segment, grasp it with
a heavy hemostat, and pull upward - technique similar to use of Carrol-Girard screw for
zygoma reduction. It is important to record orientation of removed fragments to prevent
confusion during reassembly. Placing the fragments atop a drawing of the fracture will help
to maintain the anatomic orientation of each fragment. Damaged or diseased mucosa of sinus
should be removed as well as mucosa covering mobilized fragments, but intact mucosa should
be left undisturbed.
FSOT can be visually evaluated and if there is doubt about its patency, it can be tested by
application of flurescein or diluted methylene blue followed by inspection of nasal contents.
Any suspicion of blockage of FSOT as evidenced by preoperative imaging studies or by
intraoperative inspection and testing warrants treatment by sinus obliteration. Sinus preser‐
vation with duct reconstruction with the help of drainage tube or stent has been attempted in
the past [39-41]. Unfortunately, a rate of stenosis of the duct following stent removal can be as
high as 30%. [28] Recently there has been tendency to preserve and reconstruct sinuses despite
injuries of FSOT with the help of endoscopic sinus surgery (ESS). [42]The final step is reas‐
sembly of fragments and reconstruction of anterior sinus wall using microplates or miniplates.
Small gaps (4 to 10 mm) can be reconstructed with titanium mesh (Figure 9). [38]
tendency to preserve and reconstruct sinuses despite injuries
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of FSOT with the help of endoscopic sinus surgery (ESS).
[42]The final step is reassembly of fragments and
reconstruction of anterior sinus wall using microplates or
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miniplates. Small gaps (4 to 10 mm) can be reconstructed with
titanium mesh (Figure 9). [38]
Figure 9. Fracture of FS with displacement of fragment into left orbit. Fragment is impinging on levator palpebrae su‐

perioris and displacing the globe. Reconstruction of orbital roof with titanium mesh after removal of the fragment.
Figure 9. Fracture of FS with displacement of fragment into left orbit.
Fragment is impinging on levator palpebrae superioris and displacing the
9.1.2. Endoscopic methods
globe. Reconstruction of orbital roof with titanium mesh after removal of
Throughout all surgical fields, less invasive approaches have been employed to decrease the
the fragment.
potential morbidity
of traditional open procedures. Endoscopic procedures and their appli‐
cations for management of FS fractures allow for more conservative management and sinus
8.1.2 Endoscopic methods
preservation in selected patients. [43] Trephination and endoscopic visualization of FS can be
Throughout
useful to assess the frontal recessall surgical
as well as the fields,
extent ofless invasive table
any posterior approaches
injury. Skinhave
incision
is placed midway been employed
between to decrease
the medial canthus the potential
and the glabella morbidity
and a small cutting burr is of
used
to open a 4- to 5-mm frontal sinusotomy. The posterior table and nasofrontal recess can be
traditional open procedures. Endoscopic procedures and their
examined with aapplications
0-degree and/or 30-degree
for endoscope.
management of A
FS Valsalva maneuver
fractures allow can
for assist
more with
the diagnosis of conservative
a CSF leak. [44, management
45] and sinus preservation in selected
Shumrick reported patients. [43] Trephination
on endoscopic reduction of and endoscopic
FS fractures on 19visualization
patients. The of FS
author’s
technique is similar endoscopic forehead lifting, with one central and two lateral hairline
can be useful to assess the frontal recess as well as the extent
incisions. The forehead
of any soft tissues are
posterior elevated
table subperiosteally,
injury. and is
Skin incision theplaced
fracturesmidway
are visual‐
ized by means of a 30-degree endoscope. An attempt is made to elevate the fragments with
between the medial canthus and the glabella and a small
endoscopic elevators. However, it is usually necessary to approach the fragments directly
cutting burr is used to open a 4‐ to 5‐mm frontal sinusotomy.
through small forehead incisions (preferably hidden in the brow). The fractures are elevated
using percutaneous nerve hooks, or by drilling into the fragments and grabbing them with
threaded Steinmann pins. With gentle retraction, the fragments often elevate into a reduced
position and are stable without the need for rigid fixation. Residual surface irregularities can
be camouflaged with patches of Vicryl mesh. In four patients endoscopic fracture repair was
unsuccessful, the fracture segments were unstable. These cases were converted to an open
approach with coronal incisions and rigid fixation. The described technique is appropriate
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only for anterior wall FS fractures that have several large segments without extensive com‐
minution. [44]
Alternative technique of endoscopic transnasal reduction in combination with balloon support
has also been reported. [45]
Endoscopic technique can also be used for camouflage of cosmetic deformity resulting from
untreated depressed anterior table FS fractures above the orbital rim. The repair is performed
2 to 4 months after the injury when all forehead swelling has resolved. A 3-5 cm parasagittal
working incision should be placed above the fracture, 3 cm behind the hairline and carried
through the periosteum onto bone. A 1-2 cm subperiosteal endoscope incision is then placed
at the same height, 6 cm medial to the working incision. Using an endoscopic brow lift elevator
and external palpation, subperiosteal dissection is performed down to the level of the fracture
and the periosteum is carefully elevated over the defect. Once the limits of the fracture have
been visualized, alloplastic implant is fitted to the defect and fixed with self-drilling screws
transcutaneously. [38]
Another usage of endoscopic surgery is reestablishing of patency of compromised FSOT. The
endoscopic surgery can be either part of primary FS management or can be kept in reserve for
delayed FSOT recanalization, should the obstruction develop or not resolve postoperatively.
[42, 45]
9.2. Obliteration of the frontal sinus

The principle of FS obliteration is turning it into self-contained cavity devoid completely of
mucosa, including microscopic remnants and extensions into pits of Breschet, and filling it by
choice of material, or leaving it empty for spontaneous ossification. After gaining satisfactory
access through some of the above mentioned surgical approaches, the anterior wall of sinus is
removed and preserved for later reconstruction. This can be achieved by careful removal of
fractured fragments. It is important to record orientation of removed fragments to prevent
confusion during reassembly. Placing the fragments atop a drawing of the fracture will help
to maintain the anatomic orientation of each fragment. With incomplete fractures, it is often
necessary to remove the intact remainder of the anterior table or to perform formal frontal
sinusotomy. To keep the bone cut within the confine of FS and prevent violation of intracranial
space, it is necessary to mark the extent of the sinus. This can be done using pre-prepared
sterilized film cut out or tin template based on posteroanterior skull x-ray in Caldwell
projection with the patient placed 1.8 meters (6 feet) from the x-ray tube. [46] Alternatively,
one tine of a two-pronged instrument, like tweezers, artery forceps or bipolar cautery can be
placed through defect or trephination on each side of the anterior table. The internal tine is
then used to probe the periphery of the sinus, while the outer tine is used to mark its outline.
Another technique involves trans-illumination with a light source inserted into a fracture line.
[38] Intraoperative navigation is the most accurate but requires specialized equipment.
Sometimes it is possible to preserve contralateral FS if the contralateral sinus is not injured and
the interlining septum remains intact. After the limits of the sinus have been defined, mini‐
plates can be pre-applied, spanning the osteotomy site. This allows accurate re-approximation
of the bone fragments at the end of the procedure. During osteotomy, a burr or a saw should
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be angled toward the sinus cavity to avoid intracranial penetration. Care should be taken to
avoid obliteration of the predrilled miniplate holes while performing the osteotomy. After
complete exposure of the sinus, integrity of the posterior table is evaluated. If it is stable and
free of large defects, sinus obliteration is acceptable. All sinus mucosa must be meticulously
removed from all walls of the sinus. This applies also to temporarily removed fractured or
osteotomized segments of anterior sinus wall. Inner walls of FS are reduced with a large cutting
burr and smaller diamond burrs, as the surgeon proceeds deeper into the sinus. Access to the
peripheral extensions of the sinus, especially above the orbital roofs, can be extremely difficult
in patients with pronounced pneumatization. Special attention must be paid to the scalloped
areas deep in the sinus. If the orbital roof has significant convexity, it may be necessary to
remove a portion of the roof to gain access the posterior sinus mucosa. After complete removal
of the sinus mucosa, the mucosa of the FS infundibulum is elevated and inverted into the
frontal recess. A small temporalis muscle or pericranium plug is then placed over the FSOT to
obliterate it. It can be held in place by packed oxycellulose (Surgicel®) or fibrin glue. Finally
two bone chips obtained from the calvarium can be inserted to complete isolation of FS from
the nasal cavity. [, 38] The FSOT can be further secured using the pedicled pericranial flap,
which is rotated into the sinus. The rest of the sinus is packed with autologous or alloplastic
material and anterior wall of FS is reassembled and stabilized with titanium miniplates. A
number of autogenous and alloplastic materials have been used as fillers in FS obliteration.
Autogenous fat is probably the most widely used and has the longest tradition [47]. The
advantages of fat grafts include ease of harvest, minimal donor site morbidity, ample available
volume, and favorable handling characteristics. However, complication rate was reported as
high as 18% [48]. Magnetic resonance study 24 months post-operatively found vital fatty tissue
in only 6 out of 11 cases of obliteration of FS via an osteoplastic approach. Fatty necrosis
occurred five times; whereas in four cases a transformation into granulation tissue and in one
case into connective tissue could be seen [49].The harvest of the fat is performed using sterile
technique: the surgeon will rescrub and a separate set of instruments that have not come in
contact with the infected field is used. A transverse incision is made in the left lower abdominal
quadrant, and subcutaneous fat is removed. Alternatively, a periumbilical incision can also be
made. Bleeding is controlled using monopolar cautery, but excessive cauterization should be
avoided because it may harm the fat cells and result in graft failure. Drainage of the abdomen
is usually not necessary. [46]
Autogenous muscle graft harvested from temporalis muscle has advantage of being located
within the operative field and being available in adequate volume. Like autogenous fat graft,
this nonvascularized graft undergoes necrosis and eventual replacement by fibrous tissue.
Donor site morbidity, including temporal hollowing and trismus, is unacceptable. [37]
Autogenous bone graft for FS obliteration was first described in 1969 [50]. Since then,
cancellous bone grafts, most often harvested from the ilium, have been widely used as a filler
material. Cancellous bone promotes re-ossification from both the periphery of the defect and
centrally. The main contributions of the grafts are their osteoconductive properties and
osteoinductive factors that are released from them during the process of resorption. [51]
Another advantage of cancellous bone over adipose or muscle tissue for obliteration is that it
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radiographically in postoperative period between resorption, infection,

is easier and mucocele
to distinguish formation.[13,37]
radiographically The greatest
in postoperative perioddisadvantage to the infection,
between resorption, use of
cancellous
and mucocele bone grafts
formation.[13,37] Thelies with disadvantage
greatest the potential donor
to the use ofsite morbidity.
cancellous bone [52]
grafts
lies withMuch
the potential
more donor site morbidity.
comfortable [52] Much
and safer is to more comfortable
harvest bone chips and from
safer isadjacent
to harvest
bone chips from adjacent calvarium. It can be done using bone scraper. In case the harvested
calvarium. It can be done using bone scraper. In case the harvested amount
amount of bone is not sufficient for filling of a large sinus, it can be augmented by
of bone is not sufficient for filling of a large sinus, it can be augmented by admixture
of bone substitute such as demineralized bone matrix (Figure 10) [53].
admixture of bone substitute such as demineralized bone matrix (Figure 10)
[53].

Figure 10. Fracture of left FS with minimal defect in posterior sinus wall and displacement of supraorbital rim. Recon‐
Figure 10. Fracture of left FS with minimal defect in posterior sinus wall
struction with titanium mesh and obliteration of the left FS with small pericranial flap.
and displacement of supraorbital rim. Reconstruction with titanium mesh
Pericranial flap has been widely used in anterior cranial fossa repair, reconstruction of the
and obliteration of the left FS with small pericranial flap.
middle third of face defects, full-thickness scalp defects, and orbital defects. It is composed of
the skull periosteum and the subgaleal fascia. The anteriorly based flap receives its blood
supply from the supraorbital and supratrochlear arteries. Branches of the superficial temporal
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artery supply the laterally based flap. In contrast to all other avascular grafts used for sinus
obliteration, the anteriorly based pericranial flap is composed of a well-vascularized tissue.
The high vascularity makes this flap less prone to infections and turns it into an ideal method
for obliteration of an infected cavity in a contaminated surgical field. [54]
Allografts like lyophilized cartilage [55] have the advantage of unlimited availability and lack
of donor site morbidity. They are easy to handle, well adaptable to the defect, and thus reduce
the operative time. Nevertheless, a failure in revascularization or subsequent osseointegration
may occur, with associated risk of infection and extrusion [56]. Allogenic transplantation may
be associated with increased risk of transmitting such diseases as hepatitis, AIDS or bovine
spongiform encephalopathy.
Alloplastic materials.Methyl methacrylate has been widely used alloplastic material since its
introduction in 1940. It is well tolerated by soft tissues and has a density similar to bone, low
thermal conductivity, and acceptable strength. However, the material produces a significant
exothermic reaction during polymerization and foreign body reaction has been noted when it
is polymerized in contact with tissue. [57]
Hydroxyapatite is a nonceramic calcium phosphate substance (BoneSource, Stryker Leibinger).

It has osteoconductive properties, may be contoured to a defect, adheres to adjacent bone, has
the ability to resist mucosal ingrowth, is resistant to infection, and is gradually replaced by
native bone without a loss of volume. It has been investigated in experimental and clinical
frontal sinus obliteration, but no long term observation results were reported [58]. Currently
the use of hydroxyapatite cement in FS is not recommended. Significant problems related to
material failure have been reported. [37]
Glass-ionomer cement is a hybrid glass polymer composite consisting of inorganic glass

particles in an insoluble hydrogel matrix and bonded by ionic cross-links, hydrogen bridges,
and chain entanglements. It is widely used in dentistry and also has been used in frontal sinus
reconstruction [59]. However, because of severe complications after using glass ionomer
cement next to dura mater this material has been taken off the market. [51]
Proplast, a polytetrafluoroethylene (Teflon) polymer with vitreous carbon fibers with pore
sizes of 200 to 500 μm, is extremely porous to body fluids. Fibrous tissue ingrowth occurs
rapidly and acts to mechanically stabilize the material. The material can cause a mild foreign
body reaction. [51, 60]
Glass ceramic(bioactive glass) has proved biocompatible, non-toxic and bone conducting
material for occlusion of bone cavities. Total accurate obliteration of the sinus is achieved with
different sizes of granules and blocks. Uneventful recovery and clinical outcome were seen in
92% of patients. Histopathological samples revealed a healing process progressing from the
fibrous tissue phase to bone formation with scattered fibrous tissue and granule remnants.
Bone produced by replacement of material was similar to natural frontal bone. Microbiologic
cultures obtained with histological samples revealed no growth of bacteria. [61, 62]
Spontaneous obliteration was reported long ago by Samoilenko (1913), who found oblitera‐
tion by osteofibrous ingrowth in an experimental study on cats and dogs. His results were
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confirmed by later experimental studies that found subsequent replacement of obliterated FSs
by cancellous bone to a variable degree. [51] Because FS after removal of all of its mucosa and
occluding the nasofrontal duct is nothing more than an isolated bone cavity, it is not irrational
to expect its gradual ossification. [63]
9.3. Cranialization of the frontal sinus

Cranialization is the most radical method of FS management. It can be considered an extension
of obliteration procedure with complete removal of the posterior table. In effect, it increases
the volume of anterior cranial fossa at the expense of cranialized FS, and the brain is allowed
to expand into this additional extradural dead space. Because intracranial space is entered,
and there is a possibility of encountering dura and brain injury, cranialization should always
be performed in cooperation with a neurosurgeon. The approach to FS cranialization should
be as a rule performed via a coronal incision. This approach provides wide access to the entire
upper facial skeleton, allowing repair of associated naso-orbito-ethmoid fractures. Further‐
more, it allows dissection of a pericranial flap and harvesting of split calvarial bone grafts when
necessary. [32] Maintaining integrity of the pericranial flap is critical for isolation of expanded
intracranial space from FSOT and ethmoid cells.
Cranialization can be achieved either through sinusotomy as described in previous segment
dealing with FS obliteration [13], or through frontal craniotomy. The choice is usually de‐
pendent on the degree of brain damage and preference of the neurosurgeon. [39]
In the former case, once access to the posterior table has been achieved, this is removed
carefully in pieces with a rongeur. Larger pieces are saved in moist gauze for possible use
replacing defects in the anterior table, instead of separately harvested bone grafts. When the
dura is exposed, any adherent posterior table bone fragments should be carefully dissected
off. The brain should be gently retracted and the remaining posterior table bone is then
removed using straight and angled (Kerrison) rongeurs. Small overhangs at the periphery of
the sinus should be smoothed completely, using a cutting burrs and the posterior table edge
should be made flush with the anterior sinus walls, floor, and anterior cranial fossa. [32]
In most cases cranialization is performed through frontal craniotomy. This will allow thorough
evaluation and repair of dural lacerations, immediate reconstruction of the orbital roof, medial
orbital wall, or naso-orbito-ethmoidal fractures. [37] If a craniotomy has been performed, the
portions of the posterior table associated with the craniotomy bone flap can be removed easily
and safely, working on a sterile side table. [32] Also split calvarial bone grafts can be harvested
from inner compacta of the craniotomy bone flap. Care should be taken during craniotomy to
maintain the integrity of the cribriform plate and to avoid injury to the sagittal sinus. Once all
the sinus mucosa and the posterior bony table have been removed the nonviable bone, soft
tissue or damaged brain, are debrided and dural lacerations repaired. The next step is a
reconstruction of the orbital roof, naso-orbital-ethmoid complex, or cribriform plate/fovea
ethmoidalis, as necessary. Establishing a secure barrier between the cranial fossa and the nose
is mandatory to prevent CSF leak and meningitis, but also to prevent ascending regrowth of
the sinonasal mucosa with late mucocele. The frontal recess and FSOT are occluded as
previously described in FS obliteration. Pericranial flap is sutured as far back as possible to
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the cranial base dura over the anterior cranial fossa to provide additional isolating layer of
vascularized tissue. Because the wide pedicle of this flap will prevent the access to supraorbital
rims, glabella and nasal skeleton, osteosynthesis of these parts must be completed first. A small
bony defect (slit) must be left between supraorbital rims and inferior margin of repositioned
craniotomy flap to prevent compression and ischemia of the pericranial flap. After reposition‐
ing of craniotomy flap the anterior table of FS is reconstructed as described in FS reconstruction
section previously (Figure 11).

Figure 11. Severe comminuted fracture involving anterior cranial fossa, supraorbital rims and naso-orbito-ethmoidal
Figure 11. Severe comminuted fracture involving anterior cranial fossa,
complex. Nasal dorsum, supraorbital rims and glabella are reconstructed with bone grafts harvested from inner corti‐
supraorbital
calis of craniotomy flap.rims and
Pericranial flap naso‐orbito‐ethmoidal
covers anterior cranial fossa. complex. Nasal dorsum,
supraorbital rims and glabella are reconstructed with bone grafts
harvested from inner corticalis of craniotomy flap. Pericranial flap covers
10. Indications and treatment algorithms
anterior cranial fossa.
9. Indications and treatment algorithms
Injured FS can be managed in four basic ways: 1-observation, 2-exploration and fracture

reduction without or with internal fixation, 3- obliteration and 4-cranialization. [13] The choice
Injured FS can be managed
of method is dependent on following factors: in four basic ways: 1‐observation, 2‐
exploration and fracture reduction without or with internal fixation, 3‐
a. Involvement of anterior, posterior or both walls of the sinus.
obliteration and 4‐cranialization. [13] The choice of method is dependent
b.on following factors:
b) Degree of displacement and comminution.
c. a) Involvement of anterior, posterior or both walls of the sinus.
Involvement and patency of fronto-nasal communication - FSOT.
d.b) Degree of displacement and comminution.
Involvement and degree of displacement of sinus floor – orbital roof.
c) Involvement and patency of fronto‐nasal communication ‐ FSOT.
e. Presence or absence of CSF leak.
d) Involvement and degree of displacement of sinus floor – orbital roof.
e) Presence or absence of CSF leak.
f) Associated neurological injuries
Other circumstances important for treatment planning are associated facial
injuries, patient’s general health condition, expected compliance and
availability for follow‐up, as well as availability of specialized services that
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f. Associated neurological injuries

Other circumstances important for treatment planning are associated facial injuries, patient’s
general health condition, expected compliance and availability for follow-up, as well as
availability of specialized services that could help in solving complications, namely endoscopic
sinus surgery.
Degree and combination of anterior and posterior table, with or without FSOT involvement,
would best help to determine the management protocol for FSFs, from observation to surgery
[28, 38].
Improvement in diagnostic imaging, especially introduction of CT, and surgical technology

has led to a wide variety of philosophies, protocols, and procedures. There is no universal
agreement as to how the best achieve treatment goals, and no consensus on when surgical
intervention is indicated. The choice of surgical method largely depends on the extent of the
injury, the status of the FSOT and presence or absence of CSF leak. [63, 64] Most surgeons agree
that nondisplaced fractures should be treated non-operatively. Management of patients with
more complex injuries remains controversial. Many of the previously published reports are of
poor quality (level 4 evidence) and represent retrospective case series consisting of highly
censored samples with little reference given to exclusion or inclusion criteria. Additionally,
most previous reports fail to include patients who were treated non-operatively, so little is
known about the outcome of these patients or the relative frequency of procedures in the
context of a population of trauma patients. [1]
10.1. Anterior table fractures without FSOT involvement
Nondisplaced or minimally displaced (less 2 mm) anterior table fractures can be observed. The
risk of an aesthetic deformity increases with the degree of displacement (>2 mm). An endo‐
scopic repair or repair through alternative skin incision may be indicated in this patient
population. However, many authors found it to be technically challenging.
Another option is to assess the degree of deformity after all facial edema has resolved. At this
point, the patient can make an informed decision as to whether he/she desires surgical
intervention, which can be endoscopic camouflage. A significant number of patients will opt
for no surgical intervention. [27]
More complex anterior table fractures and those extending below the orbital rim may require
open reduction using a coronal incision. The presence of improperly reduced bone segments,
comminuted sequestrae, foreign bodies, devitalized and torn sinus mucosa expose the patient
to a greater risk of infectious complications. [39] Reconstruction of the anterior wall using
miniplates is a procedure virtually free of significant complications when the FSOT is patent.
10.2. Anterior table fractures with FSOT involvement
This is the point, where controversy about appropriate treatment of FS injuries begins. The
traditional treatment for FS fractures with FSOT involvement is obliteration followed by
anterior table reconstruction. [23,64] Some authors are not only strong proponents of obliter‐
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ation, but employ this method also for some cases on nondisplaced anterior table fractures
with FSOT involvement and even cranialize patients with nondisplaced and displaced
fractures with FSOT involvement. [65]
On the other hand, the advancement in endoscopic surgery of frontal recess and modern
imaging has enabled sinus preservation as a viable alternative to FS obliteration in cases with
suspected FSOT involvement in the fracture. High-resolution, thin-section CT with sagittal
reformatting may evaluate the involvement and severity of injury of the FSOT preoperatively
and help in planning of its management. Sinus preservation may apply for displaced anterior
wall FS fractures, even with concomitant minimally displaced posterior wall fractures, and
without significant intracranial injury or persistent CSF leak. [28]
Thong and Lee [42] reported on primary endoscopic management. Patients with depressed
anterior table FS fractures that involved FSOT were managed by ORIF via a coronal incision
plus endoscopic fronto-ethmoidectomy with removal of any obstructing bony fragments, and
insertion of a stent into the fronto-ethmoidal recess. Middle meatal nasal packs were left in
situ for 1 week and patients were discharged home with prophylactic antibiotics. Frontal stents
were removed after 1 month. Patients were followed up by regular endoscopic surveillance
and CT scans were performed annually. There were no complications.
Smith at al. [45] treated 14 patients with FS and concurrent facial fractures. Seven patients were
included in the modified treatment algorithm. Postoperatively, 5 patients had spontaneous FS
ventilation. Two patients, both of whom had naso-orbito-ethmoid fractures, had persistent
FSOT obstruction. These patients were successfully managed with an endoscopic FS proce‐
dure. The decision to repair, obliterate, or cranialize the sinus is often made intraoperatively,
based on the extent of FSOT obstruction found during the procedure. [37]
10.3. Posterior table fractures
The primary decision criteria for surgical intervention are the degree of fracture displacement
and the presence of a CSF leak. Traditionally as a rule of thumb, a width of the posterior table
displacement is considered significant. [14, 32]
10.3.1. Fractures without significant displacement
Patients with posterior table displacement less than one table width and no CSF leak may be
observed. Long-term follow-up with repeat CT scans at 2 months and 1 year is appropriate to
rule out mucocele formation. If a CSF leak is present at time of injury, 1 week of observation
is indicated; 50% will resolve spontaneously. The methods of conservative treatment include
complete bed rest with oral acetazolamide 250 mg every 8 hours, prescription of laxatives and
prophylactic antibiotics, and avoidance of breath holding and straining. Acetazolamide is a
carbonic anhydrase inhibitor and is intended to reduce CSF secretion. Laxatives are given to
prevent increases in intracranial pressure caused by constipation, and antibiotics to prevent
infection. CSF drainage can be performed if the patient has intracranial infection or rapid
leakage. Persistent leak openings in the posterior wall of the frontal sinus warrant repair via
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craniotomy. CT cisternography facilitate highly accurate preoperative localization of the

fistula. [66]
10.3.2. Fractures with significant displacement
Patients with posterior table displacement greater than one table width, no CSF leak, and only
mild comminution should be considered for sinus obliteration. More severe injuries, with a
frank CSF leak and/or moderate to severe comminution, will likely require removal of posterior
table bone to repair the dural tear. If the injury or surgical repair results in disruption of more
than 25 to 30% of the posterior table, sinus cranialization should be considered. [32]
10.4. Treatment algorithms
In an effort to optimize functional and cosmetic outcomes in complex clinical situations, while
minimizing serious short- and long-term sequelae, algorithms were developed to determine
which patients should receive operative intervention and which frontal sinus procedure is
most appropriate in a given case. Following are examples of such algorithms placing emphasis
on different aspects of FSF characteristics:
It seems to be obvious that all these algorithms are to some extent simplified. To develop
algorithm taking into account all possible characteristics and circumstances would probably
result in a too -complicated diagram.
FS fracture
No CSF leak CSF leak
FSOT not FSOT Observe 7

involved involved days
ORIF of anterior ORIF of anterior Resolved Persistent

table table Sinus
obliteration
Sinus
preservation
Cranialization
According to Chen et al., 2006 [64]

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FS fracture
Displaced Non-
displaced
FNOT FNOT FNOT FNOT

involved
intact involved intact
Posterior Posterior Posterior Posterior

Observation
table table table table
comminuted nondisplaced comminuted nondisplaced
Cranialize Repair Cranialize and Repair NOE

anterior
repair anterior repair anterior
table table table
According to Bell et al., 2007 [37]
FS fracture
No FSOT FSOT
involvement involvement
Observation Obstruction No obstruction
Cranialization or No displacement Displacement

obliteration
Observation Reconstruction
According to Rodriguez at al., 2008 [65]
11. Complications of frontal sinus fractures
Frontal sinus fractures carry a risk of complications, which can be characterized as early or
late. Complication rates for patients with FS fractures range from 10% to 17%. [67] The most
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serious are early infectious complications that can endanger patient’s life. There is a greater
urgency of operative treatment in cases where intracranial infection can develop through
potential communication of the neurocranium with the non-sterile sinuses. Bellamy et al. [68]
found that delay in repair beyond 48 hours was associated with a greater than fourfold
increased risk of serious infection, even when controlling for clinical and statistical confound‐
ers. However, FS fracture patients often present with other, more severe intracranial and bodily
injuries. Thus, definitive management is often delayed until the patient’s neurologic and
medical condition has stabilized. Several additional factors are associated with serious
infection, among them use of an external cerebrospinal fluid drainage catheter and soft-tissue
infection that predisposes to deeper infection in these patients.
The recommendation of 7-days waiting period for management of persistent CSF leaks was
borne out of historical studies that predate the modern research. According to recent opinion,
there is no evidence to support 7 days as a particularly important threshold for cerebrospinal
fluid leak management to prevent intracranial infection. [68]
The efficacy of antibiotic prophylaxis, especially beyond the perioperative period, in frontal
sinus and skull base injury remains unclear. The risks of antibiotic use, evolving drug resis‐
tances and associated patient and epidemiologic costs require careful evaluation. To date, there
is no standard of care for postoperative antibiotic administration, though many surgeons
continue to administer antibiotics beyond the immediate perioperative period.[68] A variety
of adverse events can occur after fixation of a frontal sinus fracture, such as frontal sinusitis,
mucocele, mucopyocele, cerebrospinal fluid leakage, deformity, hardware infection, head‐
ache, and chronic pain in the area of the injury.[67] Potentially life threatening late complica‐
tions include thrombosis of the cavernous sinus, encephalitis, mucopyocele, or brain abscess.
[21] In the literature there is no consensus regarding the follow-up. Because of the possible
long period after trauma until complications, namely mucocele, develops, some advise to
continue to follow these patients for a lifetime. Others suggest a follow-up period of 5 or 7
years. [26]
12. Our experience in treatment of frontal bone fractures
12.1. Patients’ demographics
During a period of 10 years beginning from 2004 we treated 188 males (90%) and 22 females
(10%) admitted with diagnosis of FBF. The most frequent etiology overall was road traffic
accidents (43%), followed by falls from heights (26%) and impact of fast moving objects
(11%). Fifty injuries (24%) were work-related, most of them falls from heights at construc‐
tion sites. However, in females 70% of accidents were caused by falls from heights. These
female patients were mostly domestic helpers, who either tried to commit suicide or avoid
abuse (Graphs 1and 2).
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70
60
50
40
30
20
10
0
0-10 11-20 21-30 31-40 41-50 >50
Females Males
Graph 1. Age and sex distribution
11%
6% 5%3%
22% RTA
44% FFH
12%
HIT
Assault
Other
70%
27%
Graph 2. Etiology distribution by sex: males; outer circle, females; inner circle
12.2. Associated injuries
Solitary FBF was found in 116 patients, 82 patients suffered concomitant midfacial fracture(s),
3 patients associated mandibular fracture and 9 patients had panfacial fractures. Central
nervous injury was found in 80 patients, of whom 11 died. Seven of these fatalities were
polytraumatized with multiple non-head fractures and internal organ injuries. Non-head
injuries were found altogether in 74 patients. Serious ocular injuries (bulbus rupture and/or
traumatic optic neuropathy) were present in 14 patients (below).
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Brain injury, contusion, edema, bleeding (died) 80 (11)
Non-facial fractures (spine) 68 (17)
Eye injuries 14
Internal organ injuries 9
12.3. Our classification scheme
We founded our classification solely on CT examination. We did not attempt to include

involvement of FSOT, because its CT evaluation is often not reliable. Decisions based on status
of FSOT were done intraoperatively. We had five types namely:
Type 1 Outside frontal sinus (Figure 12)
Type 2 Non-displaced, involving one or both frontal sinus walls (Figure 13)
Type 3 Displaced anterior sinus wall, posterior wall intact or nondisplaced (Figure 14)
Type 4 Displaced anterior + posterior sinus wall (Figure 15)
Type 5 Displaced posterior sinus wall, anterior wall intact or non-displaced (Figure 16)
Figure 12. Type 1: fracture outside sinus.
Figure 13. Type 2: nondisplaced fracture involving anterior and/or posterior sinus wall.
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Figure 14. Type 3: displaced fracture of anterior sinus wall with posterior sinus wall intact or undisplaced.
Figure 15. Type 4: displaced fracture of both anterior and posterior sinus walls.
Figure 16. Type 5: displaced and comminuted posterior sinus wall with anterior wall intact or nondisplaced.
11
51 Type 1
53
Type 2
Type 3
Type 4
35 60 Type 5
Graph 3. Distribution by types of fracture.

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12.4. Surgical procedures
From patients with Type 1 injuries 4 patients died due to concomitant CNS trauma. Two
patients were operated: both of them were children with severe disruption of FB and the
purpose of surgeries was to repair calvarial defects. Only one patient from Type 2 group was
operated to remove a foreign body from the FS. In patients with Type 3 fractures, there was
the highest relative incidence of operative treatment: 24 patients were operated with 1 sinus
obliteration and 23 anterior wall reconstructions.
Type 4 group had 33 operated patients, 31 of them received cranialization and 2 obliteration
of FS. Dural tears were found in 21 patients in this group despite only 5 cases of CSF leak
noticed preoperatively.
Type 5 group had the lowest relative incidence of operated cases and only 4 patients were
operated. In five cases we were not able to reach an agreement with neurosurgery service about
the indication to operate. The overview of operative treatment and reasons for not operating
cases are given in the following table.
CSF CNS Other Neurosurgeon

Type No. Operated Died Refused Unfit Transfer
leak injury injuries Disagree
1 51 2 18 20 2 4 - - - -
2 60 0 18 23 1 0 - - - -
3 35 0 6 6 24 0 7 4 - -
4 53 5 33 19 33 7 6 3 3 1
5 11 1 5 0 4 0 1 1 - 5
∑ 210 8 80 68 64 11 14 8 3 6
12.5. Discussion
Surprisingly, only one of our operated patients developed an early infectious complication-
soft tissue abscess in the vicinity of the orbital rim, which responded to local incision and
antibiotic treatment. The other 2 patients had persistent postoperative CSF leakage and were
successfully treated by lumbar drain and bed rest. Similar to other studies we were not able
to maintain long term follow-up in the majority of operated cases, not mentioning conserva‐
tively managed cases. Supposedly, had serious complication developed and the patient was
still living in Kuwait, he/she would have looked for help in our unit, like other maxillofacial
trauma patients, who are usually refused even simple tooth extraction in other facilities other
than ours once the patient's trauma history is known to a care provider.
We recognize the importance of close cooperation with the neurosurgery service in instances
of cranio-facial injuries. However, we sometimes run into difficulties when deciding on
indications for operative treatment in patients who are in good general condition and without
signs of external deformity or CSF leakage. These are mainly patients with type 5 injuries. More
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http://dx.doi.org/10.5772/59096
often than not a neurosurgeon takes only short term perspective on a case without consider‐
ation of possible development of late complications many years later.
Author details
Petr Schütz*, Hussein Hassan Hamed Ibrahim and Bashar Rajab
*Address all correspondence to: petrschutz@yahoo.com
Al-Farwaniya Dental Center, Al-Farwaniya Hospital, Ministry of Health, State of Kuwait
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Chapter 21
Current Management of Frontal Sinus Injuries
Roozbeh Kahali and Alireza Tootoonchian
http://dx.doi.org/10.5772/59968
1. Introduction
Frontal sinus fractures are relatively uncommon and are usually seen as a part of severe head
injuries caused by high-velocity injuries. The management of frontal sinus fractures involves
many difficulties since the frontal sinus is situated at the junction between the cranium and
the face, and has anatomical features of both. Intracranial involvement should always be
anticipated when upper facial trauma is suspected. Often the planning of how to treat frontal
sinus fractures must actually be decided during the operation itself, because the fractures may
extend more widely than predicted by pre-operative examination. Posterior wall fractures
have more complications and a worse clinical outcome than fractures that only involve the
anterior wall. Acute and chronic sinusitis, mucocele, mucopyocele, osteomyelitis, meningitis,
and brain abscess are associated with frontal sinus injury. The purpose of this chapter is to
present an overview of the frontal sinus fractures, associated injuries and a rationale for
selecting surgical approach to frontal sinus injury.
2. Frontal sinus anatomy
The frontal sinus has a thick strong anterior wall, a thin fragile floor and a posterior wall. Its
floor is the roof of the orbit. Its posterior wall forms the anteroinferior portion of the anterior
wall of the anterior cranial fossa. Because the superior sagittal sinus lies against the posterior
wall of the frontal sinus, it is vulnerable to injury in fracture dislocations of the posterior wall.
Fortunately because of the toughness and resiliency of the dura, rupture of the superior sagittal
sinus is uncommon, but when it occurs, the patient often dies of uncontrollable hemorrhage
[1]. A vertical septum has commonly placed approximately in the center of the frontal sinus.
In the case of highly developed orbital ethmoidal cells, the roofs of these cells make up the
medial aspect of the frontal sinus floor. The nasofrontal ducts are located on either side of the
frontal sinus. The opening of these structures is variable. They usually drain directly into the
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frontal recess, but they also may drain above the ethmoid infundibulum, into it or above the
ethmoid bulla.
The frontal sinus is lined with pseudostratified ciliated columnar epithelium. The main source
of blood supply to the frontal sinus is a diploic branch of the supraorbital artery [2].The frontal
sinus also receives some blood supply from branches of the anterior ethmoidal artery
[1].External venous drainage is through the angular and anterior facial veins. The deep
drainage is through the foramen of Breschet which is located on the posterior wall of the sinus.
This structure is responsible for communication with the subdural venous system in the
subarachnoid space [1].
3. Frontal sinus fracture
A frontal sinus fracture is a common injury in patients who suffer high-energy trauma from
motor vehicle accidents or altercations [3].The frontal sinus fracture accounts for 5–15% of all
fractures of the maxillofacial area [4] and is often associated with neurological deficit and other
facial fractures [3].The involvement of the brain is not uncommon. It has been suggested that
more than 80% of the patients with a fracture of both the anterior and the posterior wall have
intracranial injuries, such as hemorrhages and cerebral contusions [5].Pain is a common
symptom in conscious patients with a frontal sinus fracture. Lacerations are seen in 50% of
patients. About 25% of patients have a visible depression of the forehead [6]. Other possible
symptoms are epistaxis, problems with vision, edema and paresthesia of the supraorbital
region. Leakage of cerebrospinal fluid, due to damage of the dura, is a common finding
[4].Computed tomography (CT) is the gold standard in diagnosing the degree of involvement
of the frontal sinus [3].
4. Diagnosis of frontal sinus fracture
The physical examination of patients with frontal sinus fractures is difficult because of soft
tissue swelling. The detection of cerebrospinal fluid rhinorrhea which indicates a posterior
table injury with a dural tear is an important preoperative finding. CSF rhinorrhea is rarely
detected because the fluid drains from the oropharynx. The surgeon should attempt to obtain
a sample of this by having the patient lean forward to allow drainage from the nose and test
the fluid for glucose or β-2 transferrin to confirm the diagnosis. Other signs of frontal sinus
fracture include supraorbital nerve anesthesia and a depressed frontal region [7]. The most
common associated finding is a laceration of the supraorbital ridge (Figure 1), glabella, or lower
forehead [8]. These lacerations are often extensive and may be contaminated by foreign
material [9].
Plain skull radiographs including the Caldwell and lateral views are occasionally used. Sinus
pathology is strongly suspected when the radiograph demonstrates air-fluid levels, a diffusely
cloudy sinus, or pneumocephalus. Accurate serial 1.5 mm cuts computed tomography (CT)
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Current Management of Frontal Sinus Injuries 473

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Figure 1. Left: A 52‐year‐old patient who has facial laceration due to an
Figureindustrial accident.
1. Left: A 52-year-old Right:
patient who has CT scan
facial of the
laceration same
due to patient
an industrial reveals
accident. Right: both
CT scan of the same
patientanterior and posterior table fractures of the frontal sinus.
reveals both anterior and posterior table fractures of the frontal sinus.

imaging
in both the axial (Figure 2) and coronal planes should be obtained in all cases to
determine the degree
Plain skull of injury
radiographs to the anterior
including and posterior
the Caldwell tablesviews
and lateral and nasofrontal ducts [10].
are occasionally
The CTused. scan allows
Sinus for visualization
pathology is strongly ofsuspected
the brain,when
face, the
and radiograph
orbits as well, which is often
demonstrates
necessary because
air‐fluid
of
levels, the
a high
diffusely rate of associated
cloudy sinus, injuries
or [9].
pneumocephalus. Accurate serial 1.5
mm cuts computed tomography (CT) imaging in both the axial (Figure 2) and
coronal planes should be obtained in all cases to determine the degree of injury to
the anterior and posterior tables and nasofrontal ducts [10]. The CT scan allows
for visualization of the brain, face, and orbits as well, which is often necessary
because of the high rate of associated injuries [9].

Figure 2. Left: A 26‐year‐old patient who had a motor vehicle accident
Figure 2. Left: A 26-year-old patient who had a motor vehicle accident with blunt trauma to the head. Note that there
with blunt trauma to the head. Note that there is no sign of depression or
is no sign of depression or asymmetry of the face. Right: CT scan of the same patient reveals frontal sinus fracture with
asymmetry of the face. Right: CT scan of the same patient reveals frontal
severe bone depression.
sinus fracture with severe bone depression.

TREATMENT MODALITIES
Isolation of the neurocranium, cessation of any CSF leak, prevention of early and
delayed postoperative complications and restoration of the preoperative facial
aesthetics are the aims of treatment of frontal sinus fractures. The integrity of the
posterior wall and/or involvement of the nasofrontal duct are the factors
influencing treatment. The integrity of the posterior wall is the main factor for the
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5. Treatment modalities
Isolation of the neurocranium, cessation of any CSF leak, prevention of early and delayed
postoperative complications and restoration of the preoperative facial aesthetics are the aims
of treatment of frontal sinus fractures. The integrity of the posterior wall and/or involve‐
ment of the nasofrontal duct are the factors influencing treatment. The integrity of the
posterior wall is the main factor for the separation of the intracranial contents from the
outer environment. The nasofrontal duct involvement is the decisive factor for the poten‐
tial dysfunction of the sinus mucosa. Closed fractures of the anterior wall of the frontal
sinus without displacement do not require surgical treatment and only observation is
required. The treatment of depressed fracture of the anterior wall without involvement of
the nasofrontal duct is simple elevation of the fracture and plate fixation. However, if the
duct is involved, the treatment should include the obliteration of the sinus cavity after the
sealing of the injured duct. In this way the frontal sinus is treated as an isolated cavity
precluding any potential mucosal regrowth from the nasal epithelium. If the posterior wall
is involved the determinant of successful management of the frontal sinus fracture is
removal of the displaced bony fragments of the posterior sinus wall, restoration of the dural
integrity and complete isolation of the brain from potential communication with the nose
through the injured frontal sinus and cranialization of the frontal sinus [11].
6. Surgical approach
The most common approach is the bicoronal flap. It has several advantages including provid‐
ing the best exposure of the frontal bone and the best cosmetic result in patients without
alopecia. Its disadvantages are increased intraoperative blood loss and risk of injury to the
frontal branch of the facial nerve. When using this approach, the hair is parted at the anticipated
incision site and the tufts of parted hair are brought together and secured with small rubber
bands on each side of the incision. Shaving of hair is not necessary. The incision site is infused
with local anesthetic with 1:100,000 epinephrine in a subgaleal plane. The scalp is then incised
from one temporal line to the other through the skin and subcutaneous tissues. A scalpel is
used to incise the galea. Once the galea is violated, there will be an obvious separation between
the galea and the pericranium. Bleeding from larger vessels should be tied off individually.
The application of Raney clips minimizes the risk of bleeding. Finger dissection can then be
used to elevate 2 to 3 cm on either sides of the incision, taking care to maintain the integrity of
the pericranium. Overlying the temporalis muscle superiorly, the plane of dissection should
remain in the loose areolar layer, which is deep to the temporoparietal fascia containing the
frontal branch and superficial to the deep temporal fascia. In other areas overlying bone, the
flap is raised in a plane immediately superficial to the pericranium. Carrying out the dissection
in the correct anatomic plane minimizes the risk of injury to the frontal branch of the facial
nerve. At the region of the zygomatic arch, the frontal branch of the facial nerve is most
vulnerable to injury. If the dissection is carried within 1 to 2 cm of the arch, the plane of
dissection should be one layer deeper in this area and dissection should be just deep to the
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http://dx.doi.org/10.5772/59968
superficial layer of the deep temporal fascia [12]. After the soft tissue has been retracted, the
pericranium is incised several centimeters superior to the most superior aspect of the frontal
sinus and raised inferiorly to a level approximately 1 cm below the inferior extent of the frontal
sinus. Other options for incision include the midforehead and the gull wing incisions. These
approaches offer decreased operative time, decreased blood loss, and decreased risk of injury
to the frontal branch of the facial nerve. However, they also limit exposure, increase the
incidence of damage of the ophthalmic branch of the trigeminal nerve, and leave more visible
scars [13, 14].
7. Frontal recess fracture
Frontal recess fractures only result in disruption of the frontal sinus outflow tract. Regardless
of anterior or posterior table injuries, frontal recess fractures that result in sinus outflow
obstruction will require frontal sinus obliteration. Endoscopic frontal sinusotomy has also been
described for the management of persistent obstruction. However, endoscopic frontal sinus‐
otomy following frontal recess trauma is technically challenging and should only be consid‐
ered in reliable patients.
8. Anterior table fracture
A displaced fracture of the anterior table is the most common type of frontal sinus injury [15]
which leaves a contour deformity of the forehead. Anterior table fractures involving the nasal-
orbital-ethmoidal area or supraorbital rim have a 25% to 50% incidence of nasofrontal duct
involvement [16-19]. In general, operative exposure of an anterior table fracture should also
include an intraoperative examination of the nasofrontal duct to evaluate for injury. Exposure
is best achieved by using a bicoronal incision (Figure 3).
Once the coronal incision has been made and the anterior table exposed, sinusotomy must be
planned. One prong of a bayonet forceps is placed inside the sinus to the maximum peripheral
extent. The corresponding prong then reflects its position on the external surface of the outer
table. A number 701 burr in a high-speed drill marks the perimeter adjacent to the bayonet
forceps. After sinus marking is complete, the osteotomy is accomplished using either a drill or
oscillating saw [20]. Once the frontal sinus has been entered, cultures are taken of any fluids
encountered. At this point, nasofrontal duct patency can be evaluated with the placement of
either fluorescein or methylene blue proximally at the ostium located medially at the sinus
floor. If there is no evidence of nasofrontal duct obstruction, the fracture fragments should be
reduced and fixated (Figure 4).
The severely comminuted anterior table is best repaired with a precontoured plate (Figure 5).
If there is significant comminution of the anterior table with bone loss, split calvarial graft is
the material of choice to address defects of the anterior table (Figure 6).The use of synthetic
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Figure 3. The frontal sinus fracture is approached via bicoronal incision

Figure 4. Left: Depressed fracture of the anterior table of the frontal sinus.
Figure 4. Left: Depressed
Right: fracture of
The fracture the anteriorare
fragments table of the frontal
reduced and sinus. Right:
fixated by The fracture
plates. fragments are reduced
Below:
and fixatedThe
by plates. Below: The postoperative radiograph
postoperative radiograph of the patient.
of the patient.

The severely comminuted anterior table is best repaired with a precontoured plate
(Figure 5). If there is significant comminution of the anterior table with bone loss,
split calvarial graft is the material of choice to address defects of the anterior table
(Figure 6).The use of synthetic materials, such as methyl methacrylate or even
hydroxyapatite cements, is to be discouraged because of the risk of infection
secondary to communication with the sinus floor [21].

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materials, such as methyl methacrylate or even hydroxyapatite cements, is to be discouraged

because of the risk of infection secondary to communication with the sinus floor [21].
Figure 5. The severely comminuted anterior table is repaired with a titanium mesh
Figure 6. Split calvarial graft can be used for the repair of the severely comminuted anterior table
9. Fractures involving the nasofrontal duct
The anterior table fractures do not damage the nasofrontal duct unless there are concomitant
nasal-orbital-ethmoidal complex or supraorbital fractures which extend into the sinus floor.
A patent nasofrontal communication is necessary for the normal function of the frontal sinus.
Therefore, treatment must either reestablish the communication or eliminate the sinus as a
functional unit. If only one duct is injured, removal of the intersinus septum will allow mucus
from the injured sinus to make its way to the uninjured side. Reconstruction of the duct requires
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long-term tenting (Figure 7) and mucosal flaps. However, in unilateral and bilateral nasofron‐
tal duct injuries, obliteration of the frontal sinus is preferred. The procedure involves the
removal of all mucous membrane and the inner cortical lining of the sinus and obliteration of
the nasofrontal duct and the sinus. Mucocele formation is possible if the mucosa is inade‐
quately removed during obliteration.
Figure 7. The frontal sinus approached with an open sky incision for reconstruction of the naso-frontal duct via stent‐
ing technique
10. Posterior table fracture
Extremely high-velocity injury may result in comminution of the posterior table with dural
tearing. If this happens, the intracranial contents become in direct communication with nasal
mucosa. In this setting, management principles are careful mucosal removal, nasofrontal duct
occlusion and cranialization of the frontal sinus. The neurosurgeon repairs any associated
intracranial injuries. The frontal lobes are then allowed to expand into the space where the
frontal sinus once existed.
11. Frontal sinus obliteration
Obliteration of the sinus is performed by the use of various materials, such as fat, muscle, bone
or hydroxyapatite. Meticulous removal of the entire mucosal lining is the most important
element in successful frontal sinus obliteration. Permanent occlusion of frontal recess and
complete obliteration of the sinus are essential in avoiding recurrence of infections and
preventing possible complications [22].
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Indications for frontal sinus obliteration include failure of endoscopic approaches to ade‐
quately communicate frontal sinus with the nasal cavity, loss of anterior bony table of the
frontal sinus, severe fractures of floor of the frontal sinus and benign tumors [23]. The standard
bicoronal incision is performed through the galea. The pericranium is incised as far posteriorly
as possible, and a subperiosteal dissection is carried up to the supraorbital rim, preserving the
supratrochlear and supraorbital neurovascular bundles. The frontal sinus is outlined. The
anterior bony table is then removed. Sinus mucosa is meticulously exenterated with a perios‐
teal elevator, and the interior of the sinus is carefully drilled with a medium-sized diamond
burr. Nasofrontal ducts are then plugged with temporoparietal fascia and muscle. Obliteration
of the frontal sinus is then performed with the previously mentioned materials (Figure 8).The
anterior
table plate is then replaced and plated.

Figure 8. Left: Part of the temporalis muscle is excised for frontal sinus
Figure 8. Left: Part of the temporalis muscle is excised for frontal sinus obliteration. Right: The frontal sinus is obliter‐
obliteration. Right: The frontal sinus is obliterated with muscle.
ated with muscle.

FRONTAL SINUS CRANIALIZATION
12. Frontal sinus cranialization
The primary indication for cranializing the frontal sinus is severe traumatic injury
of the frontal sinus, with involvement of both the anterior and the posterior
The primary indication for cranializing the frontal sinus is severe traumatic injury of the frontal
tables. Obliteration of the frontal sinus is an option in some cases but the loss of a
sinus, with involvement
substantial portion of ofthe bothposterior
the anteriortable
and the posterior
bone places tables.
the Obliteration
survival of ofa the fat frontal
graft
sinus is an option in some cases but the loss of a substantial portion
necessary for obliteration in doubt and makes cranialization more appropriate of the posterior table bone
places the survival of a fat graft necessary for obliteration in doubt
[24]. The presence of cerebrospinal fluid (CSF) rhinorrhea, the need for and makes cranialization
more appropriate [24]. The presence of cerebrospinal fluid (CSF) rhinorrhea, the need for
neurosurgical intervention, or simply an expectation of inadequate follow‐up are
neurosurgical intervention, or simply an expectation of inadequate follow-up are all factors
all factors that may guide one towards cranialization. The approach to frontal sinus
that may guide one towards cranialization. The approach to frontal sinus is performed via a
is performed via a bicoronal incision. Once access to the posterior table has been
bicoronal incision. Once access to the posterior table has been achieved, it is removed carefully
achieved, it is removed carefully in pieces with a rongeur. Larger pieces are saved
in pieces with a rongeur. Larger pieces are saved for possible use replacing defects in the
for possible
anterior use replacing
table. Small overhangsdefects in the of
at the periphery anterior
the sinus table.
should Small overhangs
be smoothed at the
completely,
using a cutting burr.
periphery of The end result of the removal ofcompletely, using a
the sinus should be smoothed the posterior table bone is the elimination
cutting burr. The
end result of the removal of the posterior table bone is the elimination of the
frontal sinus as a distinct space. This space is now encompassed within a new,
larger anterior cranial fossa, with the anterior table as its anterior limit.
Once the entire posterior table has been removed, all sinus mucosa is taken out.
This is done first bluntly, with a hemostat or forceps. Remnant mucosa is then
eliminated using a diamond burr. Establishing a secure barrier between the cranial
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of the frontal sinus as a distinct space. This space is now encompassed within a new, larger
anterior cranial fossa, with the anterior table as its anterior limit.
Once the entire posterior table has been removed, all sinus mucosa is taken out. This is done
first bluntly, with a hemostat or forceps. Remnant mucosa is then eliminated using a diamond
burr. Establishing a secure barrier between the cranial fossa and the nose is necessary to
prevent CSF leak, meningitis, and ascending regrowth of the sinonasal mucosa. After the
neurosurgery team has accomplished a watertight dural repair (Figure 9), and the bone and
mucosa removal are complete, the most superior aspects of the frontal duct mucosa are
elevated from the underlying bone and inverted downwards, toward the nose. The superior
portions of the ducts are then packed off using bone, fascia, and muscle.
Abdominal fat harvested through a small paraumbilical incision is filled in around the dural
closure, occupying intracranial dead space. Repair of the anterior table is essential for both
structural and cosmetic concerns. Anatomic reductions are carried out with fixation.
Figure 9. Water tight closure of the dura for prevention of CSF leakage
13. Flap closure
Closure of the coronal incision is performed in layers with interrupted 3-0 Vicryl stitches for
the galea and deep dermis, and staples for the skin within the hairline. The skin outside the
hairline is closed with interrupted 4-0 nylon stitches. Suction drains are generally avoided if
immature dural closure is present. A neurosurgical head wrap is then applied.
14. Complications
Some complications of frontal sinus management relate to the surgical technique. The frontal
branch of the facial nerve is vulnerable to injury during elevation of the coronal skin flap. The
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result is paralysis of the ipsilateral forehead. This complication can be avoided by elevating
the lateral aspects of the coronal flap in the proper plane. Too much disruption of the temporal
fat pad during the lateral dissection can cause noticeable late temporal hollowing. A noticeable
or widened scar from the coronal incision may develop. Other complications relate to the
nature of the injury itself.CSF leak/rhinorrhea, with or without infectious consequences, may
develop despite the fact that a watertight closure of the dura is performed. Management
typically involves revision surgery, although nasal packing, bed rest, and CSF decompression
via lumbar drain may be helpful adjuncts.
Appropriate management of meningitis relies on early recognition of signs, such as mental

status changes, fever, and nuchal rigidity. When meningitis is detected, broad-spectrum
antibiotics with CSF penetration should be employed empirically, with adjustments based on
the subsequent cultures. A noticeable contour defect is always a possibility in the management
of frontal sinus trauma. Meticulous reduction and fixation of all bone fragments and the
appropriate use of bone grafts, titanium mesh, and bone cements are critically important for
avoiding this complication.
The formation of a frontal mucocele, which may progress to mucopyocele, frontal bone
osteomyelitis or endbrain abscess, are well-known complications of frontal sinus fractures.
15. Conclusion
The appropriate treatment of frontal sinus fractures is a controversial issue. Frontal sinus
fractures represent only a small percentage of patients that require the evaluation by a
comprehensive trauma service. The majority of patients will also present with concomitant
facial fractures. A functional sinus can be preserved in the majority of patients, regardless of
the degree of displacement, depending on the status of the nasofrontal duct, the amount of
posterior table comminution, and the presence of significant neurologic injury or dural injuries.
Frontal sinus obliteration is not a major component in the treatment of patients. The most
important factor when treating a patient is to establish a secure barrier between the cranial
fossa and the nose to prevent CSF leak, meningitis, and ascending regrowth of the sinonasal
mucosa.
Author details
Roozbeh Kahali* and Alireza Tootoonchian
*Address all correspondence to: roozbehkahali@gmail.com
Department of Oral and Maxillofacial Surgery, Bouali Hospital, Islamic Azad University of
www.dentalbooks.co
References
[1] Donald PJ. Frontal sinus fractures in otolaryngology, head and neck surgery. Cum‐
mings, ed. St. Louis: CV Mosby Co,1986:901
[2] Hollinshead WH. Anatomy for surgeons. Vol. 1. 3rd ed. New York: Harper & Row,
1982:249
[3] Manolidis S, HollierJr LH. Management of frontal sinus fractures. PlastReconstr‐

Surg2007; 120(December (7 Suppl. 2)):32S–48S
[4] Gerbino G, Roccia F, Benech A, Caldarelli C.Analysis of 158 frontal sinus fractures:
current surgical management and complications. J CraniomaxillofacSurg
2000;28(June (3)):133–9
[5] Dewall J. The ABCs of TBI.Evidence based guidelines for adult traumatic brain injury
care. JEMS 2010;35(April (4)):54–61. quiz 63
[6] Manolidis S. Frontal sinus injuries: associated injuries and surgical management of
93patients. J Oral MaxillofacSurg 2004;62(July(7)):882–91
[7] Cantrell R: Fractures of the frontal sinus. Trans Pac Coast Otoophthalmol Soc Annu
Meet 55:101, 1974
[8] Harris L, Marano G, McCorkle D: Nasofrontal duct: CT in frontal sinus trauma. Radi‐
ology 65:195, 1987
[9] Godin D, Miller R: Frontal sinus fractures. J La State Med Soc150:50, 1998
[10] Wallis A, Donald P: Frontal sinus fractures: A review of 72cases. Laryngoscope

98:593, 1988
[11] Donald PJ, Bernstein L. Compound frontal sinus injuries with intracranial penetra‐
tion. Laryngoscope 1978;88:225-32
[12] Stuzin JM, Waystrom L, Kawamoto HK, et al: Anatomy of the frontal branch of the
facial nerve: The significance of the temporal fat pad.PlastReconstrSurg 83:265-271,
1989
[13] Montgomery WW: State-of-the-art for osteoplastic frontal sinus operation.Otolaryng‐

olClin North Am 34:167-177, 2001
[14] Hardy JM, Montgomery WW: Osteoplastic frontal sinusotomy—ananalysis of 250

operations. Ann Otolaryngol 85:523-532, 1976
[15] Sataloff R: Surgical management of the frontal sinus. Neurosurgery15:593, 1984
[16] Stevens M, Kline S: Management of frontal sinus fractures. J Craniomaxillofac Trau‐

ma 1:29, 1995
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[17] Stanley R, Becker T: Injuries of the nasofrontal orifices in frontal sinus fractures. Lar‐
yngoscope 97:728, 1987
[18] Stanley R: Fractures of the frontal sinus. ClinPlastSurg 16:115,1989
[19] Stanley R: Management of severe frontobasilar skull fractures.OtolaryngolClin North

Am 24:139, 1991
[20] Schmitz J, Lemke R, Smith B: The perimeter marking technique for rigid fixation of
frontal sinus fractures: Procedure and report of cases. J Oral MaxillofacSurg 52:1120,
1994
[21] McGraw-Wall B: Frontal sinus fractures. Facial PlastSurg 14:59,1998
[22] Kennedy DW, Bolger WE, Zinreich SJ: Diseases of the Sinuses:Diagnosis, and Man‐
agement. Hamilton and London, BC Decker, 2001
[23] Mendians AE, Marks SC: Outcome of frontal sinus obliteration.Laryngoscope

109:1495-1498, 1999
[24] Donald PJ, Ettin M: The safety of frontal sinus obliteration when sinus walls are
missing. Laryngoscope 96:190-193, 1986
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Chapter 22
Endoscopic Oral and Maxillofacial Surgery
Gholamreza Shirani,
Shiva Solahaye Kahnamouii and
http://dx.doi.org/10.5772/59160
1. Introduction
Endoscopy is the examination and inspection of the interior of body organs, joints or cavities
through an endoscope. Endoscopic surgery uses scopes that go through small incisions or
natural body openings to diagnose and treat disease. Another popular term is minimally
invasive surgery (MIS), which emphasizes that diagnosis and treatment can be done with
reduced body invasion. Endoscopes are revolutionary surgical tools that provide detailed
video images, allowing visualization of internal structures through a skin incision the width
of a thumb and an entry into the organ smaller than a pushpin. Small instruments that can cut,
sample, or destroy abnormal tissue or tumors can also be passed through these tubes, allowing
intricate surgery to be performed with little or no trauma. Endoscopy allows physicians to
peer through the body's passageways.
Construction An endoscope uses two fiber optic lines. A "light fiber" carries light into the body
cavity and an "image fiber" carries the image of the body cavity back to the physician's viewing
lens. The portion of the endoscope inserted into the body may be rigid or flexible, depending
upon the medical procedure. There is also a separate port to allow for administration of drugs,
suction, and irrigation. This port may also be used to introduce small folding instruments such
as scalpels, scissors, forceps, brushes, snares and baskets for tissue excision (removal),
sampling, or other diagnostic and therapeutic work. They are inserted through different
incisions and are used to perform the operation. Endoscopes may be used in conjunction with
a camera or video recorder to document internal mages. New endoscopes have digital
capabilities for manipulating and enhancing video images (Figures 1 and 2).
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used to perform the operation. Endoscopes may be used in conjunction with a camera or video
recorder to document internal mages. New endoscopes have digital capabilities for
manipulating and enhancing video images (Figures 1 and 2).

Figure 1: This figure shows an endoscope. The "image fiber" leads from the ocular (eye piece)
Figure 1. This figure shows an endoscope. The "image fiber" leads from the ocular (eye piece) to the inserted end of the
to the inserted end of the scope. The "light fiber" is below and leads from the light source to
scope. The "light fiber" is below and leads from the light source to the working end of the endoscope.
the working end of the endoscope.
Figure 2: Endoscopic surgery equipment and instruments
Figure 2. Endoscopic surgery equipment and instruments
2 1.1. Endoscopic plastic surgery
Endoscopic plastic surgery is one of the newest plastic surgery techniques. It allows surgeons
to operate with fewer conspicuous incisions, reducing obvious scars. Improvements in
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technology have enabled surgeons to use endoscopy for many cosmetic procedures, including
facelifts, forehead lifts, etc. Endoscopy can also be used in some reconstructive procedures. In
many cases, the use of endoscopy results in shorter recovery.
Candidates must be in good health, have no active diseases or serious pre-existing medical
conditions, and must have realistic expectations of the outcome of the surgery. Smoking,
having recently quit smoking and being exposed to second-hand smoke are all contraindica‐
tions. Primary and secondary smoking decreases blood flow to the body's tissues. This can
result in prolonged wound healing, skin loss, infection, increased scarring, and a number of
other complications depending on the kind of procedure performed.
The endoscope is merely a new tool to better achieve just that objective. Outcome enhance‐
ments initially predominated in aesthetic applications, but widespread use also in reconstruc‐
tive endeavors has proved that today there is indeed a broad scope for minimally invasive
surgery.
The goal of what today would be considered minimally invasive surgery may be to even
surpass the outcomes possible with traditional open techniques, with diminished patient
morbidity including accelerated recovery time and, at the same time, reducing overall
healthcare costs. Initially conceived as a means to allow the direct examination of internal
organs while avoiding large incisions, the origins of the clinical application of this concept can
be traced back to Hippocrates in ~400 BC who used a rectal speculum to examine hemorrhoids.
[1] The centuries to follow fostered slow, incremental improvements in instrumentation and
light sources that would eventually allow the requisite access as well as proper illumination
of the operative field. However, not until the 1950s did the advent of fiber-optic technology
permit the transmission of light from an external light source along long, flexible glass or plastic
threads so that a clear image could be obtained, yet now without risk of thermal injury.[1]
In 1990, ongoing research efforts at the University of Alabama at Birmingham culminated

in reports of a broad clinical experience in endoscopy including endoscopic brow lift.[2]
Nowhere were the early demands for minimally invasive surgery so prevalent than in
cosmetic surgery.[3]
The interest in aesthetic endoscopic plastic surgery still predominates today, [4]-[11] and there
is a concomitant explosion of novel applications in reconstructive surgery. An early thrust of
the latter included relatively simple maneuvers such as the removal of benign lesions,
decompressive fasciotomy for extremity compartment syndrome,[14] or retrieval of spare
body parts such as tendon,[15] vein,[16] or nerve[17],[18] grafts. Congenital deformities such
as torticollis[19] especially in the pediatric age group, [13] have been well suited to endoscopic
correction, as the cosmetic result often is a major consideration. Acquired defects like facial
fractures[20] may be directly or indirectly repaired. More complex indications for various
tissue manipulations have included the safe placement of tissue expanders [21], [22] or harvest
of local[23] or free adipofascial, muscle, and visceral flaps using endoscopic assistance. The
realm in the future may be endoscopic robotic surgery for even greater precision, including
not just the difficult and safe dissection of the vascular pedicles of all flaps but also the
performance even of the microanastomoses themselves.[23], [24] The capability for all these
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tissue manipulations could someday then be routinely performed in any distant land or even
on another planet, where the immediate availability and skills of a surgeon will no longer be
a concern!
2. Endoscopic sinus surgery
The sinuses are air-filled holes in the skull. They are connected to the nose and can get infected
leading to discharge, pain, etc. This may be caused by allergies, polyps, abnormal shape or
swelling inside the nose. Medical therapies, such as antibiotics, steroids, nasal sprays and
decongestants will often cure bouts of sinusitis. Sinus surgery is advocated in those patients
who fail to improve after medication. There are circumstances when immediate sinus surgery
is warranted. Tumors of the sinuses, whether benign or malignant, often require surgical
removal. Surgery may be the only option for some patients whose sinus condition aggravates
other medical problems such as asthma. Cancer or immunocompromised patients may require
drainage for culture or for treatment of a fungal infection. In the past, surgeries requiring an
performed using endoscopic technology (via small cameras through the nose), elim
incision under the lip (Caldwell-Luc) or face (external ethmoidectomy) were used to drain
sinus
the cavities.
need Most proceduresincisions.
for external are now performed using sinus
Endoscopic endoscopic technology
surgery uses (via small
small rods of light
cameras through the nose), eliminating the need for external incisions. Endoscopic sinus
surgery uses small rods of light with a camera (endoscope) to operate through the nostrils into
camera (endoscope) to operate through the nostrils into the sinuses (Figure 3).
the sinuses (Figure 3).

Figure 3. Entry to the sinus from the nostrils

This does not involve any incisions on the face, but may be combined with other external
Figure 3: Entry to the sinus from the nostrils
approaches, which may involve cuts. This surgery is usually done under general anesthesia
for patient comfort. A CT scan will serve as a road map for the surgeon. ESS has presented a
new philosophy allowing the surgeon to target the ostiumeatal complex (OMC). Obstruction
This
of thedoes
OMC not involve
can lead any incisions
to subsequent infectionon the
of the face, but
maxillary, may
frontal andbe combined
sphenoid with other e
sinuses.
approaches, which may involve cuts. This surgery is usually done under general anesthe
patient comfort. A CT scan will serve as a road map for the surgeon. ESS has presented
philosophy allowing the surgeon to target the ostiumeatal complex (OMC). Obstruction
OMC can lead to subsequent infection of the maxillary, frontal and sphenoid s
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Accordingly, ESS removes thickened and diseased tissue blocking the OMC. Most of the
healthy tissue in the sinuses is undisturbed allowing for faster and better overall recovery.
Endoscopic surgery can also be utilized for removal of polyps, nasal masses and sometimes
straightening the septum to improve nasal airflow.
2.1. Functional endoscopic sinus surgery
Functional endoscopic sinus surgery (FESS) is the mainstay in the surgical treatment of
sinusitis and nasal polyps, including bacterial, fungal, recurrent, acute and chronic sinus
problems. FESS is a relatively recent surgical procedure that uses nasal endoscopes (using
Hopkins rod lens technology) through the nostrils to avoid cutting the skin. FESS came
into existence through the pioneering work of Drs. Messerklinger (in 1960 to 1970's) and
his assistant Stamberger who became chief of the ENT department in Graz, Austria. Other
surgeons have made additional contributions (first published in the USA by Kennedy in
1985).[25]
By the early 1990's endoscopic sinus surgery become one of the most popular procedures. In
their 1990 publication, Stamberger [26] mentioned operating 4500 patients, roughly 450
patients annually. Most procedures were very limited surgical procedures; diseased ethmoid
compartments were operated on (usually the ethmoidal bulla), stenotic clefts were widened
(uncinate process) and prechambers (agar nasi cells) to the frontal and maxillary sinuses were
freed from disease.
2.2. Indications
The most common indication for endoscopic sinus surgery is “chronic rhinosinusitis”. Chronic
rhinosinusitis is a term applied to various nasal processes which involve inflammation of the
nose and sinuses that do not adequately improve with medical management. Less common
indications include (but are not limited to): recurrent infections (rather than chronic inflam‐
mation), complications of sinus infections, nasal polyps, mucoceles, chronic sinus headaches,
impaired sense of smell, tumors of the nasal and sinus cavities, cerebrospinal fluid leaks,
nasolacrimal duct obstruction, choanal atresia, and the need to decompress the orbit. Addi‐
tionally, recent advances in endoscopic techniques allow the operator to provide access to areas
of the brain and pituitary gland for neurosurgeons or to the orbits (eye sockets) for certain
ophthalmology procedures.
2.3. Technique
The frontal, maxillary, and anterior ethmoid sinuses drain into the middle meatus. Posterior
ethmoids drain into the superior meatus. Sphenoid sinuses drain into the sphenoethmoid
recess. Telescopes with diameters of 4mm (adults) and 2.7mm (pediatrics) and with a variety
of viewing angles (0 to 30, 45, 70, 90, and 120 degrees) provide good illumination of the inside
of the nasal cavity and sinuses. High-definition cameras, monitors and a host of tiny articu‐
lating instruments aid in identifying and restoring the proper drainage and ventilation
relationships between the nose and sinus cavities. Cultures and biopsies can be easily obtained
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to yield valuable diagnostic information to guide postoperative therapy for optimal long term
results.
All the sinuses can be accessed at least to some degree by means of this device: The frontal
sinuses located in the forehead, the maxillary sinuses in the cheek bones, the ethmoid sinuses
between the orbits, and the sphenoid sinuses are located in the back of the nasal cavity at the
base of the skull.
2.4. Extended approaches
Endoscopic access to pituitary tumors has been successfully accomplished for many years.
More recently, further advanced techniques have allowed the paranasal sinuses to be a
relatively low-morbidity approach to selected tumors even inside the skull or brain.
2.5. Benefits of ESS
The overall goal of sinus surgery is to improve the drainage pathway of the sinuses. By opening
the natural drainage pathway of the diseased sinus, the frequency, duration and severity of
infections should be reduced. Sinus surgery is not without risk, but it does have major benefits.
Sinus issues left uncorrected may lead to abscess formation, permanent loss of sense of smell
vision, or even death. Benefits of sinus surgery include asthma relief, polyps and fungus
removal and less recurrence of sinus infections.
Although there are patients who have mechanical obstruction due to their particular anatomy,
many patients have an intrinsic problem with the lining (mucous membrane) of their nose and
sinuses. While the patients with mechanical obstruction, will receive the maximal benefit from
surgery, the benefit for patients with mucous membrane disease is also tangible because the
larger opening created during surgery will allow better drainage and more medication and
rinses to get into the sinuses and help treat the diseased lining.
One of the most important benefits of surgery is the ability to deliver medications (e.g. sprays,
rinses, nebulized drugs) to the lining of your sinuses after they have been accessed. Therefore,
surgery is an adjunct to, not a replacement for, proper medical management. It is important
to note, however, that if you are one of the patients who have diseased mucous membranes
or form nasal polyps, no amount of surgery can change this fact. So although surgery plays a
role in managing the disease, it may not cure sinus disease with polyps or other types of chronic
inflammation. Therefore, it should be emphasized that surgery is one of the multiple steps in
managing the disease.
2.6. Possible risks and complications related to functional endoscopic sinus surgery
Extreme care is required with this surgery due to the proximity of the sinuses to the eyes, optic
nerves, brain and internal carotid arteries. However, these serious risks are rare occurrences
and there are many potential benefits from a well-performed endoscopic sinus surgery with
appropriate indications. All surgical procedures have risks and complications namely:
1. Bleeding from the nose in the days following the operation

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2. Infection
3. Injury to the nasolacrimal duct or sac
4. Need for frequent post-surgical visits for cleaning
5. CSF leak
6. Impaired taste and/or smell (usually temporary)
2.7. CT navigation
Computed tomography (CT) navigation is a tool that may be used by surgeons to better
correlate surgical anatomy with pre-operative CT imaging. A computer is used to identify the
3-dimensional location of a probe tip placed within the patient's nose or sinuses.
Definitive proof that CT navigation improves outcomes and decreases complications is
lacking. A Swedish study of 212 patients undergoing sphenoethmoidectomy published in 2008
concluded that the clinical success of the procedure was similar with or without the use of CT
navigation, and that the rate of complications might be slightly reduced.[27]
3. Endoscopic facelift (forehead lift, brow lift, midface lift)
As humans age, lines and wrinkles naturally form on the forehead due to constant muscle
movement, making one look older than he/she would like. Additionally, those horizontal lines
across the forehead, or vertical lines between the brows, can cause one to look angry, stressed,
or simply unpleasant and unapproachable. Fortunately, with the help of endoscopic surgery,
one can achieve a fresh-faced, smooth, youthful appearance.
3.1. Technique
In preparation for a classic forehead lift, the hair is tied back with rubber bands in front and
behind the incision area. An incision is usually made across the top of the head, just behind
the hairline. Forehead skin is gently lifted and portions of facial muscle and excess skin are
removed. The incision is then closed with stitches or clips. The result of a forehead lift is a
younger, more rested look (Figure 4).
In an endoscopic forehead lift, the muscles and tissues that cause the furrowing or drooping
are removed or altered to smooth the forehead, raise the eyebrows and minimize frown lines.
Surgeons may use the conventional surgical method, in which the incision is hidden just
behind the hairline; or it may be performed with the use of an endoscope. Both techniques
yield similar results, smoother forehead skin and a more animated appearance.
Low, heavy "V" shaped eyebrows create a tired, older, masculine, unfriendly appearance.
Opening up the eyes and brows and smoothing the forehead is both powerful and subtle.
Patients look more awake, fresh, healthy and youthful. Forehead surgery is normally done in
combination with an eye lift (blepharoplasty) for best results.
hairline. Forehead skin is gently lifted and portions of facial muscle and excess skin a
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The incision is then closed with stitches or clips. The result of a forehead lift is a yo
rested look (Figure 4).

Figure 4. Classic forehead lift incision
Figure 4 : Classic forehead lift incision
Before the operation, motivations and demands of the patients must be analyzed. A careful
study of the upper facial region and its relations with the rest of the face should be made. A
In an endoscopic forehead lift, the muscles and tissues that cause the furrowing or
preoperative assessment is normally conducted as required. The anesthesiologist will be seen
in consultation
removed ator the altered
latest 48 hours before surgery.
to smooth No medication
the forehead, containing
raise aspirin should
the eyebrows and minimize
be taken within 10 days prior to surgery. Smoking cessation is strongly recommended at least
one month before and one month after surgery. An antiseptic shampoo should be used the
Surgeons may use the conventional surgical method, in which the incision is hidden
night before and / or in the morning. It is essential to fast (not eat or drink) 6 hours before
surgery.
the hairline; or it may be performed with the use of an endoscope. Both techniques
results, smoother forehead skin and a more animated appearance.
3.2. Type of anesthesia
Two methods are possible:
Low, heavy "V" shaped eyebrows create a tired, older, masculine, unfriendly
• Local anesthesia deepened by intravenous tranquilizer
Opening up the eyes and brows and smoothing the forehead is both powerful
• General anesthesia
Patients
The choice look
between more
these awake,
different fresh,
techniques healthy
will and ofyouthful.
be the result a discussionForehead surgery is norm
between patient,
surgeon and the anesthesiologist.
combination with an eye lift (blepharoplasty) for best results.
Hospitalization is short. The admission is in the morning (or even the day before in the
afternoon) and the discharge is permitted either in the evening or the day after the operation.
Before the operation, motivations and demands of the patients must be analyze
3.3. Technique
study of of endoscopic
the forehead
upper facial and eyebrow
region and its lift
relations with the rest of the face should
Each surgeon adopts his/her own technique that he/she adapts to in each case in order to obtain
preoperative assessment is normally conducted as required. The anesthesiologist w
the best results. However, some common basic principles are as follows:
Incisions are between 5 and 10 mm long, are three to five in number and are placed in the scalp,
consultation at the latest 48 hours before surgery. No medication containing aspir
a few centimeters behind the forehead hairline. One of them will allow the passage of the
taken within 10 days prior to surgery. Smoking cessation is strongly recommended
endoscope connected to a mini video camera, the other giving way to the different instruments
9
Incisions are between 5 and 10 mm www.dentalbooks.co
long, are three to five in number and are placed in the
scalp, a few centimeters behind the forehead hairline. One of them will allow the passage of the
endoscope connected to a mini video camera, the other giving way to the different instruments
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specifically adapted to endoscopic surgery. The path of these incisions is of course the future
specifically adapted to endoscopic surgery. The path of these incisions is of course the future
location of scars, which are therefore virtually invisible since they are very short and hidden in
location of scars, which are therefore virtually invisible since they are very short and hidden
in the hair. Detachment includes the temples and facial bones (Figures 5 and 6).
the hair. Detachment includes the temples and facial bones (Figures 5 and 6).
Figure 5: Incision sites for endoscopic forehead (brow) lift surgery
Figure 5. Incision sites for endoscopic forehead (brow) lift surgery

10

Figure 6.Figure 6: Dissection and suturing during endoscopic surgery
Dissection and suturing during endoscopic surgery
Replacement: Loose tissue will be retightened to soften the “crow’s feet”, move the tail of the
eyebrows upward, and above all the cheek and fat under the eyes that had accumulated over
the nasolabial folds will be held in position by deep fixation.
Sutures: The small incisions are closed, often with skin staples that are easily removed or with
buried absorbable sutures.
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Replacement: Loose tissue will be retightened to soften the “crow’s feet”, move the tail of the
eyebrows upward, and above all the cheek and fat under the eyes that had accumulated over
the nasolabial folds will be held in position by deep fixation.
Sutures: The small incisions are closed, often with skin staples that are easily removed or with
buried absorbable sutures.
Depending on the surgeon, the extent of improvements and the possible need for additional
procedures, the intervention may take 2 to 3 hours. Possibly some discomfort with a feeling
of tension on the temples and cheek may occur. The postoperative course is mainly marked
by the appearance of edema (swelling) and ecchymosis (bruising) the size and duration of
which is highly variable from one individual to another. The dressing should be removed
between the 1st and 3rd days. Staples are removed between the 8th and 15th day. The stigma
of the intervention will diminish gradually, allowing the return to normal social and profes‐
sional life after a few more days (10-20 days depending on the magnitude of the surgery). Some
numbness of the operated area, possibly some itching on the skull, may be observed during
the first weeks. They gradually disappear. A delay of 3 to 6 months is necessary to assess the
final outcome. This is the time for all of the edema to be reabsorbed and for the tissues to regain
their flexibility. In most cases, intervention results in improvement and significant rejuvena‐
tion of the upper face, with an attenuation of nasolabial folds, padding the area under the eyes
and cheeks (with disappearance of the “valley tears”) and a decrease of the lower eyelid height.
The results are generally durable, although the aging process is not stopped by the interven‐
tion, the benefit of the lift will be present many years after.
3.4. Ideal candidates

Most patients opting for lifting are aged between 40 and 50 years, when brow lines and eyelids
begin to sag noticeably and wrinkles or creases begin to appear along the forehead. Heredity
sometimes causes these problems for people in their 20s and 30s, in which case a brow lift can
help. Anyone considering this procedure should have a thorough understanding of what it
can and cannot accomplish. After an in-depth discussion, some decide that a brow lift
performed in conjunction with other procedures (e.g. a facelift (rhytidectomy) or eyelid
surgery (blepharoplasty) will provide the best results
3.5. Facelift complications

All surgical procedures carry some uncertainty and risk. Even in the best hands, complications
do occur. Fortunately, these are usually treatable. Patients vary in their anatomy, physical
reaction to surgery, anesthesia, and healing capabilities, so that the outcome is never com‐
pletely predictable. Surgeons know from experience that two operations in different patients,
done almost exactly the same way, may have very different outcomes. Even operations on two
sides of the same face or body can have different outcomes, particularly in terms of discomfort,
bruising and swelling. Patients are often surprised at this.
It is best if patients anticipate having a complication, and if they do not that is a bonus. There
is a well-known phrase in surgery: “The only way to avoid complications is by not operating.”
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Experienced surgeons, particularly toward the end of their careers, are often very candid and
admit that they’ve seen just about every complication in their practice over the years. It is
important for the patient and doctor to have a mutual trustful relationship to manage com‐
plications when they develop.
A complication rate of 1% is commonly quoted. It seems small, only one in a hundred, and
perhaps this is a rate that is comfortable from a psychological standpoint, an event that
sometimes happens to other people. But it should not be too reassuring, even if it is correct. If
patients encounter a complication, it’s 100 percent as far as they are concerned. They have to
understand that it could happen to them. They should have the surgery only if they can tolerate
the risks.
Facelift risks and complications may include:
1. Excessive scarring, bleeding, hematoma, infection, skin necrosis, facial weakness or

paralysis caused by facial nerve injury, asymmetry, numbness, burning or cold sensations,
facial pain, skin contour irregularities, skin discoloration, swelling, hair loss along the
incision lines or elsewhere and corneal injury.
2. Corneal injury. It is imperative that the corneas be protected from drying out. Normally,
at night, the cornea is protected by the closed eyelids. However, after surgery, the eyelids
may not close completely, due to swelling or weakness of the orbicularis muscle that
encircles the eyelids. Incomplete eyelid closure places the cornea at risk. Until eyelid
function returns, it is imperative that the corneas be kept from drying out with the use of
lubricating ointment and eye drops.
3. Earlobe deformity ("pixie ear") is an unnaturally tethered ear. The earlobe is pulled down
by the facelift scar. Usually this results from too much skin removal around the ear, so
that there is tension on the skin closure, pulling down on the earlobe. Experienced plastic
surgeons avoid any skin tension in the area of the earlobe to prevent such a complication
of surgery.
4. The “lateral sweep,” is an unnatural, operated-on appearance that can happen after
facelifts that draw back on the skin of the lateral face, while leaving the vertical descent
of the cheek and jowl untreated. The skin form may form horizontal folds. It is not a
harmonious or pleasing appearance.
5. Another post-surgical problem is “joker’s lines,” unnatural lines of tension that extend
from the corners of the mouth to the ears. Both problems may be prevented, and treated,
with a deep-plane facelift that incorporates a cheek lift.
6. Tragal deformity: flattening of the tragus (the small bump just in front of the ear canal)
may be avoided by using a pre-tragal incision, which is my preference. The tragus is a
unique structure that is very difficult to recreate.
7. Nerve damage may concern some sensory branches and then be responsible for certain
insensitivity and itching of the forehead and scalp that eventually subside after a few
months. A paralysis of the frontal branch is much rarer and, fortunately, is only temporary
in most cases described.
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8. General dissatisfaction with the cosmetic results, possibility of revision surgery, depres‐
sion or emotional mood changes may also develop.
3.6. Preoperative instructions
Before undergoing brow lift surgery, we must provide pre-operative instructions; these may
include:
1. Stopping smoking four weeks before surgery
2. Stop taking certain medications, herbs, and vitamins (including those that thin the blood)
two weeks before surgery
3. Purchase all supplies that will be needed during recovery, including pain medication,
bandages, and groceries, before the day of surgery
4. Not eating or drinking anything after midnight the day of surgery
5. Not wearing make-up, contact lenses, or jewelry on the day of surgery
6. A family member or friend should drive the patient home.
3.7. Benefits of brow lift surgery
All men and women over the age of 40 see signs of aging in the face. The forehead is usually
one of the first places where lines and wrinkles appear due to excessive muscle movement.
Fortunately, brow lift surgery can do away with a number of cosmetic flaws on the upper third
portion of the face. The many benefits of brow lift surgery include: Increase confidence with
enhanced appearance, rejuvenated appearance, alleviation of tension in the forehead muscles,
causes minimal side effects, fast recovery, excellent, long-lasting results (up to 10 years or
more), incisions are well hidden and scarring is minimal, natural-looking results and few
potential risks or complications.
4. Endoscopic midface lift
An endoscopic mid-facelift, also known as the anti-gravity lift, is a surgical procedure able to
provide a natural, more youthful and refreshed appearance to the face by repositioning
sagging cheeks, softening smile lines, reducing lower eye hollowness, elevating the corners of
the lips, and restoring cheek fullness.
4.1. Best candidates
The best candidate for an endoscopic mid-facelift is a physically healthy man or woman who
has realistic expectations and is interested in improving the appearance of sagging or sunken
cheeks, smile lines, lower eye hollowness, and sagging corners of the lips. The procedure is
ideal for patients in their late thirties to early sixties.
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4.2. Technique
After anesthesia is administered, tiny incisions are placed inconspicuously within the hairline
at the temple and inside of the mouth. An endoscope is inserted into the incisions to help guide
the surgeon as he or she elevates the fat pads of the cheeks as well as the deeper tissues. The
incisions are then closed with sutures (Figure 7).
Figure 7. Schematic endoscopic midface lift. Tiny incisions are inconspicuously placed within the hairline at the temple
and inside of the mouth, thus allowing for no visible scarring. There is no visible scarring after an endoscopic mid-
facelift as very tiny incisions are inconspicuously placed inside of the mouth and within the hairline at the temple.
After an endoscopic mid-facelift, patients typically experience minimal discomfort which can
easily be controlled with pain medication. Swelling and bruising may occur and typically fades
within a few weeks. The head should be elevated for the first few days to help minimize
swelling. Stitches are typically removed within seven days. Patients can typically return to
work within a week after an endoscopic mid-facelift. As with all types of surgery there are
potential complications that can occur with an endoscopic mid-facelift.
5. Endoscopic repair of facial fracture
Endoscopy is not a new concept; it is however, relatively new to the field of craniomaxillofacial
surgery. Surgeons weigh the risk of an operation and its approach against the benefits of
preventing complications, and recommend surgery based on this analysis. In general, if a
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procedure has a lower risk of complications, it is more widely applied. Endoscopic techniques
may provide lower rates of complications and higher acceptance rates in patients, and
therefore, they may be more widely employed. Because these techniques are very detailed and
have a steep “learning curve,” surgeons should be patient in their evaluation and use.
5.1. Frontal sinus fracture repair
Fractures of the frontal sinus and orbit are relatively common in facial trauma patients (5 to
15% of all maxillofacial traumas).[28]-[31] Although a significant percentage of these fractures
can be managed non-operatively, operative intervention is often required to avoid late
complications. Frontal sinus fracture is commonly treated via an endoscope. If the fracture is
a simple type that places a small depression on the forehead, it is very amenable to endoscopic
techniques. Frontal sinus fractures essentially come in four types.
The first type is anterior table fracture only, which is perfect for endoscopic technique because
these fractures are the easiest to treat and the most conspicuous. The fragments must be
evaluated with anatomic precision. The bony fragments may be reduced in situ or, more likely,
removed, plated, and replaced either through a scalp or a brow incision.
The second (most common) fracture type is fracture of the anterior and posterior tables.
Because a large amount of energy is required to cause this type of fracture, patients are often
comatose or require c-spine precautions and wound care until open reduction and internal
fixation (ORIF) can be done. These fractures are often associated with CSF leakage and need
not only facial and sinus surgery, but also dural repairs and brain surgery. Patients often
require cranialization of the sinus and cannot be treated with endoscopic techniques.
The third type of fracture is fracture of the posterior table itself. These fractures are rare, but
when they occur they require a craniotomy for repair.
The fourth type of fracture is one that disrupts the ducts. If the duct is damaged, the patient
would benefit from some procedure to defunctionalize the sinus. This could be cranialization
(if a craniotomy is required) or obliterations with bone or fat.
An illustration detailing the incisions for endoscopic repair of anterior table frontal sinus
fractures can be seen in Figure 8.
5.2. Orbital fractures
Orbital fractures are common and typically occur as blow-out fractures (BOF). BOF fractures
are fractures that result in trauma directly over the orbital rim and floor. These fractures are
not associated with the typical zygomaticomaxillary complex fractures. Medial orbital
fractures are treated similarly to floor fractures except that these require more extensive
knowledge of intranasal anatomy. To undertake the endoscopic repair, you must be aware of
endoscopic skull base anatomy and be comfortable taking or medializing the middle turbinate
and taking the uncinate process and ethmoid bulla down. Medial wall fractures are essentially
an extended ethmoidectomy and treated via placement of an alloplastic sheet.
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Figure 8. Illustration of incisions used for endoscopic repair of anterior table frontal sinus fractures. The working inci‐
sion is in line with the fracture. The endoscope incision is just medial to the working incision.
The instrumentation is virtually identical. These techniques were first used for endoscopic
subcondylar repair [28]-[30] and are now also used for transantral orbital floor reconstruction,
zygomatic arch and frontal sinus repair. Subcondylar fractures are difficult to treat openly in
even the best of circumstances and seeing and treating the condyle in its native position has
numerous advantages. Once this use became more common, other facial fractures began to be
examined from an endoscopic perspective.
Some of the more typical complications of orbital fractures are diplopia from muscle entrap‐
ment, visual loss, and exophthalmoses from volume expansion into the surrounding sinus
leading to pseudoptosis. The typical complications from frontal sinus injuries are much less
common but much more significant when encountered. These include frontal contour
irregularities, spinal fluid leak (predisposing to meningitis), ocular complications including
vision loss and blindness and late complications i.e. mucoceles (Figure 9).
Traditionally, external transorbital approaches have been used in the repair of blowout fracture
(BOF) of the orbit. External approaches generally require either a medial canthal incision, a
subciliary incision, or a transconjunctival incision, depending on the location, extent and
complexity of the fracture. External repairs with transorbital incisions have known complica‐
tions that include external scars, ectropion and a frequent need for alloplastic materials to
support the fractured wall.[32]
leading to pseudoptosis. The typical complications from frontal sinus injuries are much less
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common but much more significant when encountered. These include frontal contour
irregularities, spinal fluid leak (predisposing to meningitis), ocular complications including vision
loss and blindness and late complications i.e. mucoceles (Figure 9).
Figure 9. Coronal CT views of left orbital blow-out fracture
Figure 9: Coronal CT views of left orbital blow‐out fracture
Endoscopic repair of BOF of the orbit has been reported to provide surgeons with several
advantages over conventional external repair. [32]-[42]
Traditionally, external transorbital approaches have been used in the repair of blowout fracture
First, it provides excellent visualization of the medial and inferior walls of the orbit, which
(BOF) of the orbit. External approaches generally require either a medial canthal incision, a
enables safe removal of bony fragments and clear anatomic reduction of fractures. Second, the
use of intraocular alloplastic implants, commonly used with external repairs, can be avoided
subciliary incision, or a transconjunctival incision, depending on the location, extent and complexity
or minimized.
of the fracture. External repairs with transorbital incisions have known complications that include
Third,
external endoscopy
scars, virtually
ectropion and a eliminates
frequent the risk
need ofalloplastic
for significantly visible facial
materials scarring
to support and
the eyelid
fractured
complications, reported with transorbital incisions. Fourth, endoscopic surgery can be
32
wall.performed
under local anesthesia, which makes intra-operative evaluation of ocular move‐
ments and diplopia possible.
Endoscopic repair of BOF of the orbit has been reported to provide surgeons with several
When the anterior maxillary wall is fractured, Medpor is used to support the orbital floor; an
32‐42
advantages over conventional external repair.
endoscope enables clear identification of the bony shelves so that the implant can be placed
safely and with adequate support (Figures 10 and 11).
No specific major disadvantages have been reported for endoscopic repair of BOF.[42], [43]
One potential difficulty with transantral repair of inferior BOF is in the fabrication and
maintenance of a balloon that conforms to the shape of the orbital floor to support the reduced
19
orbital tissue. Under usual circumstances, the balloon is removed three to four weeks after
surgery.
In medial BOF, the balloon can be removed early if the fracture is small or if only those bony
fragments that might interfere with ocular muscle function are removed. In inferior BOF, the
balloon can be removed early when a trapdoor type fracture is reduced with the bony fragment
intact or when the fracture site is supported by a large bony fragment or implant. Usually, the
balloon packing that supports the medial wall can be removed earlier than a balloon catheter
that supports the inferior wall because the inferior wall must be rigid enough to support the
orbit against gravity. Failure of diplopia to improve after adequate repositioning of orbital
tissue is not an infrequent outcome after surgery for BOF. [42], [45] There are a few explanations
for residual diplopia even after adequate surgery.
When the anterior maxillary wall is fractured, Medpor is used to support the orbital floor; an
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endoscope enables clear identification of the bony shelves so that the implant can be placed safely
and with adequate support (Figures 10 and 11). http://dx.doi.org/10.5772/59160
Figure 10. endoscopic repair of orbital floor fracture via alloplastic material
Figure 10: endoscopic repair of orbital floor fracture via alloplastic material
Figure 11. Medpor with the screw placed as a handle (arrow). Medpor in place to hold periorbital fat above the floor
defect.
20
• The first possible explanation is that entrapment, contusion, or hematoma of ocular muscle
by fractured
• Second, there may be an undetected, persistent palsy of the oculomotor nerve. [45],[46]
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• Third, altered globe position may occur.

Exophthalmos of greater than 2 mm is another indication for surgery, mostly for cosmetic
reasons.
Endoscopic repair of orbital blowout fractures represents an innovative and highly successful
and safe alternative to external repairs.
Early applications for endoscopic treatment of facial trauma include subcondylar fractures of
the mandible, [47]-[50] orbital blow-out fractures, [51]-[56] frontal sinus fractures, [57]-[58] and
zygomatic fractures. [57]-[58]
Advantages of endoscopic repair include the following: More accurate fracture visualization,
small external incisions, reduced soft tissue dissection, potential for visualization around
corners and reduced duration of hospital stay.
Disadvantages of endoscopic repair include the following: Need for delicate instrumentation,
moderate learning curve for the techniques, narrow field of view and limited ability for
bimanual instrumentation without an assistant.
Indications for endoscopic repair are generally related to fracture location, size, degree of
comminution, and the surgeon's ability. Some of the techniques described herein are still under
development, and surgeons contemplating the use of these techniques must determine if
institutional review board approval is necessary.
6. Endoscope-assisted transoral reduction and internal fixation of

mandibular condylar process fractures
Owing to the risk of facial nerve damage and the creation of visible scars, surgical treatment
of condylar mandible fractures using an extraoral approach remains controversial. The
transoral endoscopically assisted approach of condylar fractures has been reported to avoid
these complications. Kokemueller studied closed treatment of mandibular condylar neck
fractures by endosurgical treatments. Treatment options may yield acceptable results for
displaced condylar neck fractures. Especially in patients with severe malocclusion directly
after trauma, endoscope-assisted transoral open reduction and fixation seems to be the
appropriate treatment for prevention of occlusal disturbances.[59], [60]
The treatment of condylar mandible fractures with a minimal invasive endoscopically assisted
technique is reliable and may offer advantages for selected cases, particularly concerning the
lower occurrence of facial nerve damage.[61] In the treatment of condylar injuries, the
endoscope is not only an aid; it alters the treatment philosophy, from the conservative MMF
to anatomic repair. Each surgeon will have to decide on his or her indications for endoscopic
repair, and indeed this may depend heavily on his or her experience and patient preference.
The authors feel that anatomic reduction and fixation are the best ways to restore preinjury
facial aesthetics and mandibular dynamics and to prevent late sequelae of internal derange‐
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ment. Thus, nowadays surgeons strongly advocate endoscopic repair of adult condylar neck
and subcondylar fractures that demonstrate severe displacement or dislocation.
7. Summary
The use of endoscopes has become one of many standard methods for treatment of fractures
within the head and neck. As the boundaries of endoscopic surgery expand further, patients
will receive the benefits of shorter incisions, less pain and earlier recovery. And, as the surgeons
become more and more facile with the instruments, more indications for this type of repair are
justified, and more patients ultimately benefit from less invasive surgery. Traditional lid
incisions may lead to rates as high as 5 to 10% of lid malposition, which is quite high, consid‐
ering that the fractures in themselves have a very low rate of complications. Initial reports on
transantral approaches were met with some skepticism, but new endoscopic techniques are
much easier to perform and interest in this technique has re-emerged. The main advantages
of these endoscopic techniques for the orbital fractures are: no skin incisions, easy visualization
of the defect, and direct view of the posterior ledge. Despite all these benefits, endosurgery
requires training experience and skill of the surgeon.
Author details
Gholamreza Shirani1, Shiva Solahaye Kahnamouii2* and

Mohammad Hosein Kalantar Motamedi3
*Address all correspondence to: shiva.kahnamouii@gmail.com
1 Department of Oral and Maxillofacial Surgery, Tehran University of Medical Sciences,

Tehran, Iran
2 Department of Oral and Maxillofacial Surgery, Neuroscience Research Center, Drug Ap‐
plied Research Center, Stem Cell Research Center, Cardiovascular Research Center, Tehran
University of Medical Sciences, Tehran, Iran
3 Trauma Research Center, Baqiyatallah University of Medical Sciences and Azad Universi‐
ty of Medical Sciences, Tehran, Iran
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wall fractures. Arch Facial Plast Surg 2000; 2:269 –73.
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[40] Chen CT, Chen YR. Endoscopically assisted repair of orbital floor fractures. Plast Re‐
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[41] Persons BL, Wong GB. Transantral endoscopic orbital floor repair using resorbable
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[43] Dulley B, Fells P. Long-term follow up of orbital blowout fracture with or without
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[46] Wojno TH. The incidence of extraocular muscle and cranial nerve palsy in orbital
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[50] Manolidis S, Hollier L H., Jr Management of frontal sinus fractures. Plast Reconstr
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[51] Mackenzie D J, Arora B, Hansen J. Orbital floor repair with titanium mesh screen. J
Craniomaxillofac Trauma. 1999; 5(3):9–16. Discussion 17–18.
[52] Zingg M, Chowdhury K, Lädrach K, Vuillemin T, Sutter F, Raveh J. Treatment of 813
zygoma-lateral orbital complex fractures. New aspects. Arch Otolaryngol Head Neck
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[53] Munro I R, Fearon J A. The coronal incision revisited. Plast Reconstr Surg. 1994;
93:185–187.
[54] Wolfe S A. The influence of Paul Tessier on our current treatment of facial trauma,
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[55] Walter W L. Early surgical repair of blowout fracture of the orbital floor by using the
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[56] Strong E B, Kim K K, Diaz R C. Endoscopic approach to orbital blowout fracture re‐
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[59] Lesley WS. Endosurgical repair of an iatrogenic facial arteriovenous fistula due to
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[60] Kokemueller H, Konstantinovic VS, Barth EL, Goldhahn S, von See C, Tavassol F, Es‐
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Chapter 23
Regenerative Techniques in Oral and Maxillofacial Bone

Grafting
Arash Khojasteh, Mohammad Esmaeelinejad and

Farzad Aghdashi
http://dx.doi.org/10.5772/59236
1. Introduction
The art and science of reconstruction of maxillofacial bony defects is a field of interest for most
of maxillofacial surgeons due to its importance and prerequisite role for other surgical
procedures. Despite significant improvements during last decades in this field, challenge still
exists to determine which type of reconstruction techniques and materials is the treatment of
choice. Although dental implants are considered as a standard and effective treatment to
restore dental defects nowadays, lack of adequate bone quantity is a pitfall for dental implant
reconstruction procedures. Grafting techniques have a long history in the literature with
different donor sources and technical innovations and improvements. These methods are the
most common techniques in bone reconstruction yet, but in the era of bioengineering, new
alternative horizons lie ahead.
Regenerative techniques for maxillofacial hard tissue reconstruction like other tissue engi‐
neering procedures is based on three principle elements; stem cells, scaffolds, and growth
factors. The balanced scenario of bone induction and conduction is a critical issue in every
bone regeneration procedure [1].
Current approaches used in clinical circumstances to reconstruct bony defects include

different bone grafting methods, such as autologous bone grafts, allografts, bone-graft
substitutes, distraction osteogenesis, and guided bone regeneration.
Bone-graft substitutes have been developed to be used as scaffolds to promote cell migration,
proliferation and differentiation for bone regeneration without need to violate other tissue
from a donor site [2.[
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Distraction osteogenesis and guided bone regeneration are brilliant concepts which work
basically by modifying normal bone healing process. Soft callous enlarging guidance is the
key element in distraction osteogenesis and space maintaining for relatively slow growing
hard tissue is the fundamental of guided bone regeneration techniques. This chapter introdu‐
ces methods of bone reconstruction and regeneration in oral and maxillofacial surgery. Indeed
the knowledge of exact indications and advantages of each method is invaluable for the
surgeon.
2. Anatomy of the skeleton
The fundamental bony skeleton of the jaws consist of a mandible and two maxillary bones.
Because of the functional aspect of these structures and their atrophic changes during aging,
anatomical features have specific importance to distinguish defects and determine the proper
treatment plan. The quantity and quality of bone in the alveolar process and adjacent structures
are the key elements of this issue. The anatomical knowledge of these structures is also a
determinant factor when using them as donor sites for reconstruction.
The alveolar bone of mandible and maxilla is a functional bony process which harbors teeth
in a dentate human. After tooth loss, this bony structure loses its dimensions both vertically
and horizontally [3]. After atrophic sequences, the maxillary alveolar arch diameter decreases,
despite the fact that the mandibular alveolar arch enlarges in diameter and a pseudo-class III
relation may appear in severe atrophic alveolar ridges (Figure 1).
Figure 1. A, The atrophic changes of mandible. B, The atrophic changes of maxilla.
The quality of edentulous alveolar bone is classified to D1, D2, D3 and D4 based on cortical
bone thickness and density of trabecular bone respectively.
D1 demonstrates the thickest cortical bone and the most dense trabecular part and is usually
located in anterior mandible;
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D4 demonstrates a large volume of low density trabecular bone and thin cortices and is located
mainly in posterior maxilla.
D2 and D3 with intermediate characteristics are located in posterior mandible and anterior
maxilla respectively [4].
The maxillary tuberosity is located in the posterior maxillary bone on each side and contains
low density D4 bone and attached to the pterygoid plates at the pterygomaxillary junction. It
is located next to important anatomical structures- the pterygomaxillary fissure and pterygo‐
palatine fossa.
The maxillary sinus is a pyramidal cavity in each maxilla with a broad base medially and an
apex laterally. Its size varies depending on the patient's age and presence of teeth. During the
lifetime the sinus enlarges continuously and at the age about 12, the floor of the sinus is almost
at the level of the nasal floor. Maxillary posterior teeth loss and sinus pneumatization are
responsible for decreasing bone volume in this area.
The mandible is the largest bone of the face and generally consists of thicker cortical bone
compared to the maxilla. The anterior border of ramus as runs toward the mandibular body
creates external oblique ridges bilaterally. The mandibular canal begins from the mandibular
foramen at the middle medial surface of ramus horizontally and vertically and ends at the
mental foramen on the buccal surface of the mandibular body near the apices of the premolar
teeth on both sides. The least distance from the mandibular canal to the buccal cortex is in the
distal part of the mandibular first molars. The canal course through the mandible usually
makes a loop near the mental foramen with about a 3 mm diameter. The neurovascular bundle
travels through this canal to supply sensation and blood to the mandibular teeth and some
part of the chin.
The buccal fat pads or Bichat's fat are located lateral to the buccinator muscles bilaterally and
consist of four parts; body, temporal, buccal, and pterygoid extensions. Buccal fat pads are
supplied by the temporal and transverse facial arteries. The buccal fat pads are very useful
structures in reconstruction of oral defects [5, 6].
3. Recipient site classification and defect analysis
The importance of alveolar bone defect analysis and classification is to determine the best
regenerative treatment for each specific defect. This is more obvious when an evidence-based
decision is made according to all data presented in the literature. Parameters which can
describe alveolar bony defects are:
• Anatomic position of defect in the jaws (mandible/maxilla, anterior/posterior)

• Dimensions of the defect
• Morphology of the defect
• Type of reconstruction (vertical/horizontal)
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• Relation of augmentation and defect region (internal; inside the contour and external,
outside the ridge contour)
• Defect base width and number of residual bony walls surrounding the defect
Anterior and posterior parts of the mandible and maxilla have different bone qualities; hence
they have different regenerative capacities [7]. The length of the defect affects the degree of
vascularization. In vertical defects with no sufficient width to accept implants, the augmenta‐
tion procedure becomes complicated because both dimensions require restoration [8]. It has
been suggested that a wide bony defect base has greater capacity for bone regeneration
compared to a narrow base defect [7]. The number of surrounding bony walls around the defect
is mentioned in the literature as stabilization for the initial blood clot [8].
Different classifications to describe alveolar ridge defects have been documented [9-11]. Seibert
et al. classified the defects of the alveolar ridge based on dimension in which the resorption
had occurred: horizontal defects (class I, 33%), vertical defects (class II, 3%) and the most
common variant mixed horizontal and vertical defects (class III, 56%) [10].
Some similar classifications were suggested by other investigators according to the morphol‐
ogy of the alveolar bone defects. A classification published by Wang and Al-Shammari, the
defects were subdivided in: horizontal, vertical, and combined [12]. Each group was further
classified based on the amount of the deficiency.Studer (1996) documented the first quantita‐
tive classification of alveolar defects based on predicting need to reconstruct deficiencies, with
classes defined as < 3 mm, 3–6 mm and > 6 mm [8].
Figure 2. A, Interdental partial edentulism. Class A: two-wall defect. The arrows show the defect walls. B, Free end
partial edentulism. Class B: one-wall defect (arrow).
The Cologne classification of alveolar ridge defects uses orientation of the defect (horizontal,
vertical, combined and sinus area) reconstruction needs associated with the defect (small: < 4
mm, medium: 4-8 mm large: > 8 mm) [8].Khojasteh et al. in 2013 in a literature review stressed
the clinical importance of recipient site characteristics for vertical ridge augmentation con‐
cluded that information regarding the characteristics of the initial vertical defect is not
comprehensively incorporated in most of the studies [8]. They proposed a classification with
regard to the number of surrounding bony walls (A: Two-wall defects, B: One-wall defects, C:
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A defect with no surrounding walls) and width of defect base (I: A bony defect with a base
width of 5 mm or more, II: A bony defect with a base width of 3 mm or more, but less than 5
mm, III: A bony defect with a base width less than 3 mm, (Figure 2).
4. Donor sites in oral and maxillofacial surgery
Various donor sites to harvest free bone grafts are used in oral and maxillofacial surgeries.
Each site has its own indications, advantages and disadvantages. Ideally, the surgeons prefer
to harvest bone from a site that is close to the recipient site to operate in one surgical site and
avoid making more skin scars. In reality, the quality and quantity of bone sometimes neces‐
sitates grafting from other sites.
5. Bone harvesting from intraoral donor sites
5.1. The chin
Cortical or corticocancellous block graft in sizes up to 4 cm can be harvested from the man‐
dibular symphysis area intraorally (Figure 3). The mandibular symphysis as a donor site has
been documented to provide sufficient bone to reconstruct alveolar ridge defects 4-6 mm in
horizontal and up to 4 mm in vertical dimensions and can cover a span up to 3 teeth in length
[13]. The available block graft may be harvested from this site is 10 mm (height) 15 mm (width),
6 mm (thickness), with an average volume of 860 cc [14]. The symphysis can provide over 50%
larger graft volume in comparison to the lateral ramus region [15]. The typical symphysis
corticocancellous bone graft consists of 65% cortical bone and 36% cancellous bone [14].
Because of slow resorption rate of chin grafts, it can also be used as an onlay graft for facial
defects.
Figure 3. Block bone graft harvested from the mandibular symphysis

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5.2. Lateral ramus
The mandibular lateral ramus or retro-molar region is advocated for corticocancellous bone
harvesting with approximately 100% cortical composition (Figure 4).
Figure 4. Block bone graft harvested from mandibular lateral ramus area.
A buccal shelf block graft can provide sufficient bone to reconstruct alveolar defects 2-3 teeth
in length. Horizontal and vertical defects up to 3 to 4 mm can be augmented from this donor
site [16, 17]. The maximum dimensions of ramus cortical bone blocks are 4mm (thickness) 15
mm width and 35 mm in length depending on the regional anatomy. The clinical access,
position of the inferior alveolar canal, molar teeth, and width of the posterior mandible are
factors limiting the amount of possible graft that may be harvested [16, 17]. The morbidity of
this region has been reported lower than the mandibular symphysis region [15].
5.3. Maxillary tuberosity
Among intra-oral donor sites, the maxillary tuberosity typically provides a smaller amount of
bone (Figure 5).
Figure 5. Block bone graft harvested from the maxillary tuberosity.

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This region is usually used for harvesting cancellous bone to fill defects and for sinus lifting
procedures. Existence of the 3rd molar in this site decreases the available bone for harvesting.
Other anatomical limitations for using this site include: the maxillary sinus, pterygoid plates
and the greater palatine canal.
5.4. Anterior palate

This area is used as a donor site usually for anterior maxillary reconstruction, especially when
an impacted canine is imbedded in this region (Figure 6).
Figure 6. A, palatal flap is retracted and the donor site for harvesting palatal bone graft is exposed. B, block bone graft
harvested from the anterior palate.
The corticocancellous block, cancellous or crescent-shaped grafts can be harvested from this
site. The average amount of bone in this area in dentate patients is 2 cc and 2.4 in edentulous
patients [18].
6. Other intraoral sources
Maxilla buttress or zygomatic processes of maxilla, anterior nasal spine and bone exostosis
also have been documented as donor sites. These areas provide little bone and are prefer
choices for adjacent recipient sites or in combination with other bone substitutes.
7. Bone grafting with extra oral donor sites
7.1. Iliac crest

The iliac crestal bone is the most common extra-oral donor site for bone grafts. It may be
harvested vascularized, non-vascularized, cortical, cancellous or corticocancellous in different
shapes and in large sizes (Figure 7).
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Figure 7. Iliac bone graft harvested to reconstruct the mandible.
The location of the iliac crest permits the surgeons to harvest bone graft and operate simulta‐
neously to save operating time. A full-thickness iliac crest bone graft consists of two thick
cortices with sufficient amount of cancellous bone in between and can restore the thickness
and height of mandibular bone efficiently. The graft shows a good success rate, and dental
implant insertion is possible in this type of bone graft [19, 20]. Mandibular continuity defects
treated with free iliac bone grafting are documented with about a 70% success rate [21]. The
rate of successful union is decreased significantly where the defect is longer than 6 cm [21,
22]. The posterior iliac crest also can be used as a donor site. Morbidity rate for anterior iliac
crest bone grafts is more than posterior iliac site (23% and 2% respectively) [23].
Complications. Postoperative pain, iliac fractures, gate disturbances, hematoma, herniation
of abdominal contents, vascular injury, nerve injury, unsightly contour defects along the iliac
crest and growth disturbances in young ages [24].
7.2. Calvarial graft
The calvarium is a popular cortical bone grafting site basically for its mechanical features and
very slow resorption rate [24]. It is suggested for facial augmentation, orbital roof and floor
reconstruction, and covering midface defects rather than alveolar defects. Typically, the outer
cortex is used as a cortical plate graft (Figure 8), although a full-thickness or inner cortex graft
may be used.
The skull growth continues to the age of 8 and become thicker until the age of 20 years. The
thickest portion is located at the parietal region. This donor site can provide 8 by 10 cm of bone
[25]. Thickness of the calvarial bone is highly variable so preoperative radiographs help the
surgeon to harvest bone safely [25]. It should keep in mind that dura is tightly adherent to the
inner cortex and can easily be injured if the inner cortex is aimed to be harvested. Also various
vascular structures are located just under the bone at different sites, like the superior sagittal
sinus in the midline. The inner and outer cortices may merge together in inferior and lateral
portions. Other anatomic structures, such as transcortical emissary veins, subcortical vessels,
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Figure 8. Calvarial bone graft harvesting approach. A, The scalp is retracted and calvarium is exposed. B, The osteoto‐
my site is visible.
and aberrant arachnoid plexuses are also at risk and should be considered in the surgical
procedures [25]. Temproparietal regions can be used to harvest more curved grafts and straight
grafts can be harvested from occipital or frontal regions.
Complications. Contour deformity at the donor site and grafting bone fracture in harvesting
are the most common complications. Dural exposure or rupture is another complication but
is not common. Intracranial hemorrhage due to this type of graft harvesting has been reported.
7.3. Tibial graft
The anterior surface of the tibial plateau is mentioned as a donor site for cortical or cortico‐
cancellous bone grafts. Proper mechanical features of the tibial cortex seem to be useful in
augmentation of atrophic alveolar ridges for implant insertion or facial bone defect recon‐
struction. Up to 40 cc cancellous bone can be harvested from the tibia (Figure 9).
Figure 9. Tibial bone graft harvesting approach. A, the donor site is indicated before making the incision. B, the flap is
retracted and bone graft is harvested using a curette.
The most common approach for this purpose is laterally at Gerdy's tubercle [26].
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7.4. Rib graft
Free rib bone was one of the first autogenous bone grafts used for reconstruction of mandibular
defects. Osseous or osseochondral grafts can be harvested from fifth to seventh ribs. Although
costochondral grafts remain popular for the treatment of mandibular ramus and condylar
defects, the quality and quantity of rib bone make it less popular for jaw defect reconstruction
nowadays [27].
Complications. Postoperative chest wall pain, pleural injury leading to pneumothorax, and
overgrowth of the graft [27, 28].
8. Reconstruction techniques
Different reconstruction techniques have been known and well documented for bony defects
in the oral and maxillofacial area. Distraction osteogenesis and guided bone regeneration
techniques, grafting procedures and especially autogenous bone grafting still are the treat‐
ments of choice in most alveolar bony defects. Soft tissue consideration and management
should be borne in mind for successful stable results.
8.1. Bone grafting
"Any implanted material that promotes bone healing" is defined as a bone graft [24]. Ideally
it must be: osteoconductive, osteoinductive and osteogenic.
An osteoconductive capacity means allowing or directing the new bone to form within the
material structure.
An osteoinductive capacity describes supplying recruitment and/or differentiation factors for

bone-forming cells by the grafting material.
An osteogenic graft material provides induced or inducible bone-forming cells.
Bone grafts are used not only for a defect facilitating healing but also for contour augmenta‐
tions. For this purpose more attention is directed towards the amount and rate of graft
resorption. Graft incorporation is proportional to amount of graft resistance to resorption [24].
Bone grafts can be classified as:
Autografts (transferring bone in one human(,
Allografts (transferring inter-humans), and
Xenografts (transferring from other species, synthetic materials and any combination of them).
Autografts can be cancellous, cortical, corticocancellous, vascularized bone or aspirated bone

marrow. The main advantage of autogenous bone is retention of at least some osteogenic cells
without triggering the immune system. On the other hand donor site morbidity and limited
amount are basic disadvantages. Ideally, the bone graft should be incorporated into the
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recipient bed; the space that the bone graft occupies should finally become viable bone with
physiological remodeling mechanisms. Many factors are involved in the incorporation process
namely the graft type, graft bed (recipient site), and interface in between. Graft related factors
including the type of graft, porosity and mechanism of incorporation. Recipient site viability
and vascularity are very important in any autogenous grafting procedures. Graft incorporation
has been summarized by Bauer and Muschler in five steps [24[
1. Hematoma formation, release of bone inducing factors and cellular recruitment

2. Inflammation and development of fibrovascular tissue, connecting the graft to the
adjacent bone
3. Vascular invasion of the graft
4. Focal resorption of the graft by recruited osteoclasts
5. New bone formation, union between the graft and the surrounding bone, and graft
remodeling
Graft stabilization is other critical issue in bone graft incorporation and vascularization.
Instability leads to bone resorption and infection. Cancellous bone grafts can be packed in
defect cavities. In these cases more graft material transfer, leads to more vital cells and increase
in osteogenesis. Cortical or corticocancellous block grafts should be stabilized using fixation
devices.
8.2. Bone Grafting with intra oral donor sites (localized bone augmentation)
8.2.1. Symphysis block harvesting

There are three basic approaches to access the mandibular symphysis for bone graft harvesting:
1) sulcular, 2) attached gingiva, or 3) vestibular. The advantages of sulcular and attached
gingiva approaches are reductions in wound dehiscence and bleeding compared to the
vestibular approach. Use of the sulcular approach is not advocated in pre-existing periodontal
diseases or crowns. The vestibular approach is done through the mucosa 5 to 10 mm below
the mucogingival junction; first by partial thickness dissection apically for 3mm to maintain
3mm of periosteum and mentalis muscle fibers on the bone side, which will be used to reattach
the muscle fiber [29]. Below this level a full thickness incision is made and full thickness flap
reflection is used. Careful attention must be paid to prevent trans-section of the mental nerve
at the distal extent of the incision bilaterally (Figure 10).
It is suggested that at least 5 mm bone is maintain below the teeth apices, inferior border and
bilaterally anterior to mental foramina. When a large bone block is needed, the anterior most
portion of the symphysis the mental protuberance must be retained. If it is necessary to harvest
two graft blocks from each side, leaving a 3mm midline connection to maintain support for
the chin profile is necessary [30].The block graft can be osteotomized by a rotary bur, recipro‐
cating saw, or piezo instrument. Using rotary burs has disadvantages of losing some amount
of bone in comparison to two other methods. Osteotomies should enter the inter-cortical layer,
giving close attention not violate the lingual cortex. A fine osteotome or chisel can be used to
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Figure 10. Full mucoperiosteal flap retracted to expose the donor site for harvesting symphyseal bone. Two osteotomy
sites are determined on both sides and 3mm bone is maintained in between to support the chin profile.
reflect block bone graft from its bed. After block removal a hemostatic agent can be used in
the donor site. Some clinicians prefer to fill the donor site with Freeze Dried Bone Allograft
(FDBA), especially when a large block has been harvested. In the vestibular approach, when
closing, a resorbable suture is first used to attach the mentalis muscle to the 3mm periosteal
muscle layer left on the bone side.
8.2.2. Lateral ramus block harvesting

The approach to harvest bone graft from the lateral ramus can proceed two different ways: 1)
Vestibular or 2) Sulcular. The vestibular approach has access through the area through
vestibular incision on external oblique ridge. Advantage of this approach is lack of disturbing
the periodontium of the adjacent teeth. The indication of sulcular approach is when recipient
site is located nearby. The distal extent of the incision should not be more than occlusal plane
to minimize the risk of facial nerve damage, bleeding and exposing buccal fat. Osteotomy is
suggested to be performed in a defined sequence; superior cut, then anterior, then posterior
and finally inferior cut (Figure 11).
The superior cut length and thickness is important. This cut is usually made approximately 4
mm medial to the external oblique ridge but can be performed up to 6 mm depending on the
regional anatomy. It may be extended anteriorly to the distal area of the first molar, depending
on the anatomy. The anterior and posterior vertical cuts are made in parallel to the predicted
length and width of the bone graft block, and are limited by anatomic position of the man‐
dibular canal, which determines the harvesting block width. Complete cortical penetration of
inferior osteotomy cut is avoided due to its proximity to the mandibular canal in many cases.
An osteotome or a chisel can be used to remove the bone graft from its bed avoiding penetrating
excessively to damage mandibular canal. Closing the incision usually is done without applying
any graft or hemostatic agent.
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Figure 11. Intraoral approach to harvest the lateral ramus bone block. The
Figure 11. Intraoral approach to harvest the lateral ramus bone block. The osteotomy line of the superior cut is seen.
.osteotomy line of the superior cut is seen
8.3. Anterior iliac crest bone grafting
The superior cut length and thickness is important. This cut is usually made
approximately 4 mm
Anterior iliac crest medial
bone grafts to the
are common usedexternal
grafts not only oblique ridge surgery
in maxillofacial but but can be
also in orthopedic surgery. The iliac crest is almost subcutaneous and cortical or corticocan‐
performed up to 6 mm depending on the regional anatomy. It may be
cellous grafts in different shapes and size can be taken from this region simply and safety. The
extended anteriorly to the distal area of the first molar, depending on the
anterior superior iliac spine (ASIS), is easily palpable which is located in the most anterior and
superior portion of the crest. Posteriorly along the crest of the ilium in the widest portion is
anatomy. The anterior and posterior vertical cuts are made in parallel to the
the iliac tubercle. The incision starts 2 cm posterior to ASIS and continues up to 8 cm along the
predicted length
crest. The and width
neural branches, which are of the of bone
in risk damage, graft block, and
are iliohypogastric, are branches
subcostal limited by
and lateral
anatomic femoral cutaneous
position of the nerves. Retracting the skincanal,
mandibular medially and
which avoiding extending the the
determines
incision posteriorly are suggested to decrease this risk. Dissecting laterally and violating
harvesting block width. Complete cortical penetration of inferior
iliotibial fascia is not recommended. Harvesting bone from iliac crest can be performed osteotomy
via
cut is avoided due to its proximity to the mandibular canal in many cases
different approaches including using a trephine device, monocortically and bicortically with .
different techniques (Figure 12).
An osteotome or a chisel can be used to remove the bone graft from its bed
Usually
avoiding monocortical bone
penetrating blocks are harvested
excessively to damage from the medial surfacecanal.
mandibular with osteotomes
Closing the
or a saw. In young ages, the border portion of the iliac crest consists of chondral struc‐
incision usually is done without applying any graft or hemostatic agent
.ture which should be bypassed in the harvesting procedure. Closing the donor site is done
in three layers, and a vacuum drain usually is placed. Minor complications of this bone
Anterior iliac crest bone grafting
graft harvesting included superficial infections, superficial seromas, and minor hemato‐
Anterior iliac crest bone grafts are common used grafts not only in
maxillofacial surgery but also in orthopedic surgery. The iliac crest is almost
subcutaneous and cortical or corticocancellous grafts in different shapes
and size can be taken from this region simply and safety. The anterior
superior iliac spine (ASIS), is easily palpable which is located in the most
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Figure 12. Iliac bone graft harvesting procedure.
mas. Major complications are herniation of abdominal contents, vascular injuries, deep
infections at the donor site, neurologic injuries, deep hematoma formation requiring surgical
drainage, and iliac fractures [31].
8.4. Placing the bone graft into the recipient site
A moist environment with saline is suggested as a reservoir for the autogenous bone graft.
Cortical or corticocancellous block grafts can be adjusted for recipient site with burs, saws or
discs. The block should be prepared so that when placed in the recipient site it does not rock
and fits snuggly and is in intimate contact with the underlying host bone bed. Fixation of the
block graft is a principle issue. Screws and plates are devices, which can be used to achieve
sufficient stability. Applying two screws is recommended and using the lag screw technique
is suggested. The recipient bed and block graft may be penetrated to facilitate vascular
ingrowths. Applying particulate bone graft around the bone block is usually advocated to
maintain space for more osteogenesis. The graft structure is then covered with a barrier
membrane to prevent soft tissue ingrowth into the integrating new bone especially when
particulate materials are added. Tension free closure of the grafted site is critical to success.
8.5. Anatomic repositioning
8.5.1. Distraction osteogenesis
Distraction osteogenesis (DO) is a contemporary method that has been used in oral and
maxillofacial defects. DO is a method to generate new bone by gradual separation of bone
segments. In this procedure a distractor device is placed on two sides of an osteotomy site
(Figure 13).
After a latency period the device is gradually activated and makes a gap between two bone
segments. The new immature bone is generated between these two segments in the created
gap. Then the device will not be activated for a period to give the new bone a time to mineralize
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Figure 13. A. Patient with premaxillary deficiency. B. The patient has lost his anterior incisal teeth due to an anterior
maxillary defect. C. Intra-oral view of the premaxilla defect. D. DO device is inserted in the surgery phase.
and turn into mature bone. This is called the consolidation phase and is usually twice the
activation period. After the consolidation period the device is removed. During the activation
period the surrounding soft tissue grows simultaneously with the bone formation (Figure
14). This is why the DO is also called distraction histogenesis. DO devices are divided into two
groups of intraoral and extraoral types each of which have certain indications.
Indications. DO was generally used in orthopedics years before being used in maxillofacial
surgery. The most popular indication of DO is in hemifacial or hemimandibular microsomia.
Actually DO was used in a case of hemicraniofacial microsomia successfully for the first time
by McCarthy et al. in 1992 [32]. The most important indication of DO is in syndromes associated
with congenital anomalies like cerebral palsy, hemifacial microsomia, Treacher–Collins
syndrome, Pierre–Robin sequence, Nager syndrome and others. Investigations have shown
the successful results of DO in such cases [33].
DO in vertical dimension is another important indication. Although new methods of bone

grafting like fibular microvascular graft have been broadly used in these defects sometimes
their use is restricted by the large size of the defect. In these large defects DO is a better
technique to regenerate new bone and reconstruct the defect [34]. Sometimes the combination
of microvascularized grafts with DO procedure is an ideal technique to reconstruct large
defects especially defects caused by resection of pathologic lesions [7].
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Figure 14. Inserted DO device is shown to generate new bone for reconstruction of the maxilla. The distractor device
has been activated for months. The alveolar bone height has increased.
DO in transverse dimension is an interesting method being used in patients with arch

constriction or an alveolar cleft. Reviews of the clinical studies about the use of DO in maxillary
hypoplasia in patients with cleft lip and palate have shown the benefits of this technique as an
alternative to orthognathic surgeries [35]. The important advantage of DO in these patients is
unchanged or better velopharyngeal function. This method can be used in the mixed dentition
period which is an advantage of this procedure comparing to orthognathic surgery procedures.
DO has been recently used in patients with midface hypoplasia in craniosynostosis like
Crouzon, Apert, and Pfeiffer syndromes. Several investigations have evaluated this technique
and compared it to LeFort III osteotomy [36, 37]. Although LeFort III osteotomy has been
widely used to correct the maxillary retrusion, it is not possible to advance the midface a large
amount. Lefort III-DO technique has been suggested in patients with great discrepancy;
however trials have shown higher relapse of this method compared to the usual LeFort III
osteotomy procedure. The advantage of LeFort III-DO technique is the lower risk for severe
complications like cerebrospinal fluid leakage, meningitis, and infection.
Advantages.Simultaneous distraction of the soft tissue is a great advantage of this technique.

The quality or quantity of the soft tissue bed makes the results of bone grafting unpredictable
and reduces the success of the bone graft. In most cases DO obviates the need for bone grafting
in the future. Morbidity of a donor site is also eliminated. The process of inserting and
removing the device is less extensive as well.
Disadvantages.DO is a technique sensitive procedure and should be performed by an expert

surgeon. The quality of the device is an important factor in success rate of the DO results.
Loosening of the screws and displacement of the device may occur in some cases. DO proce‐
dures consist of two operations: one for insertion of the device and a second surgery to remove
it. Sometimes a third surgery is needed in the future to achieve the perfect outcome especially
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when DO has been performed in a young patient. Unpredictable outcomes or malocclusion

are inadvertent results. Motor and sensory nerve dysfunction is an untoward complication of
DO. This complication is especially seen in DO of the mandible which may lead to permanent
or transient weakness of marginal branch of facial nerve or hypoesthesia of inferior alveolar
nerve. Scar formation and infection should be considered a more usual complication of DO.
8.6. Nerve repositioning
Rehabilitation of edentulous patients is often complicated and requires special consideration.

In edentulous patients with atrophic bone above the mandibular canal is insufficient; reposi‐
tioning the inferior alveolar nerve (IAN) is a treatment option. This treatment is done if the
overall bone height is enough to place implant fixtures, but the IAN interferes with this
procedure. Repositioning of IAN is done to move the nerve from the canal placing it in a new
position (outside the bone).
Nerve lateralization is a procedure in which the IAN is exposed and retracted laterally while
the surgeon is inserting the fixtures. Then the nerve is left to fall back against the inserted
fixtures or the lateral cortex. In nerve transposition technique the IAN, mental nerve and
incisive nerve are exposed by corticotomy of the bone surrounding the mental foramen. Then
the IAN is transected from its junction with the incisive nerve. In this way the nerve is freed
and its retraction is much easier. The IAN is replaced posteriorly after cutting the incisive
nerve. The surgeon is able to install the implant fixture after distalization of the IAN (Figure 15).
Figure 15. A, Nerve lateralization in an atrophic mandible to eliminate the nerve interfering with implant surgery. B,
The IAN is transposed from the mandibular canal to make space for installation the implants. C, Simultaneous implant
installation is also possible in this technique.
Indications.The actual indication of IAN transposition or lateralization is in atrophic posterior

mandible where remaining bone above the mandibular canal is less than 10 mm [38,39]. There
is no actual contraindication of IAN transposition reported in the literature.
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Advantages. The risk of damage to IAN during the installation of fixtures is reduced by
retracting and repositioning the nerve. The surgeon is able to use a longer fixture which may
engage the inferior cortex of the mandible. The fixtures have more stability due to their
bicortical insertion. This procedure is performed simultaneously with implant fixture instal‐
lation with or without bone grafting.
Disadvantages. The risk of damage to the IAN is a prominent disadvantage of nerve trans‐
positioning; Traction on the nerve usually causes temporary sensory loss [40]. Mandibular
fracture, implant loss, hemorrhage, and osteomyelitis are other possible complications in long
implant installation, associated with the transposition and lateralization of the IAN [38, 41, 42].
9. Guided bone regeneration (GBR)
The treatment and rehabilitation of edentulism with dental implants has become a routine
treatment modality in contemporary dental practice. Nevertheless, tooth loss is frequently
associated with subsequent bone loss, often resulting in inadequate bone dimensions for ideal
dental implant placement. Alveolar ridge resorption in partially and totally edentulous
patients may interfere with the safe and correct positioning and placement of implants. When
ridge resorption occurs, bone augmentation is essential to guarantee adequate bone volume,
to provide patients with proper inter-arch dimensions, and to insure a satisfactory aesthetic
result.
9.1. Classic GBR
Guided bone regeneration (GBR) is an important concept concerning restoration of deficient

alveolar sites (e.g., an extraction site or deficient alveolar ridge) for implant placement. GBR
uses an occlusive membrane interface between gingiva and the alveolar bone tissue to promote
osteogenic tissue regeneration. The occlusive membrane acts as a barrier when placed into the
surgical site, preventing connective and epithelial tissue migration into the defect. Progenitor
cells located in the adjacent alveolar bone or blood are then able to recolonize the root area and
differentiate into a new osteogenic tissue with the formation of new bone.
The strategy to isolate the bone defect with a material that will function as a physical barrier
to avoid gingival cell invasion led to the development of GBR membranes. These membranes
need to exhibit: (1) biocompatibility to allow integration with the host tissues without eliciting
inflammatory responses, (2) proper degradation profile to match those of new tissue formation,
(3) adequate mechanical and physical properties to allow its placement in vivo, and (4)
sufficient sustained strength to avoid the membrane collapse and perform their barrier
function. GBR membranes are divided into two groups, nonresorbable and resorbable,
according to their degradation characteristics.
Indications. The most popular application of GBR is in dehiscence and fenestration type
defects with simultaneous implant placement (Figure 16).
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Figure 16. A, GBR is an efficient technique in correcting the dehiscence bone defects around implants. B, Exposed
threads of the fixtures are covered by bone materials and a membrane to promote the osteogenic cells to generate new
bone according to the guided regeneration concept.
The exposed threads of implants may be covered by bone materials and a membrane to prevent
migration of the epithelial and connective tissue cells to the surgical site. So the osteogenic cells
have the opportunity to migrate into the defect site and promote new bone formation. The
bony dehiscence after installation of fixtures can be treated successfully by using GBR
technique [43].
The other indication for GBR is an atrophic ridge either before or during implant surgery. The
important consideration in reconstruction of ridge atrophy is appropriate case selection. Based
on a general guide it is suggested to perform GBR procedure in A1, A2 or B1 defects of
Khojasteh et al. classification. Application of GBR technique in these defects is associated with
high implant survival rates [8]. Studies on installation of implants simultaneously with GBR
showed a survival rate of 92.2% in horizontal defects. Others have reported the success rate of
implants after the GBR procedure (non-simultaneous implant placement) reported 100%
success in horizontal defects. The mean bone augmentation in these defects was 3.31 mm [43].
Advantages. GBR allows for the re-growth of the bone and the tissue. GBR is a relatively easy
and predictable method which can be used under local anesthesia for small defects. In large
defects due to trauma or resection of tumors the combination of this technique with bone
grafting is an appropriate procedure for bone augmentation [43.[
Disadvantages. As the procedure takes approximately six months to heal completely, the
likelihood of failure is higher if the patient does not take appropriate care. Apart from this,
the success is also defect specific as the chances of success may be smaller if the condi‐
tion is severe [44].
The patient can contribute to the success of the procedure by maintaining good plaque control,
nonsmoking, anti-infective therapy, and systemic health maintenance.
9.2. Cortical tenting (Osteogenic GBR)
A usual limitation in reconstruction of the oral and maxillofacial region is the resorption of
bone grafts due to contraction of overlying soft tissue. Excessive bone grafting is not always
the ideal technique to compensate for resorption. We are not able to harvest a large amount of
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graft in all cases. Sometimes the defect size is larger than the harvested bone graft. In some
cases we prefer to harvest the bone graft from an intra-oral recipient site rather than an extra-
oral site because of its morbidity. The cortical tenting technique has been suggested as an
alternative method.
Cortical tenting is a reconstruction method in which a block bone graft together with bone
substitutes are used to augment the horizontal and vertical deficiencies [45]. The first step in
this method is to harvest an appropriate block graft for the recipient site. There are several
intraoral sites to harvest a block graft; however the ideal graft should be prepared after
weighing the advantages and disadvantages. The lateral ramus of the mandible is a popular
donor site and is used in most studies [46-48]. The cortical nature of this bone graft is the reason
for its high resistance to resorption, although prolong neovascularization and the risk of
damage to IAN are important disadvantages of this block graft [46, 49]. The other useful donor
sites are maxillary tuberosity and chin. A retrospective study by Khojasteh et al. showed that
the greatest vertical bone gain was in the defects where tuberosity was used as a block graft
[46]. The simplicity of bone harvest and lower risk for nerve damage are other advantages of
this donor site.
After preparing a block graft it must be adapted to the recipient site and fixed properly with
a gap from the surface of the defect (Figure 17A). Then bone materials are used to fill the gaps
(Figure 17B).
Figure 17. A, An anterior mandible defect after retracting the soft tissue flap. Lateral ramus bone block is harvested as
a block graft and fixed with micro-screws with a gap from the buccal surface. B, The gap between the bone graft and
alveolar bone is filled with bone materials. C, The defect has filled with new generated bone after 20 weeks.
The bone substitute could also be used to cover the bone block. With this technique we
anticipate the bone resorption and prevent this complication by tenting the periosteum [50].
Then a membrane is used to cover the site. The soft tissue flap is sutured last (Figure 18).
Indications. This technique is most useful in horizontal defects of the anterior maxilla. After
extracting the maxillary incisors a saucer-shaped defect may present in the premaxilla. This
kind of defect could be properly corrected with the tenting technique [46, 50]. This method is
also applicable in atrophic posterior mandibles [45]. Three-dimensional reconstruction with
this technique is possible in atrophic ridges [51].
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Figure 18. A, The defect of anterior maxilla is obvious after retracting the soft tissue flap. B, Lateral ramus bone block is
harvested as a block graft and fixed with micro-screws. C, The surgical site is ready for implant surgery after 20 weeks.
D, The deficiency is corrected and installation of the implant was performed without any problems.
Advantages. This technique decreases the patient's morbidity and is relatively simpler than
other procedures. This procedure can be performed under local anesthesia. The bone partic‐
ulates in the tenting technique promote the vascularization in the graft and improve bone
regeneration and remodeling [52.[
Disadvantages. The tenting technique is not suitable in most combined horizontal and vertical
defects. This method is not suitable for large defects resulting from severe trauma or resection
of pathologic lesions. Complications including hematoma and nerve damage due to bone
harvesting from chin and lateral of mandibular ramus respectively are some other disadvan‐
tages of this procedure. Inflammation, infection, graft exposure, and graft failure are other
complications mentioned in the literature [46].
9.3. GBR in combination with onlay bone graft (OBG)
Reconstruction of combined defects with representation of both horizontal and vertical bone
deficiencies requires specific consideration. Decision- making in rehabilitation of these kinds
of defects involves the patient's preferences, defect size, and cost considerations [53].Combi‐
nation of GBR and OBG is an appropriate technique in reconstruction of small combined
defects before implant surgery. By applying this procedure the surgeon is able to use longer
and wider implants, increasing the surface area resulting in a higher survival rate. In this
technique a block bone graft is harvested and fixed in the defect area usually for vertical
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augmentation followed by using classic GBR procedure to restore the remaining defects
(Figure 19).
Figure 19. A, The atrophic ridge of posterior mandible is selected as the recipient site. B, Lateral ramus bone graft is
harvested as an OBG. C, The OBG is fixed to augment the defect vertically. D, Bone materials are used to reconstruct
the horizontal defect by GBR procedure. E, The surgical site is ready for insertion of implant fixtures.
Approximately after 6 months the surgical site is ready to install the implant fixtures. The
average bone gain presented in the literature is 4.3 mm after performing this procedure [43].
Indications. This procedure is suitable for small to moderate defects in partial edentulous
patients. This technique is usually indicated in combined defects to reconstruct horizontal and
vertical defects. The common indication of this technique is in the anterior maxilla.
Advantages. This procedure can be performed under local anesthesia. This technique removes
the need for harvesting extraoral bone grafts and reduces discomfort of the patient.
Disadvantages. This technique is not for large defects. The high failure rate of this technique
in posterior of mandible is one of the major drawbacks of this technique [54].
10. Regenerative cell therapy
Although the autograft is accepted as the gold standard for the treatment of bone defects, some
drawbacks of autogenous bone grafts such as limited graft accessibility, prolonged operation
time and donor site morbidity as well as high costs, continue to drive the quest for development
of alternative methods for bone regeneration and repair. Three new strategies are recently
undergoing investigation:
Stem cell therapy; the transplantation of cultured osteogenic cells from host tissues like bone
marrow.
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Protein therapy; the application of osteoinductive growth factors in various reconstruction

techniques.
Gene therapy; the transduction of genes encoding cytokines with osteogenic capacity into cells
at the repair sites.
Bone engineering techniques consist of three main components: cell, growth factor, and carrier.
Osteogenic cells are responsible for the generation of new bone. Without existing cells with
osteogenic potential no new bone would be produced and no defect would be reconstructed.
The proteins with osteoinductive potential known as growth factors are the second factor
needed for reconstruction of defects. These growth factors are responsible for enhancement of
new bone formation by affecting the cells which play a role in bone healing. The application
of cultured cells or growth factors without any scaffold is almost impossible. Choosing the
right scaffold for delivery of the cells and growth factors and acting as mesh for new bone
formation is a significant issue in bone engineering.
11. Growth factors in bone regeneration
Protein therapy has demonstrated the most practical promise, mainly incorporating
osteoinductive morphogens. Several osteoinductive cytokines have been suggested and
investigated in the literature including bone morphogenetic proteins (BMPs), vascular
endothelial growth factor (VEGF), platelet derived growth factor (PDGF), and transform‐
ing growth factor beta (TGF-β). Bone morphogenetic proteins have the most experimental
and practical potential. Some studies however have shown the efficacy of other growth
factors on bone reconstruction[55]. Synergic effects of two or more growth factors have been
evaluated in some studies [56, 57].
Bone morphogenic proteins (BMPs). BMP is a large family of growth factors released
naturally from different human tissues and acts in regenerating bone and cartilage tissue. The
efficacy of BMP has been evaluated in several investigations [58-60]. After producing recombi‐
nant human BMP (rhBMP) the use of this cytokine became more popular in clinical studies.
BMP can be applied in the surgical site by a carrier namely absorbable collagen sponge (ACS)
or poly lactic glycolic acid (PLGA). The positive influence of BMP on bone regeneration in
defects of the oral and maxillofacial area has been shown in most studies [55].
Platelet-derived growth factor (PDGF). PDGF promotes new bone formation. This facilitating
bone regeneration factor is suggested to be used in maxillofacial defects where bone grafting
is needed [61, 62]. PDGF improves the new bone formation by three main methods including
mitogenesis, angiogenesis macrophage activation. The major role of PDGF is in differentiation
of pre-osteoblasts to osteoblasts and proliferation of mesenchymal stem cells (MSCs). The usual
carrier for PDGF has a mineral part in most investigations [55].
Vascular endothelial growth factor (VEGF). VEGF is an angiogenic factor which usually is
released in response to hypoxia or tissue damage. VEGF has been used in different studies
with both polymeric scaffolds and ceramic carriers [63, 64]. This growth factor is sometimes
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applied in combination with other promoting factors like BMP and PDGF to improve it’s the
regenerative features [65-67]. Despite all the important roles of VEGF investigated and
presented in the literature most studies showed that this growth factor is less inductive than
BMP in bone regeneration [55.[
Basic fibroblast growth factor (bFGF). bFGF is an important growth factor in wound healing,
formation of granulation tissue and remodeling [68]. Several studies evaluated the effect of
bFGF in bone regeneration; however its role is not as important as other factors like BMP [55].
Transforming growth factor beta (TGF-β). TGF-β is a group of proteins released from several
tissues including macrophages and plays an important role in healing. The bone regenerative
features of rhTGF- β1, rhTGF-β2, and TGF-β3 have been evaluated in different investigations.
The usual carrier for the delivery of this growth factor in these studies is a gelatinous matrix.
Some of these researches have shown the positive influence of this growth factor in bone
regeneration [55].
Indications. The most common usage of growth factors is in implant surgery. The defects
created during the procedure or post-operative bone dehiscences may be corrected with the
application of growth factors. Advantages. Growth factors are presented as an alternative for
bone grafts in reconstruction of maxillofacial defects. These proteins reduce the morbidity of
the patients by removing the need of harvesting bone grafts. These factors are responsible for
the major events in regeneration including angiogenesis, cell differentiation, mitogenesis, and
bone formation [69]. Furthermore the combination of these proteins with bone grafts promotes
the generation of new bone and facilitates healing of the defects.
Disadvantages. The high costs of producing growth factors are the major limitations for using
these materials in humans. Production of recombinant growth factors as rhBMP and rhPDGF
requires a period of time and high costs [70]. Application of growth factures is very technique
sensitive and the clinician should be an expert in this procedure. Choosing a slow releasing
scaffold is still a challenge among surgeons to use with the growth factor as a carrier. The
appropriate dosage and useful concentration of these proteins in bone regeneration is another
controversial issue which should be resolved. The excess amount of growth factor or wrong
application of them may lead to ectopic bone formation and result in insufficient correction of
the deficiencies.
12. Carriers in bone regeneration
Biomaterial carriers are needed for delivery and sustained release of growth factors. The
application of growth factors without a proper carrier is very hard and their handling is almost
impossible. There is no universal carrier for this purpose. Several biomaterial carriers have
been suggested to be effective in delivery of certain growth factors and accelerate bone
formation. The osteoconductive ability of the scaffold should be considered in choosing the
right carrier for the purpose. The advantages and disadvantages of usual growth factor carriers
are presented in Table 1.
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Biomaterial
Preparation technique Advantages Disadvantages
carrier
solvent casting/
Control over porosity, pore sizes and Residual solvents; limited
PLGA particulate
Crystallinity; high porosity mechanical properties
leaching
Facilitates surgical implantation and
Low porosity and low mechanical
ACS Freeze drying method retention of the growth factor at the
strength
treatment site; hemostasis
Particle aggregated Brittleness, low fracture strength,
HA High mechanical strength
scaffold and high density
Potential host reaction, limited
Production methods of
NBM High porosity and interconnectivity supply, excessive resorption, and
cadavers' bone
potential disease transmission
demineralization process
DBM High porosity Limited particle sizes range
on allogenic bone
Facilitate early revascularization
Ceramic-based injectable And accelerate bone regeneration; serves Brittleness, low fracture strength,
β-TCP
scaffold as a rich source for calcium and and high density
phosphorus
PLGA,Polylactic co-glycolic acid; ACS, Absorbable collagen sponge; HA, Hydroxyapatite; NBM, Natural bone matrix;
DBM, Demineralized bone matrix; β-TCP, Beta tri-calcium phosphate.
Table 1. The pros and cons of most common scaffolds
13. Cell therapy
13.1. MSCs harvesting sources
Cell therapy is a new technique in reconstruction of bone deficiencies presented as an alter‐

native for bone grafting. The self-renewal ability and the capability of differentiating to
osteogenic cells have made the stem cells a popular source in regeneration of bone defects.
Several tissues have been suggested as the source of stem cells including fat, umbilical cord
blood, lung, liver, skin, periosteum, and skeletal muscle [71]. Recently dental pulp was used
as a new origin for extracting stem cells for regenerative purposes [72]. The usual source of
MSCs in each study and various models is different. According to the literature the most
common origin to harvest the MSCs in rat models is human bone marrow-derived mesenchy‐
mal stem cells (hBMSCs) usually extracted from femur or tibia [73-75]. The most common
source in harvesting MSCs to regenerate the bone defects in rabbit and dog models as well as
human studies is the iliac bone [71]. By considering the reduced differentiation potential of
MSCs harvested from bone marrow investigators have attempted to find new sources of MSCs.
Birth associated tissues like umbilical cord and dental pulp as well as adipose tissue are new
sources that have been found to contain MSCs [76].
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13.2. MSCs culture and differentiation protocol
MSCs as a compartment of various cell populations are aspirated from the selected origin like
the iliac crest or buccal fat pad. The aspirated cells are cultured in a medium with Dulbecco's
modified Eagle's medium (DMEM) and fetal bovine serum (FBS) for 3 h in a 37 degrees 5%
CO2 incubator. Then the non-adherent cells are discarded after three hours and adherent cells
are washed with phosphate-buffered saline (PBS) and fresh medium is replaced. The culture
is treated with 0.5 ml of 0.25% trypsin containing 0.02% ethylene-diamine-tetra-acetic acid
(EDTA) for 2 min at room temperature when the primary culture is confluent. A purified
population of MSCs can be obtained 3 weeks after the initiation of culture [77]. The third
generation of the cells is usually used in the studies (Figure 20) [78, 79]
Figure 20. A, Proliferation of MSCs under light microscopy. B, Alizarin red staining for evaluating differentiation of
MSCs to osteoprogenitor cells. Mineralization of the extracellular matrix is visualized by this staining technique. C, Oil
red staining of MSCs, depicted adipogenic differentiation.
13.3. MSCs culture on scaffolds
Several investigations have evaluated the efficacy of stem cell regenerative ability on animals
[78-82]. The stem cells should be implanted on an appropriate scaffold before delivery to the
surgical site. According to the literature TCP is an efficient carrier for the stem cells to be loaded
on and transplanted to the surgical site [71, 80, 81]. After preparation the choice carrier for
reconstruction purpose it should be immerged into the medium impregnated with the MSCs.
The MSCs should be implanted on the scaffold after 2 hours in 37ºC. Scanning electron
microscope (SEM) is a useful assay to evaluate the presence of MSCs on the scaffold (Figure
21). Tripoding adherence of MSCs on the scaffold can be assessed under SEM [78].
13.4. Current trends in MSCs application in bone regeneration
Presentation MSCs as a novel regenerative technique in reconstructing bone defects provoked

lots of investigators to evaluate the efficacy of MSCs application in oral and maxillofacial areas.
Omitting the need for bone harvesting from a donor site and reducing the patient morbidity
by application of MSCs in bone reconstruction promises a bright future for researchers around
the world. Comparing the application of MSCs in bone regeneration to the control groups
which bone materials were used has shown the increase of new bone formation. Implantation
of MSCs together with bone minerals improves the regeneration of bone defects by delivery
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http://dx.doi.org/10.5772/59236
Figure 21. SEM Evaluation of MSCs (×50). SEM analysis shows lodging of the cells within the pores of the scaffold.
of the cells responsible for synthesizing new bone directly to the defect site [80]. Experimental
studies on rat models have shown that the maximum bone formation was 2.53 mm in the β-
TCP/MSC group 6 weeks after the surgery [79]. Histomorphometric analysis of the rabbit
experiments at 6 and 12 weeks post-operation has demonstrated significantly higher bone
formation in the group which MSCs were applied in combination with PRGF and nano-HA
[78]. Histological analysis of rabbit models in other investigations demonstrated that the mean
amount of vertical bone was higher in the MSCs group than the control group (2.09 mm versus
1.03 mm) after two months [82]. Choosing the appropriate scaffold for delivery of MSCs is
important to gain the highest rate of new bone formation. The different studies on dog
mandibles have indicated the importance of scaffolds on bone formation [61, 80, 81]. Jafarian
et al. showed that six weeks after delivering dog BMSCs with biphasic scaffold (HA/TCP) or
NBBM (Bio-Oss) in a through-and-through 10-mm mandibular defect, new bone formation
was 65.78% and 50.31%, respectively [80]. Histomorphometric analysis in Khojasteh et al. study
showed that after 8 weeks of the scaffold implantation (polycaprolactone-tricalcium phosphate
(PCL-TCP)) higher amount of lamellar bone was generated more on the test side (48.63%) than
control side (17.27%) [81]. Khojasteh et al. in another study applied MSCs with recombinant
platelet derived growth factor (rh-PDGF) in mandibular defects in dogs; however the result
showed only 21.52% new bone formation [61].
Nowadays the major concern about the application of MSCs in bone defect reconstruction is
its effectiveness and delivery technique in human cases. Application of MSCs in sinus floor
lifting in posterior atrophic maxilla has been assessed in human trials and reports. Several
organic and inorganic materials have been suggested for sinus augmentation in the literature.
MSCs seeded on an appropriate scaffold are new regenerative techniques advocated for this
procedure. High mean percentage of new generated bone in these studies may indicate the
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important inductive potential of MSCs [83]. Alveolar cleft of maxilla is another recipient site
for applying MSCs instead of autografts to reduce morbidity. Some authors have shown
successful results of using MSCs in alveolar clefts [84] whilst some others did not [85]. The
amount of new bone formation may be insufficient for reconstruction of clefts; however it is
usually enough for orthodontic tooth movements [85]. The combination of MSCs and a growth
factor may increase their inductive and regenerative potential; however the results were not
satisfactory yet [86].
Indications. Alveolar clefts are examples of the maxillofacial defects which cell therapy may
be useful [85, 86]. Cell therapy is also indicated in augmentation of the sinus floor [83].
Advantages. It avoids the drawbacks of bone grafting like donor site morbidity. The stem cells
are able to differentiate to different cell linings based on the combined growth factor. By
extracting the cells from the own patient autologous transplantation is possible and no
immune-suppressive therapy is necessary.
Disadvantages. Accessibility and the requirement for a large amount of cells are the main
disadvantages of cell therapy as well as expenditure of time and money to provide the
adequate cells for regeneration in large defects. The genetic damage occurrence of adult stem
cells is a possibility in old patients. Embryonic stem cells have the risk of rejection and
uncontrolled proliferation (turning into a teratoma).
14. Summary
Bone regeneration and anatomical bone reconstruction in defects of oral and maxillofacial
region have been always a critical and controversial issue. There are lots of regenerative
techniques suggested to be effective in oral and maxillofacial defects; however no one can
absolutely choose the best efficient procedure. The quantity and quality of the regenerated
bone is another aspect of defect reconstruction which should be highly considered. Although
several regenerative procedures can be used in a certain defect, the regenerated bone may not
be functional all the time.
Author details
Arash Khojasteh1, Mohammad Esmaeelinejad2* and Farzad Aghdashi2
*Address all correspondence to: esmaeelnejad@gmail.com
1 Department of Oral and Maxillofacial Surgery, Dental Faculty, Shahid Beheshti University
of Medical Sciences, Tehran, Iran
2 Department of Oral and Maxillofacial Surgery, Dental Faculty, Shahid Beheshti University
of Medical Sciences, Tehran, Iran
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http://dx.doi.org/10.5772/59236
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Chapter 24
Facial Augmentation with Implants
Farzin Sarkarat and Behnam Bohluli
http://dx.doi.org/10.5772/59188
1. Introduction
The public’s demand for facial beauty has increased over time. Different cosmetic procedures
have been introduced to meet this demand. The essentials of facial cosmetic surgery are: 1-
Volume replacement and 2- Facial augmentation. Better aesthetic results have been achieved
by using less invasive surgical techniques including lifting procedures, injectable fillers,
autologous fat transfer, and facial implants.
The malar eminence and chin are the most common facial sites augmented via implants.
Autologous tissues have been the gold standard for facial augmentation for years; but today
alloplastic materials are more commonly used.
Drawbacks of autogenous grafting include: donor site morbidity, limited availability, limited
moldability, and unpredictable resorption [1].An ideal alloplastic implant must be made out
of a material that has low bioactivity or toxicity. It must also be stable and biocompatible [2].
An understanding of these qualities is needed to prevent complications or to treat them should
they occur.
2. The aging process
One of the primary advancements in cosmetic facial surgery has been the realization of volume
loss in aging and volume replacement via cosmetic surgery [3-6]. The abundance of midfacial
volume is one of the main reasons that makes a person look young, which means having the
right amount of fat in the right areas of the face. The loss or shift of this fat is a main contributor
to facial aging [7]. Loss of volume and volume shift occur in all regions of the face and neck
and are the reasons for aged appearance [5, 6].The youthful midface has voluminous and
superiorly positioned malar fat pads. The malar fat pad is a triangular structure with its base
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against the nasolabial fold and its apex over the malar region. Due to actinic skin changes as
well as gravity, fat atrophy, and deep connective tissue laxity, the malar fat pads lose volume
and descend lower into the face with age. The sum of these aging changes frequently yields a
hollow midface.
3. Treatment
There are a wide variety of procedures for achieving volume replacement and facial augmen‐
tation including lifting procedures [7, 8], injectable fillers [9-11], autologous fat transfer [12,
13], and facial implants [14, 15]. Facial implants are an optimum for most patients. The main
advantage is that they are a permanent option when compared with fillers; and they are
available in many anatomical shapes and sizes. They are easily placed, the recovery is minimal,
and they have a low complication rate.
Autogenous bone and cartilage have been used to repair traumatic, congenital, and surgical
defects of the face. The increased morbidity of the donor site, limited supply, resorption, and
migration contributed to decrease in their use. Gold, silver, paraffin, and ivory fell out of favor
because of their tissue incompatibility and lack of malleability. Polymeric silicone, polyamide
mesh, expanded polytetrafluoroethylene, and high-density polyethylene, replaced the
previous materials because of their increased malleability and biocompatibility [16].
The midface is the area in which facial implants are more commonly used. Implants in the
nasojugal crease are used to correct tear trough deformity. Nasal implants are not widely used,
but can be used to correct defects caused by rhinoplasty. Malar and submalar implants (Figure
1) are the most commonly used implants in the midface [17].
The lower face is another area where facial implants are frequently used. Chin implants
(Figure 2) are one of the most common facial implants performed by cosmetic surgeons [18].
Volume restoration, in addition to the re-suspension and removal of excess tissue, remains the
current goal of aesthetic surgery. Facial implants play a major role in volume restoration.
4. Implant types
Facial implants are categorized according to their site (malar, submalar, paranasal, chin, etc.).
They can also be prefabricated, anatomical or custom-made. Facial implants are available in
many shapes and sizes. The submalar implant is best described as an implant that restores the
volume the patient has lost with age. This is in contrast to malar augmentation, which generally
changes a patient’s appearance while augmenting volume. Volume is lost in the malar region
but is significantly less than the volume lost in the submalar region. Smaller implants generally
restore a former appearance, whereas larger implants change the patient’s appearance. The
submalar zone is the area of maximum midface atrophy in most patients. Most female patients
are treated with a small submalar implant. The medium implant is most frequently used in
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Facial Augmentation with Implants 551

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the male patient. If the patient is looking for replacement of atrophic losses that occur with
aging, the smaller implant is preferable. A larger implant is reserved for the patient who desires
to not only replace volume that has been lost but also augment an appearance that was
previously unsatisfactory to the patient. Microgenia is effectively addressed with chin
augmentation [19, 20]. The placement of an extended alloplastic anatomic chin implant is a
simple, safe, and easily performed procedure. The patient’s appearance is enhanced by
restoring the chin and cervico-mental region [21, 22]. Most patients with a mild to moderately
deficient chin are well treated with an alloplastic implant [19]. In patients with severe micro‐
genia, a chin implant combined with soft tissue filling and tension restoration is most effective.

Figure 1. Malar augmentation with facial implant. Above: Before. Below: After.
Figure 1. Malar augmentation with facial implant. Above: Before. Below: After.

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Figure 2. Chin augmentation with facial implant, Above: Before, Below: After.
Figure 2. Chin augmentation with facial implant, Above: Before, Below: After.

Facial implants are made of various materials. It is crucial that the surgeon be familiar with
these materials and their advantages and disadvantages.
4.1. Metal implants

Cobalt chromium alloys, stainless steel, gold, and titanium have been used as facial implants.
The corrosive characteristics of metals placed in the body limited their use. Stainless steel was
used in the plating of skeletal fractures of the face. Titanium has largely replaced stainless steel
and cobalt-chromium alloys as the metal of choice because of its strength, low tissue reactivity,
reduced artifact on CT, safety during MRI studies and its corrosive resistance over time [23].
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Its use is generally limited to dental implants and facial skeletal plating for maxillofacial
trauma [1, 24, and 25].
4.2. Silicone implants

Silicone implants have been used for years. Polydimethylsiloxane is nonporous implant with
smooth contours. Its pliable nature and resistance to high temperatures used in sterilization
make it the most versatile facial implant. It also can be easily carved and shaped. Polydime‐
thylsiloxane becomes encapsulated in a mild chronic inflammatory process. Because no links
are formed between the polydimethylsiloxane and its fibrous tissue envelope, they are more
prone to displacement, persistent seromas and a tendency toward extrusion [26-29].
4.3. Polyester fiber

Polyester fiber is comprised of nonabsorbable strands of polyethylene terephthalate which is
a porous material, allowing tissue ingrowth and subsequent implant stability. The excellent
tensile strength, durability, biocompatibility, and flexibility of polyester fiber have led to its
use in facial implants. Infection rates are lowered with antibiotic impregnation [30, 31]. Its
disadvantages are the surgical time required to prepare the mesh with folding and suturing
and inflammatory reactions most commonly seen after facial trauma [32].
4.4. Polyamide mesh

Polyamide mesh is an organopolymer related to nylon. It has the advantage of flexibility,
ease of molding and allowing tissue ingrowth into the implant which is related to the
implant stability. Polyamide mesh creates an intense foreign body response and chronic
inflammation. Hydrolytic degradation has been noted to occur after implantation, leading
to loss of volume [33].
4.5. High-density polyethylene

High-density polyethylene (HDPE) which is more commonly known as ‘‘Medpor’’ (Prex
Surgical, Inc., College Park, Georgia), is a stable, porous and extremely inert implant with
minimal foreign body reactions which does not degrade over time. It is malleable when heated
but otherwise has a lack of pliability. Although the large average pore size encourages fibrous
tissue ingrowth, leading to firm attachment and high stability [34, 35], but fibrous ingrowth
does not guarantee stability of HDPE implants against bone and may require additional
fixation.
4.6. Polymethylmethacrylate
Polymethylmethacrylate (PMMA) has high strength and rigidity for bony reconstruction of
the face. It has been used to repair orbital, malar, and cranial defects [36-38]. PMMA is available
as a powder consisting of polymer and catalyst and a liquid form of the monomer. When mixed,
an exothermic reaction occurs. The heat generated by the reaction has led to untoward events
in orthopedic surgery, although such complications have not been reported in craniofacial
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reconstruction. PMMA is well tolerated without significant inflammatory foreign body

reactions. Being able to create customized implants unique to each patient’s needs is one of its
main advantages.
4.7. Expanded polytetrafluoroethylene
ePTFE known as ‘‘Gore-Tex’’ (W.L.Gore and Associates, Flagstaff, AZ), is a fibrillated polymer
of polytetrafluoroethylene, with pores between the fibrils averaging 22 microns in diameter
which allows limited soft tissue ingrowth while creating only a mild chronic inflammatory
response, providing early stabilization and permitting removal when necessary [39]. ePTFE is
spongy in consistency, inert, and does not change shape or resorb with time. It also has been
found to be non-carcinogenic and is rarely allergenic [28, 40]. Because ePTFE is hydrophobic,
it does not absorb antibiotic solutions [41].
4.8. Hydroxyapatite
Calcium hydroxyapatite is mixed in a fashion similar to methylmethacrylate to form a cement

that can be contoured to each individual patient’s needs. Because it forms the synthetic,
inorganic constituent of bone, it can induce osseointegration. Mixing does not result in an
exothermic reaction. It is now used more commonly as an injectable implant.
5. Implant selection
The surgeon must be able to make a decision regarding the selection of an implant based on
chemical composition, physical structure, and planned site for application. Characteristics of
an ideal implant include biocompatibility, chemical inertness, lack of elicitation of foreign body
or hypersensitivity reaction, non-carcinogenicity, and ease of shaping and carving [42].
Common implant materials include expanded PTFE, methyl methacrylate, porous polyethy‐
lene, and silicone rubber. Porous polyethylene and silicone rubber implants are the most
commonly used. Silicone rubber implants can be easily trimmed, being flexible, conform well
to underlying anatomy and become well encapsulated. They can be easily be removed or
replaced if necessary.
The structure of porous polyethylene implants allows better tissue integration, but this can
also be extremely problematic when attempting to remove or replace an implant. Significant
tissue injury, defects or implant fragmentation can occur with removal.
Most patients, as they age, lose volume in the submalar region. The submalar area includes
the hollow area of the infraorbital, anterolateral maxillary region, and canine fossa regions.
Most of these patients have a hollow submalar region. They usually have adequate and well-
defined zygomatico-malar esthetics and adequately projected cheekbones. These patients are
best treated with only submalar augmentation, as their problem is loss of submalar volume.
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The second type of common facial esthetic deficiency found is in patients who have adequate
submalar and anterior maxillary projection but deficient cheekbones and hypoplasia of the
zygomatico-malar regions. These patients are best treated with a malar implant.
The third type of common midfacial aging change is seen in a patient who has submalar
deficiency in addition to need of more zygomatico-malar augmentation. These patients need
both submalar and malar augmentation. These patients are well treated with the combined
submalar shell implant. This implant is designed to augment the submalar region as well as a
portion of the zygomatico-malar region.
Careful examination and thorough analysis aid in coming to a decision about what size of
implant to use to achieve the desired effect [43]. Clinical photography serves as a powerful
tool. A similar approach is applied to the chin and prejowl complex. This approach helps
determine what type of implant to use.
Fewer surface imperfections allow greater resilience against degradation by mechanical forces
[44]. This advantage must be balanced with the increased possibility of migration as compared
with porous implants. The implant should not create a severe immune response, one that may
harm the host or damage the implant. Synthetic implants stimulate inflammatory response
with acute and chronic phases [45]. Significant immunogenicity can result in degradation or
rejection of the implant. Bacteria are capable of implant invasion when pore size decreases.
Implants with pore sizes between 1 and 50 microns may be more susceptible to infection than
materials with larger pores, because they do not permit tissue granulation and delivery of host
inflammatory cells to mount an adequate immune response.
6. Implant placement
6.1. Malar and submalar augmentation
The placement of midfacial implants is a simple surgical procedure for experienced maxillo‐
facial surgeons. The implants are always placed in the subperiosteal plane. With the exception
of the infraorbital neurovascular bundle, there is little vulnerable anatomy in the midface
region, when dissecting in the subperiosteal plane. The implants can also be placed concomi‐
tantly with other esthetic or orthognathic procedures.
With the patient in the sitting position, the atrophic submalar area is marked and the zygomatic
arch is outlined. The patient is prepared and draped. Several approaches to the malar and
submalar region exist including subciliary, transconjunctival, and intraoral. The intraoral
approach if preferred. The procedure is begun by injecting about 5 mL of 2% lidocaine with
1:100,000 epinephrine in the subperiosteal plane along the anterior maxilla, malar region, and
the anterior zygomatic arch region. An incision is made just below the maxillary vestibule,
approximately 1 cm above the canine tooth (Figure 3). The mucosa and soft tissues are incised
in the canine fossa region and through the periosteum. Subperiosteal dissection is performed
(Figure 4).
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Figure 3. Intraoral approach for malar implant placement
Figure 4. Subperiosteal dissection for malar implant placement
The borders of this dissection pocket are the lateral portion of the inferior orbital rim, superi‐
orly, the zygomatic arch superolaterally and the masseteric fascia laterally. The buccal fat pad
must be avoided. The extent of the dissection is dictated by the shape and size of the implant.
The combined submalar and shell implants require more dissection over the malar and
zygomatic regions. The dissected pocket should be just slightly larger than the actual implant
size. As the subperiosteal dissection is begun in the anterior maxillary region, it is important
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to protect the infraorbital neurovascular bundle. After the anterior maxilla is dissected, the
periosteal elevator is angled and the remainder of the dissection is primarily in an oblique
vector over the malar region and extends over the anterior portion of the zygomatic arch. After
the implant pocket is dissected, the area is checked for hemostasis (Figure 5). The pocket is
then irrigated with antibiotic solution (300 mg of clindamycin and or gentamicin mixed with
30 mL of sterile water) and the implant is placed. The implants are also soaked in antibiotic
solution. This is especially important for porous implants (Figure 6).
Figure 5. The subperiosteal pocket is checked for hemostasis
Figure 6. The implants are also soaked in Gentamicin solution

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A well-conforming implant in a tight pocket does not generally need fixation. If the pocket is
considerably larger than the implant and there is increased mobility of the implant, a single
fixation screw can be placed. The fixation screw is best placed in the thicker bone of the buttress
area (Figure 7). Finally, the incision is closed with interrupted 4-0 absorbable suture (Figure 8).
Figure 7. Implant fixation
Figure 8. Incision closureChin augmentation

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There are two main approaches to chin augmentation; one with an intraoral incision, and one
with an incision in the submental crease. The main advantage of the intraoral incision is the
avoidance of an external scar. The submental incision is preferred because the external scar is
well camouflaged in the submental crease and there is no need to divide the mentalis muscle.
A 2-cm incision is made in the submental crease centered about the midline. Sharp and blunt
dissection is used to reach the periosteum of the lower edge of the mandible in the midline. A
sharp incision is made through the periosteum laterally. A subperiosteal dissection is per‐
formed to create a pocket for the implant. Dissection laterally should be performed as close to
the mandibular border as possible to avoid injuring the mental nerve. After the implant is
inserted a stabilizing stitch or screws may be used. The incision is then closed in two layers.
When using an intra-oral approach, a 2 to 3-cm incision is made in the mandibular labial sulcus
about 10 to 15-mm away from mucogingival junction (Figure 9). Then the mentalis muscle and
periosteum are transected and a subperiosteal dissection is performed (Figure 10). Care must
be taken not to injure the mental nerve.
The implant is inserted over the chin bone and screws are used for fixation (Figures 11 and
12). Then the mentalis muscle portions are aligned and sutured together. The mucosa is closed
with absorbable sutures.
Figure 9. Intra-oral approach for chin implant placement

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Figure 10. Subperiosteal dissection for chin implant placement
Figure 11. Implant placement

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Figure 12. Implant fixation
7. Postoperative sequelae
The patient must be warned that during the first 1 to 2 weeks he or she will experience abnormal
animation when smiling and talking. The tissue dissection violates the orbicularis oris and lip
elevator muscles, which heal uneventfully with the return of normal animation. Significant
edema is not uncommon, especially with larger implants and in the early postoperative period.
Cold packs and steroids are routinely used. Severe swelling may indicate hematoma formation
and, if necessary it must be drained. This can usually be done by opening the incision and
suctioning the blood or clot from under or around the implant without compromising the
result. Minor hematomas will usually heal uneventfully without treatment. Occasionally,
subconjunctival or periorbital ecchymosis is seen but remains a rare occurrence and heals
uneventfully.
8. Post operative care
No dressings are required and the postoperative care includes analgesics, antibiotics, and
steroids if desired. The patient is instructed to avoid significant talking and animation for the
first 48 hours and is asked to follow a liquid or soft diet for the same period. Ice packs are used
for the first 24 hours.
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9. Complications
9.1. Improper selection or placement
Improper placement of the implant is the most common complication followed by improper
implant selection. The implant should be slightly smaller than the desired increase in fullness.
Selecting too large an implant will lead to excessive soft tissue tension, which could lead to
ischemia, necrosis, or extrusion. Placement of malar implants too laterally can cause the eyes
to look too close together. Placement of the implants too medially and inferiorly will give a
chipmunk look or appearance.
9.2. Neuropraxia
Neuropraxia can occur from impingement of the nerve by a large implant, migration or
improper placement of the implant, a traction injury, a thermal injury, or a direct traumatic
injury from dissection. Most patients regain sensation and function within three weeks.
Dissection for Malar implants involves elevating tissue around the infraorbital nerve. Weak‐
ness of the zygomaticus, orbicularis oculi, or the frontalis muscles can be induced by disturb‐
ance of the temporofrontal branch of the facial nerve while dissecting posteriorly over the
middle third of the zygomatic arch. Straying from the subperiosteal plane predisposes to
dissection into the parotid and facial nerve branches and facial musculature. During dissection
of the chin, it is important to avoid the mental nerve, which is approximately underneath the
area of the premolars intraorally. The marginal mandibular branch of the facial nerve, which
supplies muscles of the lower lip and chin, is above the periosteum over the inferior border of
the mandible. A severe traction injury or perforation of the periosteum can injure the marginal
mandibular branch of the facial nerve.
9.3. Edema and ecchymosis
The majority of postoperative edema and ecchymosis resolves in two weeks, but edema can
persist for 6 months and even up to a year [46]. Implant fixation is important because excessive
continuing movement can cause tissue injury, chronic inflammation, and suboptimal soft
tissue acceptance with prolonged edema. This could also be due to a nonspecific immune
reaction to the implant material.
9.4. Hematoma and seroma
Abnormal fluid collection can be the result of inadequate hemostasis, over-dissection, trau‐
matic handling of the tissues, dead space around or underneath the implant or elevated blood
pressure. Hematomas and seromas encourage the growth of bacterial contamination potenti‐
ating cellulitis and infection. They can result in excessive fibrosis producing soft tissue defects.
Smaller hematomas (<5 cc) resolve without treatment in 10–14 days. Large hematomas need
to be recognized and evacuated with the implant removed as necessary. Seromas usually
present around 2 weeks after surgery. Presence of liquefied hematomas or seromas 2 to 4 weeks
postoperatively may be drained percutaneously [47].
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9.5. Infection
Implants can be contaminated by hematogenous, contiguous spread, or direct inoculation.

Foreign bodies have been shown to reduce the number of bacteria required to produce an
infection by 104 to 106 power [48]. Chemical composition, surface roughness, surface config‐
uration, and hydrophobicity influence the potential for implant contamination. Hydrophilic
materials are more resistant to adhesion than hydrophobic materials. Scalfani and colleagues
found that PTFE with an average pore size of 22 microns became infected at lower inoculum
counts and sooner than polyethylene with a pore size of 150 microns [48]. Most infections in
the early postoperative time period are more likely to occur with porous implants because of
increased surface area, irregularity, and surface energy, which facilitates bacterial adherence.
Infections that occur years after surgery are most probably caused by hematogenous spread
or direct violation of the implant capsule with bacterial seeding like an injection. Late malar
implant infections have been associated with dental injections as reported by Cohen and
Kawamoto [49].
S. aureus is the main pathogen and is usually susceptible to penicillin or cephalosporin. A

better chance of eradicating the infection with antibiotics and drainage is possible with
nonporous implants. In the presence of a purulent infection, the implant should be removed
and scrubbed and sterilized to remove the biofilm. In addition, debridement and copious
irrigation of the implant pocket and a prolonged postoperative antibiotic course are necessary.
If rapid improvement does not occur and the implant needs to be removed, it should not be
replaced for 6–8 weeks to allow for resolution of the infection and inflammation [50].
9.6. Migration and contour changes
Migration is usually the result of over dissection, improper implant size selection and lack of
fixation. Supraperiosteal placement can predispose the implant to mobility especially without
adequate fixation. Anatomic implants have decreased the potential for migration, rotation,
and displacement. Delayed contour changes have been reported in association with silastic
implants. This is thought to be associated with capsular contracture around the implant in
addition to calcification of the capsule itself.
9.7. Extrusion
Adequate soft tissue bulk with good quality tissue for coverage of the implant and tension-
free correct plane insertion are critical to preventing implant extrusion. Decreased tissue
perfusion causes wound healing problems. Highly scarred and thinned tissues tend to atrophy
over time and are at a higher risk for postoperative infection, exposure, and extrusion [35].
Excessive tension is a result of placing too large an implant in a small pocket. In addition to
tension free closure, subperiosteal placement helps prevent exposure.
9.8. Palpability
This can be the result of improper implant size selection, improper contour selection, improper
positioning, improper fixation or capsular contracture. Thin overlying tissue and supraper‐
iosteal placement of the implant predispose to palpability.
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9.9. Lip dysfunction
Altered lip function occurs because dissection can interfere with the muscles responsible for
smiling mimetics. Other factors include edema, interposition of a solid implant which stretches
the muscles of the midface, or interference with the facial nerve during dissection over the
zygomatic arch. The edema can cause dysfunction in the muscles of the lips resembling facial
nerve dysfunction. When dysfunction is due to muscle displacement, it usually takes 1–3
months for the muscles to reattach and the capsule to become soft and distensible.
9.10. Bone resorption
Bone erosion under alloplastic implants was a significant problem with early implants. It was
often attributed to foreign body reaction between the implant and the bone or to pressure from
the mentalis muscle against the implant. Improper implant positioning, pressure due to an
oversized implant, subperiosteal placement and hardness of the implant were also considered.
The resorption from anatomic malar and chin implants is minimal and self-limiting. Bone
erosion occurs less with anatomic extended implants because of greater distribution of the
pressure forces over a broader anatomic area. Resorption appears to occur in the first 12 months
after placement but can appear radiographically as soon as 2 months. Labial incompetence and
hyperactive mentalis lead to pressure and migration of the implant superiorly onto the thinner
bone of the alveolus, which predisposes to resorption. When severe resorption is present, the
implant must be removed.
9.11. Postoperative asymmetry
Asymmetry is more likely to be noticed in malar implants. It is usually caused by initial

malposition or by creation of asymmetric bilaterally dissected spaces. It can also be the result
of unrecognized preoperative skeletal or soft tissue deficiencies. It is important to point out
preexisting asymmetry before treatment selection. Although major asymmetries require a
second surgery, minor asymmetries have a natural tendency to adjust and correct themselves
over a 6-month postoperative period as healing progresses and the tissue around the implant
relaxes and softens.
10. Summary
Loss of volume and volume shift occur in all regions of the face and neck and contribute to the
aged appearance. Volume replacement and contour augmentation of the face are the essentials
of facial cosmetic surgery. The development of less invasive volume replacement procedures
has been an evolution in achieving better aesthetic results. These procedures include lifting
procedures, injectable fillers, autologous fat transfer, and facial implants.
Facial volume augmentation by using facial implants is a very safe procedure that is used
widely for facial rejuvenation which can be used concomitantly with other rejuvenation
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procedures. It is crucial for the cosmetic surgeons to be familiar with various implant materials
and their advantages and disadvantages.
Author details
Farzin Sarkarat* and Behnam Bohluli
*Address all correspondence to: sarkarat@hotmail.com
Department of Oral and Maxillofacial Surgery, Bouali Hospital, Islamic Azad University of
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[49] Cohen SR, Kawamoto HK. Infection of proplast malar implants following dental in‐
jections. Plast Reconstr Surg 1992;89(6):1148–51.
[50] Louis PJ, Cuzalina LA. Alloplastic augmentation of the face. Atlas Oral Maxillofac
Surg Clin North Am 2000; 8(2):127–91.
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Chapter 25
Management of Bone Grafting Complications in

Advanced Implant Surgery
Mehdi Sezavar, Vahid Mesgarzadeh,

Shahrouz Shafayifard and M. Reza Soleimanpour
http://dx.doi.org/10.5772/59967
1. Introduction
1.1. The perfect bone graft
In spite of the fact that the bone materials that are currently being used are not absolutely
perfect,the bone graft material of choice must have 2 mandatory features:
1. Immunologically neutral
2. Physiologically safe
In an immunological point of view, the graft should neither be rejected nor be contaminated
to transmit microbial diseases. The graft should be biologically compatible, preferably
resorbed after formation of new bone, though supplying a scaffold and sustaining mechanical
stability for new bone regeneration. In a physiological point of view, a perfect bone graft
substance should support the host osteogenically,osteoinductively and osteoconductively.
2. Biosafety of bone grafting material
Contagious substances should be absent in an ideal biocompatible bone grafting material.

Carbonate, Calcium phosphate and Sulfate bone graft materials are typically biocompatible
with no risk of being rejected by the host. Virus, Prion and bacterial contamination of bone
grafting materials are not of our concern in autogenous or alloplastic bone grafts. The preva‐
lence of HIV infection in freeze-dried bone and demineralized freeze-dried bone allografts has
been reported to be 1 in 8,000,000 and 1 in 2.800.000 respectively. The prevalence of bovine
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spongiform encephalopathy transmission with bovine xenograft reckoned to be less than that
of being hit by lightning.
Thus, the risk of disease transmission from an allograft or xenograft is almost zero as long as
the disinfection/sterilization protocols are followed by manufacturers. The world health
organization affirmed that bone is classified as type IV (no transmission) for prion diseases.
Therefore all currently available bone graft materials are secure and reliable concerning disease
transmission potential.
3. Bone grafting drawbacks
3.1. Preservation of the alveolar socket
Socket preservation procedure serves to maintain the alveolar bone existing volume including
height and width by delivering graft materials into the alveolar socket after extraction and to
enhance new bone formation inside the socket. Various techniques and materials have been
applied and so far they have shown favorable results. Complications may either be caused by
surgical procedures or treatment planning. Excessive amounts of graft should be avoided.
Graft materials should gently be compacted keeping adequate between its particles to allow
revascularization and penetration of proteins and growth factors. Furthermore the flap design
has to be considered regarding the augmentation site specially in critical sites such as esthetic
zone. Park and Wang introduced the mucogingival pouch flap design to preserve the papil‐
la,improve graft retention and reduce exposure of the membrane. However in case that the
interdental space is less than 6mm, the mucogingival pouch flap may threaten the overall blood
supply of the flap caused by the vertical releasing incision. Thus wise treatment planning is
needed to avoid possible complications. Disappearance and contamination of the grafts placed
inside the dental socket may be expectable. Membranes used for GBR also strengthen the risk
of exposure and infection. Froum evaluated the healing of sockets underwent preservation
using hydroxyapatite and nonabsorbable inorganic bovine bone mineral covered by either
ePTFE membrane or acellular dermal matrix allograft. Having not adequately covered the
socket with soft tissue, 1 of 8 sockets covered by acellular dermal matrix and 6 of 8 sockets
covered by ePTFE exhibited exposure of membranes which consequently led to early removal
of the membranes because of potential infection. Reduction of facial facial keratinized tissue
followed by primary closure itself can be considered as a complication. Though this can be
avoided by wise treatment planning and allowing the socket to heal for 6 to 8 weeks in advance
before grafting. Recently formed keratinized tissue growing over the dental socket will provide
adequate coverage without giving away the facial width.
3.2. Guided bone regeneration or ridge augmentation

Guided bone regeneration (GBR) was proved to be effective in regenerating new bone on
alveolar ridges with atrophies both vertically and horizontally accompanied with membranes.
Much the same as onlay bone graft which also acts as a space maintainer, GBR may serve
similar complications related to the use of onlay grafts. Furthermore, GBR may also include
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the use of membrane and sometimes microscrews. Thus, complications that pertain to GBR
may vary such as membrane exposure, microscrew exposure and infection. Critical inflam‐
matory reactions have also been recorded. The prevalence of flap sloughing associated with
nonabsorbable membranes was high. Exposure of fixation screw or membrane may often lead
to local inflammations accompanied with decreased new bone formation. There have been
arguments over the significance of early membrane exposure on regenerative outcome of
guided tissue regeneration and GBR operations. Several studies have reported that the
responses were better when the membranes remained submerged while some other studies
cast doubt on this issue.
3.3. Monocortical onlay grafts
Complications with regard to ridge augmentation using the onlay bone grafts mainly include
infection, opening of the incision line, bone fracture, Nerve malfunction, rupture of mucosa
over the implant, loss of portion of the bone graft, dehiscence of the wound and graft move‐
ment. While the most common complication is the incision line opening that leads to contam‐
ination of graft, delay in vascularization and loss of graft material, the most deleterious
outcome on survival of implants in the augmentation site is related to wound dehiscence.The
prevalence of unintentional skin/mucosa perforation was 5.2% for mandible as augmentation
site with onlay bone graft and the incidence for infection occurred in 1 of the 11 patients(9.1%)
that resulted in partial loss of graft. Infection of the graft can be caused by endogenous bacteria,
deprived aseptic surgical technique or inadequacy of primary closure. Antibiotics were used
to prevent bacterial infection and to enhance collagen formation. However it was found that
tetracycline arrests the bone formation chelating calcium at the graft. Thus, other antibiotics
such as penicillin or clindamycin have been suggested.
3.4. Sinus lifting
Sinus lifting procedure is performed when there is insufficient height for implant placement
by lifting the Schneiderian membrane apically with bone grafting materials at the posterior
maxillary edentulous ridge. Perforation of the Schneiderian membrane, opening of the incision
line, sinusitis, formation of cysts, misplacement of graft particles and mucosal dehiscence are
complications with regard to sinus lift procedures. Perforation of sinus membrane can either
be pre existing or be caused by tearing during the operation and its prevalence has been
reported ranging from 10% to 34%. Sinus perforation can be managed using an absorbable
membrane. Pathologic conditions affiliated with paranasal sinuses are very prevalent. More
than 31 million people around the world suffer from sinusitis each year. The infection of sinus
may potentially cause critical complications such as sinusitis, orbital cellulitis, meningitis,
cavernous sinus thrombosis and osteomyelitis. The incidence of acute sinusitis is reported to
be around 3%. Moreover sinusitis may result in more complicated situations. Loss of bone
graft particles and sequestrae is not prevalent but possible. Failure of Branemark implants at
the grafted sites after a mean period of 32 months was 6.7%. A comprehensive pre operative
assessment is important to detect any existing pathologic condition in maxillary sinus. This
surely can reduce the risk of mucus and bacterial infection in the surgical field and compro‐
mising bone healing. Moreover due to vicinity of the maxillary sinus to vital structures such
as brain, cavernous sinus, etc, post-operative complications can be critical and life threatening.
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4. Etiologies related with bone grafting complications
4.1. Technique associated
Precautions have to be taken while harvesting bone from the ramus when the inferior cut is
below the inferior alveolar canal. Elevation of the bone graft should be avoided unless assured
that the nerve is not attached to the inside surface of the bone graft. As the thickest area of the
ramus is 12.23 mm and the thinnest area is 2.35mm, the thickness of bone graft will not be
homogenous. About 60% of the inferor alveolar canals were reported to be notched to the inner
surface of the mandibular cortical plate or the third molar root surface. Thus it is recommended
that whie performing the osteotomy, after 2 mm of penetration great care be taken with the
surgical bur short before reaching cancellous bone to avoid damaging the inferior alveolar
nerve. The mean thickness of the lateral cortical wall of the maxillary sinus has been reported
to be 0.91±0.43 mm. Cautious removal of the bone with surgical bur while performing the sinus
lift procedure is crucial in preservation of sinus membrane integrity. A recently developed
piezoelectric ultrasonic surgical device(piezotome, Acteon, Bordeaux, France) presents an
alternative way to safely remove hard tissue keeping the soft tissue intact,is an effective tool
for sinus lift procedures as well as harvesting autogenous bone from the ramus. Attaching an
onlay bone graft to the host site can affect revascularization of a graft. A loose graft may
develop nonunion and become compressed and encapsulated. To ensure close adaptation, the
fixation screws should be tightened. Contamination is usually an outcome of poor infection
control during the surgery. Rinsing with chlorhexidine before surgery is recommended before
the surgery on order to reduce the risk of infection. A study showed that infections were more
prevalent when using nonresorbable membranes for GBR comparing with the use of bioab‐
sorbable membranes over a bovine bone xenograft. A suitable membrane and proper mem‐
brane removal timing may be effective in reduction of the risk of infection. To prevent exposure
of membrane or fixation microscrews, tension free flap is mandatory.
4.2. Anatomy related
Ramus
Complications with regard to harvesting bone from the ramus may include damage to the
nerve, opening of the incision line, fracture of the mandible and trismus. The prevalence of
nerve damage caused by harvesting autogenous bone from the ramus is far less comparing to
that of the mandibular symphysis. Buccal nerve damage followed by incision along the
external oblique ridge is expectable. Nevertheless rarely are any reports present with regard
to the incidence of buccal mucosa sensory loss and patients do not often pay attention to the
change. On the contrary in this procedure, the potential of injuring the inferior alveolar nerve
is of great consideration. A great understanding of the local normal anatomy is required to
prevent such complications. Trismus may also be experienced by the patient underwent bone
harvesting from the ramus area because of the masseter muscle retraction. But the symptom
is not permanent. Furthermore, other complications related to ramus harvesting procedure
may consist of third molar involvement and mandibular fracture ; though not reported.
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Mandibular symphysis
Associated with mandibular symphysis/chin graft, complications such as insufficient bone

regeneration, altered sensation, nerve damage, pulp necrosis, vascular damage, opening of the
incision line and bone fracture may occur. Incomplete bone regeneration was found more
prevalent in old patients. Nevertheless, it was reported that the change in profile was not
obvious. Change in sensation of mandibular anterior incisors after loss of support of the
mentalis muscle was reported. The manifestation of dullness usually resolved within 6 months.
A high incidence of anterior mandibular incisors pulp necrosis was reported. Negative pulpal
reaction and canal obliteration may be caused by damage to pulp vasculature. There have been
reports on prevalence of nonvital teeth after genioplasty or subapical osteotomy. An effective
preventive way is to keep about 4 to 5 mm clearance from the root apices and avoidance of
harvesting bone close to them. Patients should also be informed about possible disturbances
that may occur in the function of the inferior alveolar nerve which may last longer than 12
months. Damage to incisal branch of the inferior alveolar nerve is expectable if the graft is
harvested too deep into the cancellous bone. Similarly mental nerve damage may occur if the
graft is harvested too distally. Fracture and posterior displacement of the lingual cortical plate
of the anterior mandible was reported as a specific complication which occurred during the
healing phase but not at the time of surgery. On the whole, careful measurement and assess‐
ment before the surgery are required to avoid facing most of the complications.
Maxillary tuberosity
Precaution has to be taken with regard to the adjacent anatomical elements such as the
maxillary sinus, pterygoid plates, proximal teeth and the greater palatine canal when using
the maxillary tuberosity as harvesting site. Although rare, oral-antral communication may
occur when harvesting bone which can be closed using the buccal fat flap as coverage,
antibiotics and decongestants. Bleeding and tethering of the lateral and medial pterygoid
muscles has been reported to be a potential complication when the tuberosity was fractured.
4.3. Patient related
Systemic issues affecting bone grafting include smoking, diabetes, alcoholism, radiation,
osteoporosis and medication.
4.3.1. Bisphosphonates
An inorganic analog of pyrophosphate, Bisphosphonate has recently been used to treat

osteoporosis or bone metastatic malignancies by reduction of osteoclastic differentiation and
induction of osteoclastic apoptosis. Bisphosphonate lets remodeling spaces be filled with new
bone by its anti-osteoclastic effect and as a result, abates the prevalence of fractures and also
increases the bone strength. Nevertheless, it was also found that not only does the bisphosph‐
onate suppress bone turnover but also interacts with micro-damage repair mechanism of bone.
The accumulation of the micro-damage reduces the strength of the bone resistance against
traumas. Furthermore, another drawback of the bisphophonate is that it decreases vascularity
in regenerative connective tissue. It was found that IV use of bisphosphonate in metastatic
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malignancies may contribute to osteonecrosis of the jaw. However the relationship between
osteonecrosis and use of bisphosphonate has not yet been recognized. Bisphosphonate related
osteonecrosis appears to be multifactorial. The susceptibility of osteonecrosis in patients
underwent IV bisphosphonate therapy for cancer was four times more than others. For patients
who receive IV bisphosphonate, aggressive dental procedures should be avoided due to risk
of jaw osteonecrosis. With insufficient research documents, guided regeneration and bone
grafts should be applied with great caution (see Dental management of patients receiving oral
bisphosphonate therapy, expert panel recommendations, report of the council on scientific
affairs, ADA, June 2006)as reduced integrity of the bone and decreased vascularity may have
negative drawbacks on grafted site. The incidence of osteonecrosis caused by oral adminis‐
tration of bisphosphonate is considered to be very low among the most common alendronates
prescribed. Thus, patients underwent IV bisphophonate therapy are contraindicated for
advanced surgical operations. This includes but not limited to implant placement, dental
extraction and periodontal procedures. Latterly, suggested that dentist should discuss the
risks, benefits and alternative treatments with the patients underwent bisphosphonate therapy
before any surgical procedures. Before starting the treatment, the discussion and the patient
informed approval should be documented.
4.3.2. Smoking
Almost 75% of the patients referred to periodontists were either current tobacco users or
claimed previous use of tobacco. It was reported that smoking has negative effects on revas‐
cularization of the bone regenerative treatments such as bone grafting, majorly because of its
vasoconstriction effect on arteries. Retardation of graft integration is caused as a consequent
of decreased blood supply. The rate of infection caused by smoking-induced change in oral
flora is 2 to 3 times more in smokers contributing to negative effects on complications of
periodontal procedures, including bone grafting. Levin and Schwartz-Arad reported that
nicotine, carbon monoxide and hydrogen cynide from smoking are possible risk factors that
result in weakened wound healing. This consequently threatens the success of bone grafting
and implant surgeries. Notwithstanding the cigarettes smoked, a patient with a smoking
history, presented higher rate of failure of implants placed in grafted maxillary sinus. Smoking
has negative influences on onlay grafts. While nonsmokers presented only 23.1% rate of
complications in monocortical onlay grafts,smokers had a 50% rate. Nevertheless no relations
were found in this article between sinus lift procedure complications and smoking tendency.
Surprisingly failure rate in maxillary bone was 1.6 times more than that of mandible under‐
going the same periodontal procedure showing that the maxilla was more prone to negative
reactions of tobacco. Furthermore bone grafting procedures are negatively affected by use of
tobacco with bone loss of 4 times as much as in nonsmokers. Such bone loss was majorly a
consequent of estrogens suppression caused by over expression of interleukin-1, interleukin-6
and tumor necrotising factor(TNF)-α. Quitting smoking has been shown to decrease the
progression of periodontal diseases and contribute the healing process of the bone graft.
4.3.3. Diabetes
Diabetes is able to enhance expression of TNF-α which has been blamed to be responsible for
apoptosis of osteoblasts and their precursors. This enhanced apoptosis is considered to be
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influential to the bone healing process. cellular malfunctions such as prolonged infiltration of
inflammatory cells, decreased production of growth factors and cell synthesis and increased
proteolytic activities are all assumed to be blamed for delayed healing and failure of bone
grafts. Osteopenia and delayed bone healing are both characteristics of diabetic bone disease.
Moreover, recurrent nonenzymatic protein glycation contributes to formation of advanced
glycation end product(AGE) that can be accumulated in different tissues such as bone. Further
alveolar bone loss can occur followed by accumulation of AGE.
4.3.4. Radiation
Osteopenia may be experienced, after one yearin mature patients underwent head and neck
radiotherapy. Osteoblasts activities may be diminished by radiation and results in decrease of
bone matrix. Moreover, following long-term vascular damage caused by radiotherapy,
osteonecrosis might happen. Due to poor blood supply and superficial location of mandible,
most cases of head and neck radionecrosis were found in that area. Weakened areas of the
bone are more susceptible to fracture. However, Despite the drawbacks mentioned above, one
study reported that bone grafting in radiated bone tissues showed a survival rate of 89%.
Another study reported that the prevalence of post-radiotherapy operative complications was
42%, while bone grafting procedures in nonirradiated sites had a 28% complication rate.
4.3.5. Alcoholism
The use of alcohol is shown to have adverse impact on intraoral bone grafting operations by
increasing osteoclast activities and weakening oseoblast proliferation. An animal study
reported that alcoholic beverages caused considerable delay in reparative process of alveolus.
Another study demonstrated that use of ethanol led to suppression of bone turnover and
provoked bone resorption. Other negative effects on bone grafting procedures attributed to
the use of alcohol may be ascribed to possible direct toxic effect of ethanol in periodontal
structures and other elements in oropharynx. Even a higher rate of complication in surgical
procedures of the mandible was presented by patients consuming large amounts of alcohol
when combined with other predisposing factors such as poor nutrition. Thus, it has been
suggested that quitting ethanol consumption should be applied a few weeks before aggressive
dental operations to minimize complications.
5. Complications of autogenous bone grafting
The use of autogenous bone graft with dental implants was originally discussed by Branemark.
5.1. Maxillary tuberosity bone graft

The major complication with maxillary tuberosity graft harvesting is oroantral communica‐
tion. Grafts may be harvested with a chisel or rongeurs. The chisel edge should be kept slightly
superficial to the maxilla to shave off pieces of tuberosity bone and prevent inadvertent sinus
communication.
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5.2. Mandibular symphysis bone graft
A CT scan or panoramic radiograph is used to evaluate the available bone at this donor site.
Lateral cephalometric radiograph can be useful to determine the anteroposterior dimension
of the anterior mandible. A vestibular incision is made in the mucosa between the cuspid teeth.
Limiting the distal extent of the incision will reduce the risk of mental nerve injury. The
mandibular symphysis is associated with a higher incidence of postoperative complications.
Incidence of temporary mental nerve paresthesia for symphysis graft patients is usually low.
Ptosis of the chin has not occurred and can be prevented by avoiding complete degloving of
the mandible.
5.3. Mandibular ramus
The limits of the ramus area are dictated by clinical access. After graft preparation, the donor
site is not augmented with bone substitutes because the inferior alveolar nerve may be exposed
and irritated by the graft particles. The potential for damage to the IAN, as opposed to its
peripheral mental branches is of greater concern with the ramus graft technique. Patients may
experience trismus following surgery and should be placed on postoperative glucocorticoids
and NSAIDs medications to help reduce dysfunction.
5.4. Tibia
There has been a low reported incidence of significant complications with this procedure.
Complications may include hematoma formation, wound dehiscence, infection and fracture.
The patient should avoid strenuous exercise for 4 to 6 weeks. Although quite rare most cases
of tibia fracture are due to a bony access too low on the leg.
5.5. Ilium
The grafting of larger areas of bone deficiency often requires bone harvesting from the ilium.
The crestal incision is made about 2cm below the anterior superior iliac spine and extending
caudally 4 to 5 cm. Care is taken not to cut through the external oblique or gluteal muscles
during this incision because this increases postoperative discomfort and slows ambulation.
All bleeding from the marrow is controlled with small amounts of bone wax or collagen
hemostatic. The patient is advised to avoid any lifting or twisting for the next 6 weeks to
preclude hip fracture. The use of a pain pump with long acting local anesthetics has dramat‐
ically reduced the level of postoperative pain from the hip area.
5.6. Rib graft
The preferred donor ribs are the fourth and fifth ribs. The fifth rib is superior to the fourth in
growing female patients. A major complication in rib harvesting is pleural perforation. In this
case a chest tube catheter is inserted in to the area of pleural compromise to a length of
approximately 1 to 2 cm; with the red rubber catheter in position, a purse string suture is placed
to fix the tube which should be attached to a chest tube bottle. For small perforations the
anesthesiologist provides positive pressure and maintains this position while a surgical knot
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is tightened. All patients having costochondral or rib harvests require a postoperative chest
radiograph performed and clinical inspection for pneumothorax. If a pneumothorax is noted
a chest tube may be placed.
5.7. Cranial bone
Cranial bone just superior and posterior to the temporal crest is generally quite thick and
accidental full thickness harvest and or dural perforation is minimized. An incision is made
beginning 1cm inferior to superior temporal line to avoid main arterial trunks of the superficial
temporal and posterior auricular arteries thus reducing bleeding; the parietal bone, which is
flat and also quite thick as compared with other areas of the cranium.
5.8. Grafting recipient sites
The bone graft should have intimate contact with underlying host bone. Following harvest,
the bone graft may be stored in sterile saline. The graft is mortised into position and fixated to
the ridge with screws. Complete flap coverage and tension free closure is essential to the
successful incorporation of the bone graft. After the periosteal releasing incision is made, the
flap is gently stretched to assess closure without tension. Although it is important that the flap
margins are well approximated, the sutures should not be pulled too tightly or ischemia will
occur. It is imperative that the graft is immobilized during healing postoperatively. The patient
should continue antibiotic therapy for at least 1 week. Smoking has been associated with a
high rate of wound dehiscence and graft failure. Cholorhexidine rinsing is used for oral
hygiene until the sutures are removed.
6. Complications of inferior alveolar nerve repositioning
Nerve mobilization procedures are precise methods that require clinical experience, knowl‐
edge of anatomy, and the ability to intervene in the event of potential accidents and/or
complications. [1] In the last few years, IAN repositioning has been used widely as an
alternative to short implants or bone grafts for osseointegrated implant placement in the
posterior mandible of patients who do not have sufficient bone height for conventional
treatment. Among the advantages of IAN repositioning is the option to use standard implants
with bicortical anchorage, increasing primary stability, which is essential in the osseointegra‐
tion process. Osseointegrated implants placed in combination with IAN repositioning present
a lower risk of bone loss than short implants when both are placed in similar circumstances.
[2] For clinical situations with less than the minimum height for short implants (5 mm), IAN
repositioning is the technique indicated. [3] This procedure also increases the resistance to
occlusal forces and promotes a good proportion between implant and prosthesis. [4] Com‐
pared to the option of performing a graft to allow placement of standard implants, in addition
to the lower cost, IAN repositioning can be performed under local anesthetic, does not require
a donor site, and has a lower morbidity rate. [5, 6]
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IAN repositioning also presents many disadvantages. The technique does not recover the
alveolar ridge anatomy and temporarily weakens the mandible. Mandibular fractures
associated with endosseous implants have been documented and are generally related to high
levels of resorption in edentulous mandibles. Also, nerve mobilization leads to many factors
that can increase the occurrence of fractures. [7, 9] A large portion of the buccal cortex is
removed, reducing the structural integrity of a region that is under constant stress during
chewing. [8] In addition to that, sites that have been prepared and subsequently abandoned
due to bad angulation or insufficient initial stability are areas of bone fragility susceptible to
fracture. [7] Poor nutrition as a consequence of blood perfusion changes associated with this
nerve mobilization can also be a cause of fracture. [10] Another disadvantage of IAN reposi‐
tioning is the risk of nerve damage. The duration and degree of neurosensory disturbance has
been related directly to the amount of compression and tension applied to the nerve during
the procedure, [11] or to chronic distension/compression of the nerve after the surgery. [12]
Hypoesthesia, paresthesia, and hyperesthesia are the most common complications. [13]
The success rate of the lateralization procedure, regarding the osseointegration process, varies
from 93.8% to 100%, and thus both patients and surgeons believe this to be a safe procedure;
however, a small percentage of patients will have nerve damage for the rest of their lives. [14]
Concerning the use of materials as barriers between the implant and nerve, there is controversy
in the literature, because while some authors consider the use of resorbable membranes to be
helpful, [4] others have observed faster healing of the bone wound without barriers, followed
by the restoration of the mandibular canal. [15] One advancement is the utilization of piezo‐
electric devices, which allow the surgeon to perform the osteotomy without damaging soft
tissue, because piezoelectric devices only affect mineralized tissues. In vitro tests have shown
a lower risk of injury when piezoelectric devices are used compared to conventional rotary
devices. [16]
7. Complications of sinus lifting
A variety of complications can happen during and after sinus lifting. As all the other surgical
techniques, this procedure is prone to all common complications of oral surgery but in this
chapter we will focus on complications of this procedure.
7.1. Membrane perforations
The most common complication during sinus graft surgery is tearing of the sinus membrane.
Causes of this condition include: Pre-existing perforations, tearing during scoring of the lateral
wall window, existing or previous pathologic condition, and elevating of the membrane from
the bony walls. This complications occurs about 10% to 34% of the time. The perforation of the
sinus membrane should be sealed to prevent contamination of the graft from the mucus and
the contents of the sinus and to prevent the graft materials from extruding into the sinus proper.
The surgical correction of a perforation is initiated by elevating the sinus mucosal regions distal
from the opening. Once the tissues are elevated away from the opening, the membrane
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elevation with a sinus curette should approach the tear from all sides so that the torn region
may be elevated without increasing the opening size. The antral membrane elevation techni‐
que decreases the overall size of the antrum, thus folding the membrane over itself and
resulting in closure of the perforation.
If the sinus membrane tear is larger than 6 mm and cannot be closed off with the circumele‐
vation approach, then a resorbable collagen membrane, but of a longer resorption cycle, may
be used to seal the opening. The remaining sinus mucosa is first elevated as described
previously. A piece of collagen matrix is to cut to cover sinus tear opening and overlap the
margins more than 5 millimeters. Because no antibiotic is used on the collagen to make this
procedure easier to perform, additional antibiotic is added to the graft material. Once the
opening is sealed, the sinus graft procedure maybe completed in the routine fashion. A sinus
perforation may cause an increased risk of short-term complications. A torn membrane may
increase the risk of bacterial penetration into the graft material. Furthermore, mucus may
violate the graft influencing the amount of bone formation. Drip of the graft material into the
sinus proper may occur as a result of torn membrane, travel to and through the ostium and
either be abolished through the nose or block the ostium and prevent normal sinus drainage.
Ostium obstruction is also possible from swelling of the membrane related to the surgery.
These conditions increase the risk of infection. However, despite these potential complications,
the risk of infection is low (less than 5%)
7.2. Antral septa
Antral septa are the most common osseous anatomical variant seen in the maxillary sinus.
Sinus septa may create added difficulty at the time of surgery. Maxillary septa can prevent
adequate access and visualization to the sinus floor; therefore inadequate or incomplete sinus
grafting is possible. These dense projections complicate the surgery in several ways. After
scoring the lateral-access window in the usual fashion, the lateral-access window may not
fracture and rotate into its medial position. The strut reinforcement is also more likely to tear
the membrane during the releasing of the access window.
7.3. Management of septa based on location
The septa maybe in the anterior, middle, or distal partof the antrum. When the septum is found
in the anterior section, the lateral access window is divided into sections: one in front of the
septa and another distal to the structure. This permits the release of each section of the lateral
wall after tapping with a blunt instrument. The elevation of each released section permits
investigation into the exact location of the septa and to continue the mucosal elevation.
When the strut is located in the middle region of the sinus, it is more difficult to make two
separate access windows within the direct vision of the surgeon. As a result, one access window
is made in front of the septa. The sinus curette then proceeds up the anterior aspect of the web,
towards its apex. The curette then slides toward the lateral wall and above the septum apex.
The curette may slide over the crest of septum approximately 1 to 2 mm. A firm pulling action
fractures the apex of the septum. Once the septum is separated off the floor, the curette may
proceed more distal along the floor and walls.
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When the septum is in the posterior compartment of the sinus, it is often distal to the last
implant site. When this occurs, the posterior septum is treated through the posterior wall of
the sinus.
8. Short-term postoperative complications
8.1. Incision line opening
Incision line opening is uncommon for this procedure because the crestal incision is in attached
gingiva and at least 5 mm away from the lateral access window. Incision line opening occurs
more commonly when lateral augmentation is performed at the same time as sinus graft
surgery, or when implants are placed over above the residual crest and covered with the soft
tissue. It may also occur when a soft tissue-supported prosthesis compresses the surgical area
during function before suture removal. The consequences of the incision line opening are
delayed healing, leaking of the graft material into the oral cavity, and increased risk of
infection. However, if the incision line failure is not related to the lateral onlay graft and is only
on the crest of the ridge and away from the sinus access window, then the posterior crestal
area is allowed to heal by secondary intention. If incision line opening includes a portion of
nonresorbable membrane, then the membrane should be cleaned at least twice daily with oral
rinses of chlorhexidine. If the incision line does not close after two months, then a surgical
procedure should reenter the site, expand the tissues, remove the bone regeneration mem‐
brane, and reapproximate the tissue.
8.2. Nerve impairment
In severely atrophic maxillas, the infra orbital neurovascular structures exiting the foramen
may be close to the intraoral residual ridge and should be avoided when performing sinus
graft procedures to minimize possible nerve impairment.
8.3. Acute maxillary sinus rhinosinusitis
Acute postoperative sinusitis occurs as a complication in approximately 3% to 20% of sinus

graft procedures, and it represents the most common short term complication. Most often the
infection begins more than 1 week after surgery.
Radiographic evaluation of acute rhinosinustis is both expensive and often inaccurate. As such,
a patient history for acute sinusitis is a benefit and is diagnostic when two or more of the
following factors are present: (1)facial congestion or fullness, (2)nasal obstruction or blockage,
(3)nasal discharge, (4)purulence or discolored postnasal discharge, (5)facial pain or pressure,
(6)hyposomia or anosomia, (7)purulence in the nares on physical examination, (8)fever,
(9)headache, (10)halitosis, (11)dental pain, (12)cough, (13)ear pain.
Previous studies and treatment modalities used amoxicillin as the first drug of choice.
However, with the increasing prevalence of penicillinase and beta-lactamase producing strains
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of haemaphilus influenza and moraxells catarrhalis, along with penicillin-resistant strains of

streptococcus pneumonia, other alternative antibiotic drugs should be selected. If symptoms
are not alleviated with antibiotic and decongestant medications, then possible referral to the
patient’s physician or otolaryngologist is warranted.
8.4. Overfilling the sinus
The maximum length requirement of an implant with adequate surface of design is rarely more
than 15 mm, and as a result, the goal of the initial sinus graft is to obtain at least 16mm of
vertical bone from the crest of ridge. Overfilling the sinus can result in blockage of the ostium,
especially if membrane inflammation or the presence of a thickened sinus mucosa exists. The
majority of sinus graft overfills do not have postoperative complications. If, however, a
postoperative sinus infection occurs without initial resolution, re-entry and removal of a
portion of the graft and changing the antibiotic protocol may be appropriate. [17, 18]
Author details
Mehdi Sezavar*, Vahid Mesgarzadeh, Shahrouz Shafayifard and M. Reza Soleimanpour
*Address all correspondence to: m_s7605@yahoo.com
Department of Oral and Maxillofacial Surgery,Islamic Azad University,Dental branch, Teh‐

ran, Iran
References
[1] Babbush CA. Transpositioning and repositioning the inferior alveolar and mental
nerves in conjunction with endosteal implant reconstruction. Periodontology 1998;17:
183–90.
[2] Vasco MA, Hecke MB, Bezzon OL. Analysis of short implants and lateralization of
the inferior alveolar nerve with 2-stage dental implants by finite element method. J
CraniofacSurg 2011;22:2064–71.
[3] Fernandez Dıaz J.O., Naval Gıas L. Rehabilitation of edentulous posterior atrophic
mandible: inferior alveolar nerve lateralization by piezotome and immediate implant
placement. Int J Oral MaxillofacSurg 2013;42:521–6.
[4] Sethi A. Inferior alveolar nerve repositioning in implant dentistry: a preliminary re‐
port. Int J Periodontics Restorative Dent 1995;15: 474–81.
[5] Rosenquist B. Fixture placement posterior to the mental foramen with transposition‐
ing of the inferior alveolar nerve. Int J Oral Maxillofac Implants 1992;7:45–50.
www.dentalbooks.co
[6] Dario LJ, English Jr R. Achieving implant reconstruction through bilateral mandibu‐
lar nerve repositioning. J Am Dent Assoc 1994;125:305–9.
[7] Luna AH, Passeri LA, de Moraes M, Moreira RW. Endosseous implant placement in
conjunction with inferior alveolar nerve trans-position: a report of an unusual com‐
plication and surgical management. Int J Oral Max-illofac Implants 2008;23:133–6.
[8] Karlis V, Bae RD, Glickman RS. Mandibular fracture as a complication of inferior al‐
veolar nerve transposition and placement of endosseous implants: a case report. Im‐
plant Dent 2003;12:211–6.
[9] Kan JY, Lozada JL, Boyne PJ, Goodacre CJ, Rungcharassaeng K. Mandibular fracture
after endosseous implant placement in con-junction with inferior alveolar nerve
transposition: a patient treatment report. Int J Oral Maxillofac Implants 1997;12: 655–
9.
[10] Bradley JC. The clinical significance of age changes in the vascular supply to the
mandible. Int J Oral Surg 1981;10(Suppl. 1):71–6..
[11] Robinson PP. Observations on the recovery of sensation following inferior alveolar
nerve injuries. Br J Oral MaxillofacSurg 1988;26:177–89.
[12] Nocini PF, De Santis D, Fracasso E, Zanette G. Clinical and electrophysiological as‐
sessment of inferior alveolar nerve function after lateral nerve transposition. Clin Or‐
al Implants Res 1999;10:120–30.
[13] Sandstedt P, Sorensen S. Neurosensory disturbances of the trigeminal nerve: a long‐

term follow-up of traumatic injuries. J Oral MaxillofacSurg 1995;53:498–505.
[14] Hirsch JM, Bra°nemark PI. Fixture stability and nerve function after transposition
and lateralization of the inferior alveolar nerve and fixture installation. Br J Oral
MaxillofacSurg 1995;33:276–81.
[15] Yoshimoto M, Watanabe IS, Martins MT, Salles MB, Ten Eyck GR, Coelho PG. Micro‐
structural and ultrastructural assessment of inferior alveolar nerve damage following
nerve lateralization and implant placement: an experimental study in rabbits. Int J
Oral Maxillofac Implants 2009; 24:859–65.
[16] Metzger MC, Bormann KH, Schoen R, Gell-rich NC, Schmelzeisen R. Inferior alveo‐
lar nerve transposition—an in vitro comparison between piezosurgery and conven‐
tional bur use. J Oral Implantol 2006;32:19–25
[17] Misch CE: Contemporary implant dentistry, 2008,third edition
[18] Lindhe J: Clinical periodontology and implant dentistry,2008, fifth edition
[19] Fonseca Raymond.J; Oral and Maxillofacial Surgery; 2009; Vol 1 Second Ed
[20] Epker Bruce; Dentofacial Deformities: Integrated Orthodontic and surgical correc‐
tion; Volume III
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Chapter 26
Reconstruction of
Facial Hair Bearing Areas
in the Male Patient
Shahram Nazerani
http://dx.doi.org/10.5772/59191
1. Introduction
Hair bearing regions of the face have been the hallmarks of Manhood through the ages and
the defects of these regions are psychologically traumatizing and sometimes demeaning for
the male patients in several cultures. The reconstruction of these areas is very difficult due to
scarcity of donor areas and the available donors such as scalp have anatomically different hair
morphology and the hair follicles’ proximity is quite different from the face, on the other hand
the facial skin thickness and texture is another matter of concern making a “look alike”
reconstruction almost impossible. In this chapter we will try to address this difficult recon‐
struction challenge.
1.1. Terminology
In humans, usually only pubescent or adult males are able to grow beards. [1, 2]
The Beard or Barba is defined as:

1. The hair on a man's chins, cheeks, and throat.
2. A hairy or hair like growth such as that on or near the face of certain mammals.
Moustache or Mustache refers to:
1. The unshaved growth of hair above the upper lip and sometimes down the sides of the
mouth, especially when grown and groomed.
2. Something similar to the grown and groomed hair above the human upper lip
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1.2. Historical background [3]
Throughout the course of history, societal attitudes towards male beards have varied depend‐
ing on factors such as prevailing cultural-religious traditions and the fashion trends. Some
religions (such as Islam and Sikhism and Judaism) have always considered a full beard to be
absolutely essential for all males able to grow one. [4]
1.2.1. Ancient Egypt [3]
The highest ranking Ancient Egyptians grew hair on their chins which was often dyed or
hennaed (reddish brown) and sometimes plaited with interwoven gold thread. A metal false
beard, or postiche, which was a sign of sovereignty, was worn by queens and kings. This was
held in place by a ribbon tied over the head and attached to a gold chin strap, a fashion existing
from about 3000 to 1580 BC. [5] Mesopotamian civilizations (Sumerian, Assyrians, Babyloni‐
ans, Chaldeans and Medians) devoted great care to oiling and dressing their beards, using
tongs and curling irons to create elaborate ringlets and tiered patterns.
1.2.2. Ancient Iran [3]
The Iranians (Persians) were fond of long beards (Figure 1), and almost all the Iranian kings
had a beard. In Travels by Adam Olearius, a King of Iran commands his steward's head to be
cut off, and on its being brought to him, remarks, "what a pity it was, that a man possessing
such fine mustachios, should have been executed." Men in the Achaemenid era wore long
beards, with warriors adorning theirs with jewelry. Men also commonly wore beards during
the Safavid and Qajar eras. [6]
Figure 1. A 19th century painting of an Old Persian man after lunch, note the full beard.
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1.2.3. Ancient Macedonia [3]
At the time of Alexander the Great the custom of smooth shaving was introduced. [7, 8]
Reportedly, Alexander ordered his soldiers to be clean-shaven, fearing that their beards would
serve as handles for their enemies to grab and to hold the soldier as he was killed. The practice
of shaving spread from the Macedonians, whose kings are represented on coins, etc. with
smooth faces, throughout the whole known world of the Macedonian Empire (Figure 2).
Figure 2. A coin depicting a cleanly shaven Alexander the Great.
Laws were passed against it, without effect, at Rhodes and Byzantium; and even Aristotle
conformed to the new custom, unlike the other philosophers, who retained the beard as a badge
of their profession. A man with a beard after the Macedonian period implied a philosopher,
and there are many allusions to this custom of the later philosophers in such proverbs as: "The
beard does not make the sage." [9]
1.2.4. Ancient Rome 3
Shaving seems to have not been known to the Romans during their early history (under the
Kings of Rome and the early Republic). Pliny tells us that Ticinius was the first who brought
a barber to Rome, which was in the 454th year from the founding of the city (that is, around
299 BC). Scipio Africanus was apparently the first among the Romans who shaved his beard.
However, after that point, shaving seems to have caught on very quickly, and soon almost all
Roman men were clean-shaven; being clean-shaven became a sign of being Roman and not
Greek. Only in the later times of the Republic did the Roman youth begin shaving their beards
only partially, trimming it into an ornamental form; prepubescent boys oiled their chins in
hopes of forcing premature growth of a beard. [10]
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1.2.5. The middle ages [3]
In the middle ages, the beard had still an important role, figure 3 depicts the picture of El Cid
or “ The Mister” in Arabic. (Figure 3). [11]
Figure 3. Charles IV, Holy Roman Emperor.
While most noblemen and knights were bearded, the Catholic clergy were generally required
to be clean-shaven. This was understood as a symbol of their celibacy. By the early 20th century
beards began a slow decline in popularity. Although retained by some prominent figures who
were young men in the Victorian period (like Sigmund Freud), most men who retained facial
hair during the 1920s and 1930s limited themselves to a moustache or a goatee (such as with
Marcel Proust, Albert Einstein, Vladimir Lenin, Leon Trotsky, Adolf Hitler, and Joseph Stalin).
In America, meanwhile, popular movies portrayed heroes with clean-shaven faces and "crew
cuts". Concurrently, the psychological mass marketing of companies like Gillette popularize
short hair and clean shaven faces as the only acceptable style for decades to come. Those who
grow beards are frequently either old, Central Europeans, members of a religious sect that
require it or those who are in academia.
1.3. Modern prohibition of beards [3]
Professional airline pilots are required to be clean shaven to facilitate a tight seal with auxiliary
oxygen masks. Similarly, firefighters may also be prohibited from full beards to obtain a proper
seal with equipment. This restriction is also fairly common in the oil and gas industry for the
same reason in locations where hydrogen sulfide gas is a common danger. Other jobs may
prohibit beards as necessary to wear masks or respirators. [12] Isezaki city in Gunma, Japan,
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Figure 4. An Asian scalp hair, note the roundness of the hair, reprinted by permission of The Society of Cosmetic
Chemists
decided to ban beards for male municipal employees on May 19, 2010. [13] Brigham Young
University generally requires its students and employees to be clean-shaven. However,
Brigham Young himself was often seen with a beard. [14]
2. Anatomy and physiology of facial hair
Human hair has been categorized into three ethnic groups according to distinguishable
characteristics: Asian, Caucasian, and African hair. These ethnic groupings show distinct
characteristics in hair density, diameter, shape, mechanical properties and composition. [15]
The hair follicle itself determines the appearance of the hair. The typical hair follicle of Asian
hair is round (Figures 4 and 5), whereas those of Caucasians and Africans are ovoid and
elliptical, respectively. [16]
The shape of the hair follicle is thus believed to contribute to the appearance and the geometry
of the hair. Asian hair has a circular geometry, African hair has an elliptical shape, and hair of
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Figure 5. Asian beard hair, note the different contour of the beard hair from scalp hair, reprinted by permission of The
Society of Cosmetic Chemists
Caucasians is of an intermediate shape. The chemical and protein composition of hair does not
vary across ethnic groups, and there is no difference in the keratin types. However, African
hair generally has less tensile strength and breaks more easily.
3. The units of the face
The face consists of 6 major aesthetic units comprised of: forehead, eye/eyebrow, nose, lips,
chin, and cheek. These aesthetic units can be subdivided into additional anatomical subunits.
For example, the nose can be divided into nasal tip, dorsum, columella, soft-tissue triangles,
sidewalls, and nasal alar regions. Correct orientation of planned incisions next to these mobile
functional and aesthetic facial structures is important to avoid distortion when closing
wounds.
In this chapter we focus on the hair bearing units of the male face which are designated as the
mustache and beard namely units 4c, d, 5a, b, 7 and some part of unit 9 in the neck (Figures
7 and 8).
y has less tensile strength and breaks more easily.
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Figure 6. Comparison of the cuticular patterns of scalp and beard hair, reprinted by permission of The Society of Cos‐
Chemists
6: Comparison
metic of the cuticular patterns of scalp and beard hair, repri
on of The Society of Cosmetic Chemists
nits of the face
consists of 6 major aesthetic units comprised of: forehead, eye/eyebrow, n
d cheek. These aesthetic units can be subdivided into additional anatomical s
mple, the nose can be divided into nasal tip, dorsum, columella, soft‐tissue t
s, and nasal alar regions. Correct orientation of planned incisions next to thes
al and aesthetic facial structures is important to avoid distortion when closing w

Figure 7. The human face units, used by permission of author Davide Brunelli M.D, www.med-ars.it
Figure 7: The human face units, used by permission of author Davide Brunelli M.D, www.med‐
ars.it
In this chapter we focus on the hair bearing units of the male face which are designated as the
mustache and beard namely units 4c, d, 5a, b, 7 and some part of unit 9 in the neck (Figures 7
and 8).
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Figure 8. The hair bearing units in the male face, used by permission of author Davide Brunelli M.D, www.med-ars.it
Figure 9. The mustache unit, used by permission of the author Davide Brunelli M.D, www.med-ars.it
3.1. The Mustache
Loss of the mustache in the male patient causes cosmetic and psychological problems. The
mustache also has the ability to cover the perioral scars and defects and is favored by the
patients with scars around the mouth and upper lip such as cleft lip patients (Figure 9).
Full thickness defects of the units 5a and b or upper lip area in addition to esthetically
unappealing elicit the functional problems such as drooling, speech disorders and poor oral
hygiene, the partial thickness defects are more of an esthetic nature with asymmetrical
structure.
The two potential sources of hair-bearing skin are the bearded face, neck and the scalp. The
texture, hair bearing quality, and color match make local beard skin on the face a preferable
donor site, but this is possible only for relatively small defects; otherwise, the resulting scar at
the donor site is unacceptable. In these cases, local advancement or V-Y advancement flaps are
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Figure 10. Flap prefabrication stages, vascular pedicle transferred under the skin paddle and the pedicle is wrapped by
either Gore-Tex or silicone and a tissue expander is inserted for expansion, after proper expansion the flap is transfer‐
red as a free or island flap. The prelaminated flap can then be transferred to reconstruct the mustache or beard area.
[23] Distant pedicled scalp flaps such as the extended midline forehead flap, transposition or island scalp flap, and
bipedicle visor flap are other viable options.
used. Tissue expansion of this hair-bearing region to increase the surface area of the bearded
face with Abbe and submental flaps have been described to bring hair-bearing tissue to the
upper lip from the lower lip and bearded face and vice versa. [17] However, one must note the
difference in hair distribution in the upper and lower lips when planning this flap.
The submental island flap reported by Martin et al is another source of hair bearing tissue with
acceptable donor scar. [18]
The hair follicle match of the submental area is excellent and the follicle orientation is also
correct, this flap can be transferred as a bipedicle type with limited arc of rotation and several
other flap types reported by Tsur and Hyakusoku. [19]-[22]
The main drawback of submental flap is the need for several revision procedures, which have
the potential risk of Alopecia due to too much thinning of the flap or damaging the vascular
supply of the flap. [17, 22]
The flap prelamination is another option, in this technique a vascular pedicle is transposed
under a random pattern flap and after maturation this composite tissue is transferred, it has
some drawbacks such as the need for microvascular expertise and the potential risk of
peripheral flap failure. (Figure 10)
3.2. Beard and Sideburns
The male bearded region can be subdivided into a preauricular zone, which includes the
sideburn and the buccomandibular zone (Figure 11).
The sideburn is an important anatomical structure determining the boundary between the
head and the face and providing an aesthetic reference for balanced facial symmetry. The
normal sideburn dimensions have been well described by Giraldo. [24] The sideburn shape is
largely rectangular or trapezoidal. According to Juri, the most frequent causes for absence of
the sideburn are trauma, burns, surgery, and infection. [25] Small defects within or involving
the sideburn can be reconstructed with a single V-Y flap, opposing V-Y flaps, extended V-Y
flaps, or double extended V-Y flaps. V-Y flaps are designed within hair-bearing regions and
non–hair-bearing regions according to the characteristics of the tissue to be replaced. Addi‐
tional options for sideburn reconstruction include a scalp transposition flap. Larger defects
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Figure 11. The side burn area, used by permission of author Davide Brunelli M.D, www.med-ars.it
including the sideburn and adjacent cheek or beard region can be reconstructed with a
combination of any of these three primary options: the scalp transposition flap, the cervicofa‐
cial advancement flap, or the pedicled submental flap.
4. Cheek reconstruction
The cheek provides abundant subcutaneous tissue, which is mobile and has a perfect color
match. Because of the laxity of the cheek, adjacent undermining and primary closure can be
used to reconstruct many defects. Flaps can be designed within this tissue with minimal
distortion to surrounding facial features and minimal dead space (Figure 12).
Figure 12. The cheek unit with subdivision of c and d, used by permission of author Davide Brunelli M.D, www.med-ars.it
In females the face has almost no hair so the reconstruction can begin at a younger age and
more donor sites are available than the male patients. In the female neck skin can be expanded
and be used to cover the chin and even cheek defects (Figure 13 - 15).
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Figure 13. Bilateral cheek scars, expanded neck skin via tissue expander
Figure 14. Frontal view of the scar after 5 years
Figure 15. Result 8 years postoperatively

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In the male child or adolescent, a facial skin defect reconstruction is completely different from
females because transferring a hair bearing flap in a child is unsightly and the definite
reconstruction of the facial hair bearing areas must be postponed until the patient has grown
hair (Figures 16 and 17).
Figure 16. A 14-year-old male patient with a unit 4 scar
Figure 17. Lateral view of the same patient
5. Neck reconstruction
Zone 9 is the neck area contiguous with the chin and if the facial hair is present there is no need
to reconstruct this area with hair bearing flaps, in these instances the patient can cover the neck
scar with a beard.
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6. Available donor sites
6.1. Submental island flap
6.1.1. Anatomy
The submental island flap is a fasciocutaneous flap that includes a rhomboid area of skin,
subcutaneous tissue, and platysma located below the inferior border of the mandible (Figure
18). This flap was first reported by Martin et al. [26]
Figure 18. The submental flap raised on its vascular pedicle
Injection studies into the submental artery have found that it can supply a large skin paddle,
as large as 10 _16 cm, reaching from one angle of the mandible to the contralateral angle. [27]
Although this horizontal dimension includes an area supplied by bilateral submental arteries,
the entire flap can be perfused by one side. Practically speaking, the anteroposterior dimension
of the skin flap that can be harvested is limited by the ability to achieve primary closure, which
depends on the patient’s skin laxity and age, which can be estimated by marking out the
desired anteroposterior dimension of the flap and attempting to pinch the marks together with
forceps.
The locations of the perforator vessels connecting the submental artery to the subdermal plexus
(which perfuses the areas listed above) are variable. This flap has a shorter pedicle compared
to scalp flaps, is rather thick and arch of rotation or pivot point is short; in the young the donor
site scar becomes hypertrophic and in view.
6.2. Expanded scalp
The expanded scalp has two benefits namely thinning the density of the hair follicles and also
a thinner skin brought in to the defect. These flaps can be transferred as pedicle flaps or free
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flaps. [28, 29] The expanded flap can be covered by the scalp hair is not very noticeable until
late in expansion (Figure 19).
Figure 19. The expander is in place; the patients usually grow hair on the opposite side of the expansion area to com‐
pensate.
6.3. Visor flap
The frontal visor flap first described by Leon Dufourmental in 1919 has stood the test of time;
and with tissue expansion to overcome the donor site morbidity it is the only solution in
bilateral facial defects in the male patient. [30] The scalp visor flap has an excellent blood
supply, guaranteed by its double pedicle with the two superficial temporal arteries.
6.4. Adjacent skin reconstruction, expanded and non-expanded
In small defects it is possible to expand the adjacent skin and reconstruct the defect by the
“same skin".
6.5. Hair transplantation
Another option for reconstruction of facial hair is Hair Transplantation; there are differ‐
ent techniques of hair transplantation, each with their inherent advantages and disadvantag‐
es. The most common and known hair transplantation method is the so-called ‘strip’
method. [31]
A strip of skin containing hair follicles is removed, cut into grafts and implanted in the recipient
area. In the past years, new methods have developed of which the most promising is the follicle
unit extraction (FUE). [32] With this method, whole follicle units are extracted one by one and
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implanted one by one into the recipient area. Although the FUE method is more patient
friendly and leaves only tiny scars compared with the strip method, which leaves visible linear
scars at the donor area, the major disadvantage of both methods is that the extracted hair
follicles are removed and the source of potential grafts will be consumed in time. The only way
to preserve a significant part of the donor hair follicles could be partial FUE. This idea is not
unrealistic and is supported by different experiments [33] Reynolds found that, although the
dermal papillae of humans cannot induce new hair growth, the sheath of the lower part of the
hair follicle can.
The main drawback of hair transplantation is the esthetic result; in a full thickness facial scar
with depressed and discolored skin with poor vascularity the result might not be very
satisfactory.
Hair transplantation can be very useful in small and patchy hair bearing area defects or as an
adjunct operation in the remaining hairless scar.
7. Algorithm of treatment
In the female patient the final reconstruction can be done at any time but the male patient’s
reconstruction should be postponed until the facial hair has grown because a bearded face in
a child is not socially acceptable and a non-hair bearing reconstruction of the face in these
patients, although reported in the literature, might lead to dissatisfaction in later years.
Although at some point during the treatment of the patients we have combined all the
treatment modalities such as covering a flap scar with hair transplantation or combining
expansion with adjacent tissue VY or Z plasty I propose an algorithm of treatment based on
the face units. There are generally four types of hair bearing area defects:
Type 1 is a partial unit defect
Type 2 is total unit defect
Type 3 is bilateral or multiple unit defects with two subtypes type 3a: multiple unit and 3b:
bilateral
Type 4 is isolated unit 9 defect
7.1. Type 1 defect
For partial unit defects (Figures 20 to 22), the treatment modalities available are:
1. Defect resection and primary repair
2. Local tissue expansion and reconstruction
3. Hair transplantation
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Figure 20. A partial unit defect can be anywhere on the face, used by permission of author Davide Brunelli M.D,
www.med-ars.it
Figure 21. A type one defect of unit 4
Figure 22. After resection and repair and one stage hair transplantation. Some areas need more transplantation
7.2. Type 2 defect
Total unit defects which can be either unit 4 or 5 (Figures 23 to 34).

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The reconstruction options are :
1. Expanded scalp
2. Expanded submental flap
Figure 23. Unit 5 defects, used by permission of author Davide Brunelli M.D, www.med-ars.it
Figure 24. A unit five defect 20 years after reconstruction by an expanded scalp visor flap
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Figure 25. A unit five defect 20 years after reconstruction by an expanded scalp visor flap
Figure 26. Unit 4 defect, used by permission of author Davide Brunelli M.D, www.med-ars.it
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Figure 27. Unit 7 full thickness defect
Figure 28. The expanded scalp flap

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Figure 29. Expansion is complete.
Figure 30. The defect after resection of scar tissues

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Figure 31. Outline of the flap design is over the highest expanded area to bring a less dense follicle area to the recipient
site.
Figure 32. The flap is elevated on the superficial temporal vessels as a pedicle flap
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Figure 33. The flap covers the defect completely. Note the pedicle lying over the face.
Figure 34. The flap pedicle ready to be severed and returned to its original place.
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Figure 35. The flap after severance
Figure 36. The patient 5 years after the last operation.

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7.3. Type 3 defect
Bilateral unit defects or multiple unit defects may be best treated via an expanded Visor flap
(Figures 35 to 45).
Type 3a
Figure 37. Type 3a defect, bilateral involvement of units or combined units, used by permission of author Davide Bru‐
nelli M.D, www.med-ars.it
Figure 38. A bilateral unit 4 and 7 defect

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Figure 39. The expanded occipital flap
Figure 40. The flap is transferred on the temporal pedicle

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Figure 41. Ten years after the operation
Figure 42. Another view with small Z- plasties to cover the scar
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Figure 43. Type 3a : multiple unit with sideburn involvement; units 4 and 5 partial defects with expansion in place
Figure 44. Expanded supraclavicular skin for forehead coverage and expanded scalp for reconstruction of multiple
units.
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Figure 45. The result after two years
Figure 46. Ten years after operation

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Figure 47. Another view of the patient with Z- plasties to cover the scar
Type 3b
Bilateral near total defects (Figures 46 to 49)
Figure 48. Bilateral unit 4 and 9 involvement with expansion in place.

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Figure 49. The flap in place
Figure 50. The result after two years.

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Figure 51. Ten years after the operation.
7.4. Type 4 defect
7.4.1. Isolated unit 9 defects
These defects are unique in that although they bear hair they can be reconstructed with non-
hair bearing flaps especially when unit 4 is intact. The beard will cover the scar of this area
(Figures 52 - 55)
Figure 52. Isolated unit 9 defects can be reconstructed with non-hair bearing flaps
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Figure 53. An isolated unit 9 defect reconstructed by an expanded trapezius flap, the anterior trunk was involved in
the scar.
Figure 54. The flap after defatting, note the hair which was present before defatting has become very thin after defat‐
ting or transfer.
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Figure 55. The end result after 7 years, the flap is hidden behind the beard.
8. Summary
Facial hair bearing area reconstruction is one of the most demanding reconstructive procedures
and the options available are not an exact match. The facial region recognition and available
donors are the prerequisites for the reconstructive surgeon treating these difficult conditions.
Author details
Shahram Nazerani*
Address all correspondence to: Snazeranimd@gamil.com
Dept. of Surgery, Firuzgar Medical Center, Iran University of Medical Sciences, Tehran, Iran
References
[1] Darwin, Charles (2004). The Descent Of Man And Selection In Relation To Sex. Kes‐
singer Publishing. p. 554.
[2] Randall VA (2008). "Androgens and hair growth". Dermatol Ther 21 (5): 314–28.
www.dentalbooks.co
[3] Sahih Bukhari, Book 72, Hadith #780 Allah's Apostle, salallahu aleihi wa sallam/
peace and blessings of Allah be upon him, said, "Cut the moustaches short and leave
the beard (as it is)."
[4] Zokon Yisrael KiHilchso, http://holmininternational613.com/books/

BEARD_JEWISH_LAW-E.pdf
[5] Sherrow, Victoria (2006). Encyclopedia of Hair: A Cultural History. Greenwood Pub‐
lishing Group. p. 59.
[6] The Oxford Handbook of Iranian History, PP300
[7] Helen Bunkin, Randall Williams: Beards, Beards, Beards (Hunter & Cyr, 2000)
[8] Chrysippus ap. Athen. xiii. 565 a
[9] Ancient Greek: πωγωνοτροφία φιλόσοφον οὐ ποιεῖ. De Is. et Osir. 3 (cited by Peck)
[10] Petron. 75, 10 (cited by Peck)
[11] Corpus Christianorum, Continuatio Mediaevalis LXII, Apologiae duae: Gozechini

epistola ad Walcherum; Burchardi, ut videtur, Abbatis Bellevallis Apologia de Bar‐
bis. Edited by R.B.C. Huygens, with an introduction on beards in the Middle Ages by
Giles Constable. Turnholti 1985
[12] Citing Lucian's Demonax 13, Cynicus 1 - John Sellars (1988). The art of living: the Sto‐
ics on the nature and function of philosophy. Burlington, VT: Ashgate Publishing
Limited
[13] "Gunma bureaucrats get beard ban | The Japan Times Online". Search.japan‐
times.co.jp. 2010-05-20. Retrieved 2011-11-24.
[14] Job Bulletin". Agency.governmentjobs.com. 2013-03-22. Retrieved 2014-02-26
[15] Franbourg A, Hallegot P, Baltenneck F, et al. Current research on ethnic hair. J Am

Acad Dermatol 2003; 48(6):S115–9
[16] Tolgyesi E, Coble F., Fang S., Kairinen E.O., A comparative study of beard and scalp
hair. J Soc Cosmet Chemists, 1982; 34, 361-382
[17] Zhang B, Wang JG, Chen WL, et al. Reverse facialsubmental artery island flap for re‐
construction of oropharyngeal defects following middle and advanced-stage carcino‐
ma ablation. Br J Oral Maxillofac Surg 2011;49:194–7
[18] Koshima I, Inagawa K, Urushibara K, et al. Combined submental flap with toe web
for reconstruction of the lip with oral commissure. Br J Plast Surg 2000; 53:616–9
[19] Yilmaz M, Menderes A, Barutçu A. Submental artery island flap for reconstruction
of the lower and mid face. Ann Plast Surg 1997;39:30–5.
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[20] Zhang B, Wang JG, Chen WL, et al. Reverse facialsubmental artery island flap for re‐
construction of oropharyngeal defects following middle and advanced-stage carcino‐
ma ablation. Br J Oral Maxillofac Surg 2011;49:194–7.
[21] Wang WH, Hwang TZ, Chang CH, et al. Reconstruction of pharyngeal defects with a
submental island flap after hypopharyngeal carcinoma ablation. ORL J Otorhinolar‐
yngol Relat Spec 2012;74:304–9.
[22] Abboud O, Shedid D, Ayad T. Reconstruction of the prevertebral space with a sub‐
mental flap: a novel application. J Plast Reconstr Aesthet Surg 2013; 66(12):1763–5.
[23] a textbook of advanced Oral and Maxillofacial surgery, chapter 18, p. 516
[24] Giraldo F1, González C, Garnica I, Ferrón M, Rus JA. A Sideburn reconstruction with
an expanded supraauricular trapezoidal flap, Plast Reconstr Surg. 1997 Jul;100(1):
257-61.
[25] Juri J, Juri C, Colnago A. The surgical treatment of temporal and sideburn alopecia.
Br J Plast Surg. 1981 Apr;34(2):186-93
[26] Martin D, Baudet J, Mondie JM, et al. The submental island skin flap. A surgical pro‐
tocol. Prospects of use. Ann Chir Plast Esthet 1990;35:480–4
[27] Faltaous AA, Yetman RJ. The submental artery flap: an anatomic study. Plast Re‐
constr Surg 1996; 97:56–60 [discussion: 61–2
[28] Expanded tubed flap in scalp reconstruction: a modern option in an old technique.
Caleffi E, Fasano D, Bocchi A, Papadia F. Plast Reconstr Surg. 1988 Dec;82(6):1075-8
Microvascular transplantation of expanded free scalp flaps between identical twins.
[29] Valauri FA, Buncke HJ, Alpert BS, Lineaweaver WC, Argenta LC. Plast Reconstr
Surg. 1990 Mar;85(3):432-6
[30] Dufourmentael L. Essai de reconstruction totale u massif maxillaire inferieur. Re‐

constr Maxillofacial 1919:3:141-156
[31] Bisaccia E, Scarborough D. Hair transplant by incisional strip harvesting. J Dermatol

Surg Oncol 1994;20(7):443–8
[32] Rassman WR, Bernstein RM, McClellan R, Jones R, Worton E, Uyttendaele H. Follic‐
ular unit extraction: minimally invasive surgery for hair transplantation. Dermatol
Surg 2002;28((August) 8):720–8
[33] Gurlek A, Alaybeyoglu N, Demir CY, Aydogan H, Bilen BT, Ozturk A. Aesthetic re‐
construction of large scalp defects by sequential tissue expansion without interval.
Aesthetic Plast Surg 2004;28((July–August) 4):245–50
[34] Kim JC, Choi YC. Regrowth of grafted human scalphair after removal of the bulb.
Dermatol Surg 1995;21(4):312–3.
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Chapter 27
Basics of Microvascular Reconstruction of

Maxillomandibular Defects
Reza Tabrizi and Barbad Zamiri
http://dx.doi.org/10.5772/59303
1. Introduction
Effective reconstruction following ablative surgery of maxillomandibular defects requires the

provision for adequate oral lining, skin, and replacement of missing bone; in some situations,
restitution of function of the temporomandibular joint also requires reconstruction-preferably
achieved in one stage. Conventional replacement of bone defects usually involves the use of
autogenous cancellous bone grafts from either the iliac crest or ribs after provision of adequate
skin cover by pedicled axial-pattern skin flaps such as a pectoralis major flap.[1]
Early reconstructive efforts with nonvascularized bone grafts were plagued by a high inci‐
dence of postoperative complications and poor long-term outcomes. [2] Inadequate local blood
supply due to poorly vascularized flaps or irradiation resulted in rapid resorption of the grafts.
The advent of techniques in which composite flaps containing skin and bone together with
their own independent blood supply transferred either as pedicled osteocutaneous flaps or
free osteocutaneous flaps has revolutionized the concepts of head and neck reconstruction.[1]
Early postoperative complications decreased even in the setting of postoperative radiation;
and expectations for successful oral rehabilitation, including placement of osseointegrated
implants, rose markedly.[2]
1.1. History
The first vascular anastomosis was introduced by J.B. Murphy in 1892; and Alexis Carrel
made an end to end anastomosis by using a three-stay suture technique. [3] The first
anastomosis in a dog was performed by Krizek. [4] Following him, the first free flap was
published in 1971. [3]
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2. Assessment of maxillomandibular defects
Each defect is individualized according to the missing component. In the maxillomandibular

area the size of soft tissue as well as bone defect, the underlying etiology (cancer, trauma, and
infection), anatomic location, aesthetic visibility, associated functional disabilities and the
availability of a local and or distant donor site should be evaluated. [5] Compatibility of the
donor tissue with the area being reconstructed should be considered with regard to skin color,
texture, thickness of soft tissue, bone quantity and quality and also shape of the bone compo‐
nent to restore the mandible and maxilla; further restoration with dental implants can be done.
It has been shown that any mandibular defect greater than 6.0 cm is prone to failure and thus
free flaps in these defects are indicated.[6] Restoration of stable retentive dentition is a
prerequisite to a successful functional oral rehabilitation. This is best achieved with endosseous
implants, capable of supporting a stable dental prosthesis, placed directly into vascularized
bone flaps at the time of mandibular reconstruction The iliac crest is the most consistently
implantable donor site, followed by the scapula, fibula, and radius (with 83%, 78%, 67%, and
21% of sections from each donor site satisfying the criteria for implantability respectively).
Consistent regional differences in implantability were encountered at each donor site except
the scapula. [7] In a cadaver study, the dimensions of bone available for implant placement
from the iliac crest, scapula, fibula, and radius osseous flaps were measured. The iliac crest
and fibula flaps had bone dimensions consistently adequate for implant placement. Bone
availability for the safe placement of implants into the scapula flap was found in the majority
of specimens. The radius flap group had the highest number of specimens that were inadequate
for implant placement. [8] Another study demonstrated that nearly all of the iliac crests had
adequate dimensions for the positioning of four 10 mm implants. In 63% of the scapulae, it
Figure 1. Four implants placed after a fibula flap graft.

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was also possible to place four 10 mm implants. In the case of the scapula, half of the female
subjects lacked enough available bone for the insertion of four 10 mm implants because of their
inadequate width. Bone density and cortical thickness were found to be similar in the iliac crest
and scapula. Age and side do not have an important influence on cortical bone dimensions
and density. In contrast to the iliac crest, the lateral margin of the scapula astonishingly showed
increasing values for bone density and increasing thickness of the cortex. Analogical advanced
biological age works in conformity with the scapula flap (Figure 1). [9]
3. Microvascular composite tissue transplantation
In the maxillomandibular area, surgeons encounter soft and hard tissue defects due to ablation
of cancer or severe destructive trauma. After introducing the ability to repair vessels less than
2 mm in diameter, microvascular transplantation found its place in reconstruction surgery. A
microvascular composite transplantation was defined as a composite flap (soft and hard tissue
with their associated blood supply) which is removed from a part of the body and anastomosed
to the recipient site vessels. It has been shown that a reliable anastomosis can be achieved with
an external lumen diameter of 0.5 to 2mm with a patency rate of 95%. [10]
The frequency of using various free flaps is different according to defect site, the surgeon’s
experience and condition of the patient. In a retrospective study, flap donor sites included
radial forearm (n = 183), fibula (n = 145), rectus abdominis (n = 38), subscapular system (n =
28), iliac crest (n = 5), and a jejunal flap. Age, sex, diagnosis, comorbidities, tumor stage, defect
site, primary vs. secondary reconstruction, and history of surgery, radiation therapy, or
chemotherapy were considered for choosing a flap. [11]
4. Common microvascular flaps in the maxillomandibular region
Radical cancer ablative surgery and severe traumatic injury can result in complicated defects
in the maxillomandibular area which need a complex reconstruction plane. In a small or simple
defect, it may be appreciated that the defect is restored with a regional flap. However,
microvascular reconstruction of large defects with hard and soft tissue deficiency is a standard
approach. The primary use of the free muscle or musculocutaneous flap in the maxilloman‐
dibular area consist of provision of tissue bulk for a large defect, coverage of vital structures,
provision of skin for the face and mucosa for intraoral lining.[12] Furthermore, a composite
osteocutaneous flap provides a skeletal framework to restore function.[12]
5. Radial forearm flap
As the radial forearm flap was originally developed in China, it is often named the China flap.
[13] Primarily this flap was introduced as a large flap incorporating most of the circumference
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of the forearm and was applied as a free flap to cover burns contractures, mainly in the head
and neck. [14] The radial forearm flap is a good flap for intraoral reconstruction, offering thin,
pliable predominantly hairless skin to replace oral mucosa. The vascularity of the area allows
considerable variation in the design of this fasciocutaneous flap and offers the possibility of
including bone as an osteocutaneous flap. Furthermore, the vascular anatomy of the flap
simplifies the technical aspects of free tissue transfer. Based on ten clinical cases the design of
the flap is described and its versatility in differing clinical situations is illustrated. [15] The rich
vascularity of the flap results in rapid healing and minimizes wound healing complications,
and there is a potential for sensory reinnervation. The flap can be harvested at the same time
of tumor surgery. [13]
The radial forearm flap has mostly been used to reconstruct the oral floor, tongue and the
maxilla [16] (Figure 2). The osteocutaneous radial flap is robust, reliable, and relatively simple
to harvest, which will ensure that it remains one of the established reconstructive options in
most maxillofacial units. Many surgeons prefer to use a limited number of trusted flaps, and
these qualities will ensure that in the intermediate future most surgical trainees will continue
to be shown the fasciocutaneous radial flap as both the basic training flap and the established
option for reconstruction. Evidence from observational clinical studies and one randomized
clinical trial indicates that there is increasing support for the use of the evolutionary technique
of suprafascial dissection to minimize morbidity at the donor site. The suprafascial donor site
may be repaired with either a meshed or unmeshed partial-thickness skin graft, or a fenestrated
full-thickness skin graft, with good rates of successful healing. The application of a negative
pressure dressing to the wound seems to facilitate the healing of all types of skin grafts. The
subfascial donor site, however, remains more prone to complications. It may be helpful to
position the donor site of the flap more proximally, but this has not been proven. These
refinements probably produce the best outcomes that can currently be achieved, given the
inherent flaws of the radial donor site.[17] Evidence based on clinical observational studies
and biomechanical studies supports the routine or selective use of prophylactic internal
fixation to strengthen the radial osteocutaneous donor site. This allows safe harvesting of the
maximum volume of available bone, up to half of the circumference, with minimal risk of
fracture or long term complications. The incidence of fracture with the plate placed either
anteriorly or posteriorly is equally low, but the anterior position is technically easier and
probably less likely to cause additional morbidity. The introduction of prophylactic internal
fixation consolidates the role of the osteocutaneous radial flap for repair of defects that require
a relatively small volume of bone and an appreciable area of thin soft tissue, particularly when
a long vascular pedicle is desirable. This includes low level defects of the maxilla, some defects
of the mandible and niche reconstructions, such as the orbital rim. The radial forearm flap
remains useful as a first choice when there is appreciable peripheral vascular disease, when
there are other serious coexisting medical conditions, when it is the preferred choice of the
patient for functional reasons such as mobility of the lower limb or hip or when it is a salvage
flap used when other reconstructive options have been exhausted. [18]
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Figure 2. A radial forearm flap used to reconstruction of tongue after hemiglossectomy.
5.1. Flap anatomy
The radial artery branches from the brachial artery near the antecubital fossa and courses deep
between the flexor carpi radialis and brachioradialis muscles in the proximal forearm. The
artery emerges from this muscle approximately 7 cm cephalic to the wrist crease to enter the
subcutaneous tissue.[19] Nine fasciocutaneous branches from the radial artery supply the skin
of the forearm, four in the proximal forearm arising between the brachio-radialis and pronator
teres muscles and nine in the distal forearm arising between the brachioradialis and flexor
carpi radialis muscles.[14] Venus drainage is through either the venae comitante that accom‐
pany the radial artery or the much larger superficial venous drainage system via the cephalic
vein. The cephalic vein courses subcutaneously on the radial side of the wrist near the
superficial radial nerve. The vein goes cephalically supramedially toward the antecubital fossa.
Several branches of the superficial radial nerve are found cephalad to the anatomical snuffbox
in intimate relation to the cephalic vein. Saving of this nerve is important to maintain sensation
over the radial aspect and the index finger. [19]
5.2. Flap component
This is a true septocutaneous flap with a main vessel lying in the septum, giving perforators
superficially to supply the fascia, fat and skin and deeper branches to supply underlying
tendons, muscles, nerves and bone.[14] The Allen test is noninvasive and reliably detects
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circulation problems by evaluation of arterial inflow in the presence of one functioning artery.
Edgar V. Allen first introduced the test in 1929 as a non-invasive assessment of hand circulation
in patients with thromboangiitis obliterans. The test was modified in the 1950s to assess the
ulnar artery before cannulation of the radial artery. A similar method is used today to detect
the ulnar artery inflow before harvesting the radial forearm flap. [19] The nondominant arm
is usually selected for flap harvest. The design and position of the skin island in the volar
forearm depend on several factors, including the desire to include the superficial venous
drainage system and specific functional and cosmetic requirements at the recipient site. [19] It
is usually projected over the course of the radial artery and one of the subcutaneous veins. The
paddle is frequently outlined over the distal radius to obtain a vascular pedicle of greatest
length (Figure 3). [13]
Figure 3. A radial forearm flap
5.3. Flap dimensions
The skin part of the flap commonly has 12 cm length (range 4-30 cm) and 5 cm width (range
4-15 cm) and 1 cm thickness (range 0.5-2cm). The bone part of the flap has 10 cm length (range
6-14 cm) and 1 cm width (range 0.7-1.5 cm) and 1 cm thickness (range 0.7-1.5 cm).[14]
5.4. A common radial forearm flap harvesting technique
A tourniquet is placed. The skin island is outlined over the distal forearm, including the radial
artery and cephalic vein, and the flap edges are incised. The incision is extended deeply to
include the deep fascia, except along the proximal edge, where the superficial veins and nerves
are in the immediate subcutaneous tissue plane. The radial artery is exposed and temporarily
closed to assess the adequacy of the circulation to the hand through the ulnar artery. The flap
is raised from the ulnar and radial sides. It is necessary to include the deep fascia but saving
the final peritenon. [19] Where bone is to be included in the lateral intermuscular septum, the
periosteum of the radius must be preserved. Available bone extends from the insertion of the
pronator teres to the distal styloid where there is no muscle attachment on the radial border.
This provides a length of about 10-12 cm. Dissection can be performed as described, but, at the
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radial border of palmaris longus, the plane is deepened to expose the flexor pollicis longus
and pronator quadratus.
5.5. Complications
A major problem with radial forearm flap relates to its donor site and the effect on function
and aesthetics (Figure 4). Injury to the superficial radial nerve results in numbness over the
anatomic snuffbox and radial side of the thumb and index finger. A devastating complication
is vascular problems of the hand because of inadequate blood supply by the ulnar artery. It
has been shown that a significant functional forearm and wrist range-of-motion morbidity
associated with the harvest of a radial forearm fasciocutaneous free flap may occur in the early
postoperative period. [20]
The radial forearm free flap results in measurable quantitative changes in hand function and
limited changes in patient perception. [21]
Figure 4. A severe scar of the donor site after a radial forearm flap
5.6. Radial forearm flap updates
The radial forearm flap has been used for reconstruction of palatal defects and for total lower
lip reconstruction.[22, 23] It is suggested to use a full-thickness skin graft from the neck to cover
the radial forearm free flap donor site in patients undergoing neck dissection and microvas‐
cular reconstruction for ablative head and neck oncologic surgery. The primary advantage is
avoiding a third surgical site. Complications were comparable to those using Full-thickness
Skin Grafting from other harvest sites. Importantly, cross-contamination from the head and
neck with the forearm was not a problem. [24] The pre-operative application of topical tissue
expansion tapes produces measurable changes in skin biomechanical properties. The location
of this change on the dorsal forearm is consistent with the method of tape application. This
increase in skin pliability may account for the improved rate of primary donor site closure
reported using this technique. [25] AlloDerm with split-thickness skin graft has been used to
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cover the donor site after radial forearm flaps. Results demonstrated thicker coverage of the
forearm defect, with minimal donor site morbidity and superior cosmetic results. [26]
6. Fibula flap
The fibula bone is most commonly used in oral and maxillofacial reconstruction following
benign or malignant jaw tumor ablation Hidalgo, in 1989, reported the first mandibular
reconstruction using a vascularized fibula free flap. [27]. It has several advantages over other
bones, including being the longest bone with lengths up to 25 cm, having bicortical structures
that can support osseointegrated dental implants, having a large caliber and long vascular
pedicles which provide easier anastomosis, and having thin and pliable skin paddles as well
as available muscular cuffs around the fibula which can be used for reconstructing the various
soft tissue defects (Figures 5 and 6). The morbidity at the donor site is also low and the operation
time is reduced because of a two-team approach.
Figure 5. A composite fibula flap used to restore the hemimandible and the oral floor.
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Figure 6. A composite fibula flap for reconstruction of the hemimandible and soft tissue defect on the face.
6.1. Flap anatomy
The arterial supply of the fibula flap is the peroneal artery. The peroneal artery branches from
the posterior tibial artery just proximal to the head of the fibula. The external diameter of the
peroneal artery is 1.5-2.5 mm. The pedicle length varies and may be quite long if a large
segment of the proximal part of the bone is resected. The skin over the lateral leg is also
nourished by the peroneal artery via septocutaneous vessels that course posterior to the fibula
to enter the posterior crural intermuscular septum. [19] Venous drainage of the flap is primarily
by venae comitante (two) of the peroneal artery. The venae comitante often merge to form a
single large vein near the posterior tibial artery. Sensory innervation to the corresponding
lateral leg skin is mostly supplied by the lateral sural nerve. It can be detected under micro‐
scopic view. It is possible to enclose the lateral sural nerve with the fibula flap to improve
function of recipient site (Figure 7). [28]
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Figure 7. Anatomy of a free fibula flap
6.2. Flap component
The fibula flap is harvested as a bone flap and may consist of muscles (soleus or flexor hallucis
longus), overlying fascia and/or skin (Figure 8). [28]
Figure 8. Components of a fibula flap

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The skin paddle length can be 12 cm and its width can be 6 cm. The bony part length is 16 cm
(range 6-26 cm) and its thickness 2 cm.
6.4. A common fibula flap harvesting technique
A tourniquet is placed on the thigh and the knee is partially flexed for access to the postero‐
lateral leg. Firstly, the fibula bone outline and a skin paddle (if it is included in the flap) are
marked on the skin. Then an incision is made on the anterior outline. Dissection proceeds
anterior to the posterior intramuscular septum, through which fasciocutaneous perforators
run. The common peroneal nerve which runs below the level of the head of the fibula is
identified and preserved with the peroneal muscles of the anterior surface of the fibula,
reflecting the peroneus longus and brevis muscles. The anterior intermuscular septum is
incised to gain access to the anterior part. Dissection is extended through the extensor
is incised to gain access to the anterior part. Dissection is extended
digitorum and extensor hallucis longus. After access to the fibula bone, the maximum length
through the extensor digitorum and extensor hallucis longus. After
of the bone is included with proximal osteotomy 6 cm inferior to the fibular head and distal
access to the fibula bone, the maximum length of the bone is included
osteotomy 8 with
cm superior
proximal toosteotomy
the lateral6 malleolus (Figure
cm inferior to the 9).[28]
fibular head and distal
osteotomy 8 cm superior to the lateral malleolus (Figure 10).[28]
(a)

(b)
Figure 10 A: The outline of a fibula flap with a skin paddle
Figure 9. (a): The outline of a fibula flap with a skin paddle. (b): A fibula flap harvest. Note its vascular pedicle.

Figure 10 B: A fibula flap harvest. Note its vascular pedicle.
14

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6.5. Complications
The most feared potential donor site complication in fibula flap transfer is foot ischemia
secondary to the sacrifice of the peroneal artery. In the most common situation, terminal
branches of the peroneal artery arise at the level of the ankle, and the blood supply to the foot
is provided by the anterior and posterior tibia arteries. In patients with atherosclerosis of the
anterior or posterior tibial vessels, collaterals from the peroneal artery may provide a signifi‐
cant contribution to pedal circulation. The majority of patients with peripheral vascular disease
of the lower extremities are easily identified on the basis of history and physical examination.
However, there is another group of patients with congenital vascular anomalies for whom the
peroneal artery provides a significant contribution to the foot circulation. This subpopulation
of patients present a unique difficulty when performing a preoperative evaluation in antici‐
pation of performing a fibula free flap, because they may have a normal history and physical
examination.[29] In general, the patient perception of donor-site morbidity is low. Complaints
however, were frequently mentioned, including pain (60 percent), dysesthesia (50 percent), a
feeling of ankle instability (30 percent), and inability to run (20 percent). Gait analyses revealed
that patients walked at a lower preferred velocity, compared with control subjects. Further‐
more, it was demonstrated that significant increases in the coefficients of variation of stride
time during walking under visual and cognitive loads and during walking at a velocity higher
than the preferred compared with normal walking.[30] Noticeable limitation and discomfort
in ankle function and range of motion with aggressive physical activity may result after fibula
harvest, particularly if tibiofibular fusion is performed.[28] Commonly the bone flap may
tolerate venous thrombosis for up to 24 hours because of spontaneous bleeding from the
medullary canal before the artery undergoes thrombosis, but venous drainage of the skin
paddle must be managed by reoperation.[28]
6.6. Fibula flap updates
Proximal peroneal perforator in the dual-skin paddle configuration of fibula free flap has been
used to reconstruct composite oral defects. The proximal peroneal perforator was found to be
anatomically reliable and clinically useful in composite oral cavity reconstruction. [31] The free
fibula flap has been reported to be an appropriate option for mandibular reconstruction in
bisphosphonate-related osteonecrosis of the jaws. [32] The keys for gaining maximum success
in a fibula flap include:
1. Harvesting the distal fibula when recipient vessels are distant
2. Flap selection based on the anatomy of perforators
3. Use of the skin paddle for postoperative flap monitoring
4. Protection of the flap's soft-tissue cuff
5. Preventing venous thrombosis which is essential to reduce flap complications
6. Aligning fibular struts and protecting the vascular pedicle when the double-barrel
technique is used
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7. Minimizing the gap between the double-barrel struts and implementing a long-term
follow-up of dental implants
8. Selecting osteosynthesis materials
9. Mastering the learning curve and clinical competence in microvascular reconstruction.
[33]
It has been shown that function can reliably be reestablished after segmental mandibulectomy
and condylectomy reconstructed with a vascularized fibula flap whose distal end is not
precisely contoured or actively seated in the glenoid fossa, as a valid alternative to condylar
reconstruction. [34] Skin paddle harvesting is a factor that influences the operation time and
patient satisfaction of fibula free flap surgery. An increase in body mass index is related to an
increase in donor-site morbidity after fibula free flap transfer. [27]
7. Deep circumflex iliac artery flap
For large oromandibular defects such as subtotal glossectomy with anterior mandibulectomy
the options for reconstruction are limited. The composite fibular flap will not easily provide
the mass of soft tissue required or the mobility to set it in. A scapular free flap can supply the
tissue needed in a chimerical fashion but without the quality or length of bone, and it requires
the patient to be turned. Two free flaps can be used such as a fibular with an anterolateral thigh
flap, but this lengthens the operating time, and increases morbidity and complications.
A deep circumflex iliac artery flap (DCIA) flap is a good single flap option in these circum‐
stances. [35] DCIA flap, a composite osteomusculocutaneous flap of the iliac crest, abdominal
wall musculature and overlying skin, has evolved significantly during the previous 30 years
since its inception in the late 1970s. With an increasingly reported role for a range of facial,
lower limb, and upper limb reconstructions, its most widespread utility has been for hemi‐
mandibular defect reconstruction. Furthermore, the iliac crest has long been used for these
various bony reconstructions, its versatility as a composite flap has largely been limited by an
understanding of the finer vascular anatomy of the region. Initial attempts to harvest the iliac
crest flap using the superficial circumflex iliac artery as its vascular supply in 1978 met with
less than ideal results. Although greater success was achieved with the DCIA pedicle flap after
the landmark report by Taylor and Townsend in 1979, detailing the DCIA as the main blood
supply to the iliac crest, a lack of familiarity with the DCIA perforators in these early studies
limited the use of the DCIA flap as a composite flap. [36]
7.1. Flap anatomy
Vessel branches supplying the flap are the ascending branch, which supplies the internal
oblique muscle, nutrient endosteal perforators, and periosteal contributions to the iliac crest,
and musculocutaneous perforators which supply the overlying skin. The dominant blood
supply to the iliac crest flap is provided by deep circumflex iliac (DCIA) artery (length=9 cm
and diameter=2.8 mm). The DCIA generally arises deep to the inguinal ligament from the
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femoral artery or the external iliac artery deep to the inguinal ligament or less frequently from
the external iliac artery superior to the inguinal ligament. Venous drainage of the flap is to the
deep circumflex iliac vein. This flap does not have a motor reinnervation. Sensory nerve comes
from T12 (Figure 10). [37]
Figure 10. Anatomy of the DCIA flap
7.2. Flap components
The iliac crest flap provides for a great many options in flap composition. It may be harvested
as a bone-only or a composite flap, which may include muscle, fascia, fat and skin.
Skin island length commonly is 15 cm and its width 8-10 cm with variable thicknesses. The
bony part length is commonly 7 cm and its height 4 cm with 1 cm thickness.
7.4. A common deep circumflex iliac artery flap harvesting technique
An incision is first made 2 cm above the mid-point of the line between the anterior superior
iliac spine and the pubic tubercle to identify the origin of the deep circumflex iliac artery;
dissection is performed following the course of the deep circumflex artery. Around the anterior
superior iliac spine, one can find the ascending branch arise to enter the abdominal muscula‐
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ture, which is dissected free as a backup vessel. The insertion of the abdominal musculature
to the inner lip of the iliac bone is detached, with a small muscular cuff preserved between the
deep circumflex artery and the iliac crest to protect the minute osteomusculocutaneous
branches entering the inner cortex. After detachment of the abdominal musculature along the
superior edge of the iliac crest is performed for about 6.5 cm, the deep circumflex artery can
be found to sweep medially upward into the abdominal musculature, ending as a musculo‐
cutaneous perforator, nourishing the overlying skin. Meticulous dissection is performed to
isolate the vascular pedicle from the abdominal musculature; the skin paddle is centered on
the perforator with the previous incision along the iliac crest as the inferolateral margin of the
cutaneous flap; finally the flap is harvested to the actual need. [38]
7.5. Complications
Bulky skin paddle may result in poor cosmetic or functional outcomes. A hernia or abdominal
contour deformity can occur in 10% of patients. [37] Postoperative sequelae include injury to
the lateral femoral cutaneous and ilioinguinal nerves, which can produce unpleasant dyses‐
thesia or anesthesia. [13] The incidence of gait disturbance and chronic hip pain after the flap
harvesting may be greatly decreased by preserving the anterior superior iliac spine and using
unicortical bone flap.
7.6. Deep circumflex iliac artery flap updates
A free vascularized iliac bone flap based on superficial circumflex iliac perforators (SCIPs) has
been introduced. Compared with a conventional iliac bone flap, which is based on deep
circumflex iliac vessels, this flap is less invasive, less bulky and can include a reliable skin
island. In addition, an SCIP-deep inferior epigastric perforator (DIEP) bipedicle soft--tissue
flap has been developed, which can contribute to safe transfer of larger DIEP flaps.[39] An
anatomical study described variations in DCIA flap. The origin of the DCIA was 5.30 ± 6.22
mm (mean ± SD) superior to the inguinal ligament, and the DCIV was 4.75 ± 3.14 mm medial
to the origin of the DCIA. The length of the DCIA from its origin to the level of the anterior
superior iliac spine was 59.35 ± 9.06 mm, and the vertical distance between the anterior superior
iliac spine and DCIA was 18.50 ± 3.82 mm. With regard to the branching pattern of the
ascending branch, most cases (n = 18, 90%) exhibited 1 origin and 2 branches, and the remaining
2 cases (10%) had 2 origins and 2 branches. The distance from the DCIA origin to the branch
point in cases exhibiting 1 origin and 2 branches was 36.83 ± 16.10 mm. [40]
8. Scapular flap
The scapular region is an excellent source of cutaneous, fascial, muscular, osteomuscular-

cutaneous free or pedicled flaps based on the subscapular artery and its branches. In 1978, the
scapular free flap was introduced by Sajio. The flap was based on the circumflex scapular
vessels. These vessels supply the vast thoracodorsal fascial network of the back, which provide
an abundant tissue source beyond the flap margin. The scapular osteocutaneous free flap has
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been used mostly in reconstruction of craniomaxillofacial defects, including the orbit, the
maxilla and palatal defects. [13] Scapular bone provides thin bone for restoring orbital floor
defects in conjunction with malar regions, orbital rim and alveolar defects.
8.1. Flap anatomy
The subscapular artery gives rise to the circumflex scapular artery supplying the scapular and
parascapular skin. The superficial branch of the circumflex scapular artery reaches the
subcutaneous tissue at the level of the triangular space. At this point it provides several
branches. The main two branches are the horizontal and vertical ones. [41] Venae comitante
of the horizontal and vertical branches of the circumflex scapular vein are the venous drainages
of the flap. The horizontal and vertical branches drain into the circumflex scapular vein, then
the subscapular vein and finally the axillary vein. The third, fourth and fifth intercostal nerves
through lateral and posterior branches provide sensory innervation of this region. There is no
motor nerve involvement in this procedure (Figure 11).
Figure 11. Anatomy of the scapular flap.
8.2. Flap components
This is a skin and subcutaneous flap which may include bone, fascia and muscle. These flaps
are extremely reliable with a consistent vascular pedicle of good length and large caliber. The
color of the back skin may provide a better match for head and neck reconstruction.
Skin island length is 18-20 cm with 7-8 cm width and 2 cm thickness. The bone length is about
10-14 cm with 2-3 cm width and 1.5-3 cm thickness.
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8.4. A common scapular flap harvesting technique
The site of flap incision is infiltrated with lidocaine with2% epinephrine. The outline of skin
paddle is marked. It is important to mark the location of the flap on the patient’s back relative
to flap size, and to mark the orientation relative to the pedicle and its branches. An incision is
made from the posterior border of the deltoid muscle 3 cm lateral and parallel to the lateral
border of the scapula, ending approximately at the angle. The dissection of the cutaneous flap
is extended medially in a plane just superficial to the deep muscular fascia of the infraspinatus
muscle. The thoracodorsal fascia is preserved during dissection. The circumflex vessels arise
sharply over the lateral edge of the scapula and are just superficial to the facial base of
dissection. [13] The lateral scapular bone flap and the branches to the bone from the pedicle
are carefully dissected and preserved in the triangular space. An incision is made 2 to 3 cm
medial to the bone edge through the muscles on the scapula inferior to the bone. If a bipedicle
bone flap is desired with 2 vascular sources on the same pedicle, in this situation the angular
branch from thoracodorsal vessel should be included in the flap design. The donor site is closed
primarily, with the use of appropriate drain placement and the patient is turned to the supine
position (Figure 12).
Figure 12. A skin paddle of the scapular flap.
8.5. Complications
Extended scapular flap loss is a major problem because a large area remains uncovered.
Closure of the donor site under tension will result scar dehiscence and an unsightly result.
8.6. Scapular flap updates
The scapular tip free flap (STFF) has been used in reconstruction of mandibular defects. Low
morbidity, early ambulation time, possibility of simultaneous harvesting with the tumor
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resection and large musculocutaneous paddles in the chimerical version of the flap are
advantages of the STFF. This makes it a good choice in elderly patients, when other bone
containing free flaps are not indicated because of the related morbidity, when other flaps are
not available or when wide composite defects are approached.[42] Fibular and scapular
osseous free flaps for oromandibular reconstruction were compared based on a patient-
centered approach to flap selection. Results demonstrated the free fibula flaps and subscapular
flaps are complementary options for oromandibular reconstruction. The fibular free flaps are
ideal for younger patients, extended defects, multiple osteotomies, and limited soft-tissue
requirements. The subscapular system free flaps are excellent options for (1) elderly patients;
(2) those with significant comorbidities, such as peripheral vascular disease; and (3) mandible
defects associated with complex soft-tissue requirements.[43] For immediate mandibular
reconstruction, a scapular flap provides short-term results equivalent to those with a fibular
flap but with less donor-site morbidity. The major drawbacks of the fibular flap include
prolonged healing of the donor site and the delayed mobilization of patients. Although our
first choice of vascularized bone graft is the fibular flap, the scapular flap is an alternative for
those patients, especially elderly patients, in whom fibula harvest can result in significant
morbidity. [44] Minimally invasive harvesting techniques may reduce potential donor-site
morbidity. A reverse-flow scapular osteocutaneous flap has been introduced for head and neck
reconstruction. The distal end of the thoracodorsal artery and subscapular vein were used in
this type of the flap. There has been no report on endoscopically assisted harvesting of the
scapular adipofascial flap. [45, 46]
Author details
Reza Tabrizi1* and Barbad Zamiri2
*Address all correspondence to: tabmed@gmail.com
1 Assistant Professor, Department of Oral and Maxillofacial Surgery, Shahid Beheshti

University of Medical Sciences School of Dentistry, Shiraz, Iran
2 Associated Professor, Department of Oral and Maxillofacial Surgery, Shiraz University of

Medical Sciences School of Dentistry, Shiraz, Iran
References
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joint and mandible using a compound pectoralis major osteo-muscular flap. Br J Plast
Surg, 1983. 36(4): p. 491-7.
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[2] Hidalgo, D.A., A.L. Pusic, and F.-C. Wei, Free-flap mandibular reconstruction: a 10-
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[3] Fu-Chan Wei, S.S., Principle and Techniques of microvascular surgery. Plastic sur‐
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[4] Krizek, T.J., et al., Experimental transplantation of composite grafts by microsurgical
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[6] Nandra, B. The Maximum length of free bone grafts for Mandibular reconstruction-
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[8] Frodel, J.L., et al., Osseointegrated implants: a comparative study of bone thickness
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[11] Suh, J.D., et al., Analysis of outcome and complications in 400 cases of microvascular
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[12] Mathes JS, H.S., Flap classification and application. Plastic surgery. Saunders-Elsevi‐
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[13] Quershy FA, P.M., Reconstruction of the maxillomandibular cancer patient. Fonseca
oral and maxillofacial surgery,Saunders, 2000. 7: p. 361-444.
[14] S.Souter, D., Radial forarm flap. Flaps and reconstruction surgery,Saunders-Elsevier,
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[15] Soutar, D., et al., The radial forearm flap: a versatile method for intra-oral reconstruc‐
tion. British Journal of Plastic Surgery, 1983. 36(1): p. 1-8.
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[16] Santamaria, E., M. Granados, and J.L. Barrera‐Franco, Radial forearm free tissue
transfer for head and neck reconstruction: versatility and reliability of a single donor
site. Microsurgery, 2000. 20(4): p. 195-201.
[17] Avery, C., Review of the radial free flap: is it still evolving, or is it facing extinction?
Part one: soft-tissue radial flap. British Journal of Oral and Maxillofacial Surgery,
2010. 48(4): p. 245-252.
[18] Avery, C., Review of the radial free flap: still evolving or facing extinction? Part two:
osteocutaneous radial free flap. British Journal of Oral and Maxillofacial Surgery,
2010. 48(4): p. 253-260.
[19] Dolan, R., Microvascular surgery. Lore and Medina, An atlas of head and neck sur‐
gery,Saunders-El, 2005: p. 1417-1470.
[20] Skoner, J.M., et al., Short‐Term Functional Donor Site Morbidity After Radial Fore‐
arm Fasciocutaneous Free Flap Harvest. The Laryngoscope, 2003. 113(12): p.
2091-2094.
[21] Sardesai, M.G., et al., Donor-site morbidity following radial forearm free tissue trans‐
fer in head and neck surgery. Journal of otolaryngology-head & neck surgery= Le
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411-416.
[22] Ahuja, R.B., P. Chatterjee, and P. Shrivastava, A novel route for placing free flap
pedicle from a palatal defect. Indian journal of plastic surgery: official publication of
the Association of Plastic Surgeons of India, 2014. 47(2): p. 249.
[23] Silberstein, E., et al., Total Lip Reconstruction with Tendinofasciocutaneous Radial
Forearm Flap. The Scientific World Journal, 2014. 2014.
[24] Hanna, T.C., W.S. McKenzie, and J.D. Holmes, Full-Thickness Skin Graft from the
Neck for Coverage of the Radial Forearm Free Flap Donor Site. Journal of Oral and
Maxillofacial Surgery, 2014.
[25] Chung, J., et al., The effect of topically applied tissue expanders on radial forearm
skin pliability: a prospective self-controlled study. Journal of Otolaryngology-Head
& Neck Surgery, 2014. 43(1): p. 8.
[26] Wester, J.L., et al., AlloDerm with split-thickness skin graft for coverage of the fore‐
arm free flap donor site. Otolaryngology--Head and Neck Surgery, 2014. 150(1): p.
47-52.
[27] Vittayakittipong, P., Donor-site morbidity after fibula free flap transfer: a comparison
of subjective evaluation using a visual analogue scale and point evaluation system.
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[28] Christopher J.Salgado, S.L.M., Samir Mardani,Fu-chan Wei, Fibula flap. 1th edition
ed. 2009: Saunders,Elesiever 439-455.
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[29] Blackwell, K.E., Donor site evaluation for fibula free flap transfer. American journal
of otolaryngology, 1998. 19(2): p. 89-95.
[30] Bodde, E.W., et al., Donor-site morbidity after free vascularized autogenous fibular
transfer: subjective and quantitative analyses. Plastic and reconstructive surgery,
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[31] Potter, J.K., et al., Proximal Peroneal Perforator in Dual–Skin Paddle Configuration of
Fibula Free Flap for Composite Oral Reconstruction. Plastic and reconstructive sur‐
gery, 2014. 133(6): p. 1485-1492.
[32] Spinelli, G., et al., Microsurgical Reconstruction After Bisphosphonate-Related Osteo‐

necrosis of the Jaw: Our Experience With Fibula Free Flap. Journal of Craniofacial
Surgery, 2014. 25(3): p. 788-792.
[33] Pitak-Arnnop, P., et al., Fibular flap for mandibular reconstruction: Are there old
tricks for an old dog? Revue de stomatologie, de chirurgie maxillo-faciale et de chir‐
urgie orale, 2013. 114(1): p. 15-18.
[34] Chao, J.W., et al., Oral Rehabilitation Outcomes After Free Fibula Reconstruction of
the Mandible Without Condylar Restoration. Journal of Craniofacial Surgery, 2014.
25(2): p. 415-417.
[35] Bisase, B., et al., The deep circumflex iliac artery perforator flap (DCIAP)—A recon‐
structive option for the large composite oro-mandibular cutaneous defect. British
Journal of Oral and Maxillofacial Surgery, 2013. 51(8): p. 962-964.
[36] Ting, J., et al., Developments in image-guided deep circumflex iliac artery flap har‐
vest: a step-by-step guide and literature review. Journal of oral and maxillofacial sur‐
gery: 2014. 72(1): p. 186-197.
[37] Elisabeth K.Beahm, M.M., Hanasono,Saleh Shenaq, Flaps and reconstruction sur‐
gery,Iliac Flap. 2009: Saunders,Elesiever 339-357.
[38] Zheng, H.-P., et al., Modified deep iliac circumflex osteocutaneous flap for extremity
reconstruction: Anatomical study and clinical application. Journal of Plastic, Recon‐
structive & Aesthetic Surgery, 2013. 66(9): p. 1256-1262.
[39] Iida, T., et al., A free vascularized iliac bone flap based on superficial circumflex iliac
perforators for head and neck reconstruction. Journal of Plastic, Reconstructive &
Aesthetic Surgery, 2013. 66(11): p. 1596-1599.
[40] Kim, H.-S., et al., Anatomical basis of the deep circumflex iliac artery flap. Journal of
Craniofacial Surgery, 2013. 24(2): p. 605-609.
[41] Claudio Angrigiani, J.P., Marcelo MackFarlane Fapls and reconstruction sur‐
gery,Scapular and parascapular flap. 2009: Saunders,Elsevier. 271-285.
[42] Bianchi, B., et al., Reconstruction of mandibular defects using the scapular tip free
flap. Microsurgery, 2014.
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[43] Dowthwaite, S.A., et al., Comparison of fibular and scapular osseous free flaps for or‐
omandibular reconstruction: a patient-centered approach to flap selection. JAMA
Otolaryngology–Head & Neck Surgery, 2013. 139(3): p. 285-292.
[44] Fujiki, M., et al., A comparison of perioperative complications following transfer of

fibular and scapular flaps for immediate mandibular reconstruction. Journal of Plas‐
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[45] Al-Benna, S., J.J. Kirkpatrick, and I. Taggart, Minimally Invasive Harvesting of Adi‐
pofascial Scapular Flaps. Annals of plastic surgery, 2014. 72: p. 666-669.
[46] Zevallos, J.P. and M.L. Urken, Reverse‐flow scapular osteocutaneous flap for head
and neck reconstruction. Head & neck, 2013. 35(6): p. E171-E174.
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Chapter 28
Reconstruction of the Face Following Cancer Ablation
Ata Garajei, Ali Arabkheradmand,

Mohammad Hosein Kalantar Motamedi,
Alex E. Pazoki and Ashkan Rashad
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1. Introduction
Following ablation of a tumor that is the primary lesion or metastatic tissue, facial reconstruc‐
tion is needed to restore and replace both hard and soft tissue losses. Ideally, reconstruction
should strive to restore the maxillofacial form, quality of tissues, oral competence, and oral
cavity functions, allowing the patient to return and adapt to society. Each area to be recon‐
structed must be considered individually to define the characteristics needed to provide the
structural bed for total functional return. To focus on the reconstructive approaches and goals,
an anatomic list should be compiled that includes:
1. Structures that are missing and their function,

2. Structures that are present but with compromised blood supply and/or function, and
3. Structures that are present and working well [1].
In general, goals of the reconstructive surgeon revolve around the restoration of functions,
including normal deglutition with tongue and pharyngeal components; adequate oral
competence; adequate mandibular mobility for functional mastication, with complete dental
rehabilitation; airway support and patency after a tracheotomy to allow decannulation; fluent
speech function paralleling deglutition; protective sensory function, especially sensations of
the tongue, corneal blink reflexes, and trigeminal facial sensory nerves; and overall movement
of the head and neck region, including shoulder lift and the muscles of the face [2]. As with all
aspects of life, form usually follows function. Special attention must be paid to the preoperative
facial aesthetic units that can be redefined, such as the mandibular symphysis, angle of the
jaw, malar regions, nose, and teeth. The end result is a patient who is able to return to a normal
lifestyle, engaging in routine activities of family life, work, and society. Reconstructive
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principles have been formulated to increase the predictability of successful surgery. They
include the use of a team approach to decrease operative time by synchronous resection and
flap preparation; avoidance of multiple flaps and vein grafts whenever possible; minimizing
of flap ischemia by shaping the flap while still vascularized; and slight overcorrection of the
soft tissue deficiency with well-vascularized soft tissues [3]. The ideal technique must be fast,
reliable, and cost efficient, imposing minimal morbidity on the patient [4]. Considerable debate
involving immediate versus delayed reconstruction continues. The reconstructive process may
involve multiple staged surgical procedures, for which the patient will require extensive
preoperative counseling.
Advocates of delayed treatment wait months to years after the original surgical resection [5].
Factors that disfavor an immediate approach include the covering of the primary site and
therefore the inability to detect a recurrence, a longer surgical time, the possibility of seeding
cancer cells in newly dissected tissue planes, and an increased risk of graft infection from the
contaminated salivary environment [6]. In contrast, Markowitz and colleagues [7] were not
able to demonstrate any advantage for delayed reconstruction. In fact, secondary surgery, or
two-stage reconstruction, is associated with higher overall complication rate, longer hospital
stay, and greater cost [8]. Heller and associates [9] studied the long-term benefits in 47 patients
who underwent immediate reconstruction of the mandible and found acceptable functional
and long-term survival results. Leaving the patient unreconstructed was advocated by those
who felt that an adequate follow-up period to detect recurrence was required before complete
reconstruction. Since the advent of extensive noninvasive imaging systems such as computed
tomography (CT), magnetic resonance imaging (MRI), and single photon emission CT (SPECT)
technology, physicians are better able to identify an early recurrence. Over the past decade,
one-stage reconstructive efforts using musculocutaneous flaps and microvascular free tissue
transfers have significantly improved the quality of life of such patients. When such a recon‐
struction is performed during the primary surgery, it allows postoperative radiation treatment
to be administered in a timely fashion. Delaying postoperative radiation can result in increased
morbidity and increase the risk of recurrence [10]. Furthermore, delayed reconstruction is
preceded by considerable fibrosis and soft tissue contraction, increasing the difficulty of
subsequent reconstruction and compromising functional and cosmetic restoration.
The advantages of immediate or early reconstruction in summary are as follows: reduction

in the total number of surgical procedures, less time that the patient must endure deformity
and morbidity, protection and preservation of vital structures, reduced economic cost of
treatment, and rapid oral rehabilitation and return to normal social lifestyle [4]. The surgical
result after cancer resection of the oral cavity and oropharynx is a significant functional and
cosmetic defect. For example, a partial glossectomy leaves a patient with varying degrees of
articulation and swallowing difficulties, depending on the amount of tongue tissue removed.
Bony resection of the involved mandible produces masticatory problems, as well as alteration
of facial contour.
A multidisciplinary team is often involved in the assessment and treatment of cancer patients.
This team consists of head and neck surgeons, plastic surgeons, oral and maxillofacial
surgeons, maxillofacial prosthodontists, radiation oncologists, medical oncologists, radiolog‐
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Reconstruction of the Face Following Cancer Ablation 645

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ists, pathologists, speech and occupational therapists, internists, and psychologists. Preoper‐
ative evaluation of the patient must include a full assessment of the patient's overall health,
ability to tolerate prolonged general anesthesia and blood loss, emotional and intellectual
abilities, motivation, and expectations. In addition, the status of the patient's airway and
nutritional needs must be addressed. Preoperative physical examinations, endoscopies or
panendoscopy, and radiologic evaluation (CT scans, MRI) must outline the tumor size,
location, and tissue type (biopsy) and rule out other concomitant lesions. The choice of which
reconstructive modality is used depends on the extent of the defect preoperatively. The stage
of the disease, the type of node dissection, and the availability of neck vessels are determined
by the surgeon. Transverse CT scan and a lateral cephalogram provide the model of the
mandible in two dimensions. Enhanced three-dimensional reconstructive CT scans further
outline the preoperative mandibular contours and provide a more complete model. Before
surgery, it is equally important that the patient be evaluated by a prosthodontist to aid in the
achievement of proper bimaxillary arch alignment for postsurgical dental rehabilitation.
Angiograms or noninvasive Doppler studies of the recipient and donor vessels are obtained
if their adequacy is in doubt, providing information regarding their vascular status. Successful
outcome can be ensured when the overall medical condition of the patient, the extent of the
disease and prognosis, and the potential donor sites are thoroughly evaluated in the preop‐
erative setting. [11]
Reconstruction in head and neck cancer patients requires a thorough understanding of
function and tissue defects needs to be restored. Anatomically, a classification system for
maxillofacial rehabilitation has been described.
Maxillary defects encompass minor defects of the hard and soft palate to extensive hard and
soft tissue losses from resections of the maxilla, soft palate, sinuses, and adjacent structures
(i.e., orbit and cheek).
Mandibular defects include alveolar segments with associated soft tissues, as well as portions
of the tongue and floor of the mouth.
Facial defects include structures of the orbit, nose, ear, and/ or cheek. Defects of the oral cavity
and oropharynx of small to moderate size can be successfully closed primarily, as long as
tongue mobility and the gingival sulcus are not compromised. The goal of reconstructive
surgery is to achieve coverage of the soft tissue defect, providing a definitive separation
between the oral cavity and the neck. This can be accomplished by use of either split-thickness
or full-thickness skin grafts or local, regional flaps. Functional and aesthetic outcomes become
less favorable as the extent of resection increases. Large defects, depending on the location,
require vascularized skin, soft tissue, and muscle. The advantages of myocutaneous flaps are
abundant blood supply, greater reliability, better effectiveness and predictability. These
pedicled osteomyocutaneous flaps facilitate resistance to infection and resorption, which is
directly related to the osseous vascular supply. Flap geometry, bone availability, and muscle
bulk restrict the degree to which the pedicled flap will adapt to the defect [12]. The use of free
microvascular flaps is another option for reconstruction in this region. The free microflaps
provide vascularized skin and bone to regions formerly considered impossible to reconstruct
owing to limitations of the donor site tissue. The most widely used free microvascular flaps
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are radial forearm flaps for the floor of the mouth defects involving segments of the mandible.
Flap selection is based on the quantity and contour of bone required, as well as the volume of
soft tissue necessary to accommodate the patient's needs. Whenever possible, it is best to use
adjacent soft tissue. If this is not feasible, then a regional flap (e.g., pectoralis major myocuta‐
neous flap or deltopectoral flap) may be required. Reconstruction of mandibular defects
requires the use of myocutaneous and microvascular free flaps, in conjunction with osseoin‐
tegrated dental implants, to provide satisfactory masticatory function. The goal of recon‐
structing a tooth-bearing mandible with adequate strength, with appropriate vestibular sulci,
and without excessive soft tissue bulk continues to invite surgeons to develop new treatment
options. Once the mandibular segments are properly aligned to restore a normal relationship
with the maxilla, oral rehabilitation is easily accomplished by a maxillofacial prosthodontist.
One area of oromandibular reconstruction that has challenged reconstructive surgeons is the
restoration of preoperative sensory and motor functions. Both pedicled and free tissue flaps
are large, insensitive tissue blocks that are used to replace oral tissues, thus compromising
swallowing and speech mechanisms. It has been difficult to reproduce the complex neurosen‐
sory and muscular activities of the oral and pharyngeal viscera. There is a need for thin, pliable,
sensate tissue to facilitate oral rehabilitation. Radial forearm, dorsalis pedis, lateral thigh,
lateral arm, and fibular osteocutaneous flaps all possess thin, pliable tissue and identifiable
sensory nerves that may be integrated into the reconstructive plan. [4] Urken and Moscoso [13]
reported 80% sensory recovery in 40 cases of mandibular reconstruction with radial forearm
flaps. Reconstruction of other bony defects typically requires bone grafting (cortical versus
cancellous), bone containing vascularized pedicled or free flaps, and free nonvascularized
bone grafts. With the advent of rigid fixation, bone grafting techniques have been enhanced,
allowing broader applications. Alloplastic materials such as silicone and hydroxyapatite have
been used to "fill in" bony defects and not to replace functional and structural tissue loss. The
success of bone grafting is completely dependent on adequate stabilization, immobilization,
and healthy soft tissue coverage. Once tissue has been irradiated, its repair capacity is
compromised. In bone, hypovascularity, damage to osteoprogenitor cells and hypoxic tissue
are responsible.
When a patient has received doses greater than 5000 rads (50 Gy) after ablative tumor surgery,
significant reconstructive difficulties are encountered. Grafts placed into irradiated tissue beds
have high rates of complications.
Hyperbaric oxygen (HBO) has been reported to help poorly perfused tissues by allowing
hyperoxygenation [14], providing antimicrobial activity (cidal to anaerobes and static to
microaerophilic organisms) [15], increasing fibroblastic proliferative activity [16], improving
neovascularization and angiogenesis [17], increasing bone matrix formation [18], increasing
mineralization [19], promoting osteoclastic activity to remove necrotic bone[20]; and enhanc‐
ing the transport capacity of erythrocytes by increasing their deformability [21]. Ganstrom [22]
suggested a protocol for HBO delivery: The patient is seated in a pressurized closed chamber
that is above one atmospheric pressure. The patient breathes 100% oxygen, with oxygen
toxicity avoided by regulating time and dose limits. Routinely, a single treatment (dive) varies
from 90 to 120 minutes once or twice a day. Another protocol developed by Marx'" is as follows:
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20 sessions of HBO at 2.4 atmospheres (ATA) for 90 minutes of oxygen breathing, once daily
for 5 or 6 days per week. This is followed by the surgical procedure. Postoperatively, the patient
undergoes 10 sessions of HBO, following the same preoperative regimen. The disadvantage
of HBO is time consumption without improvement in the quantity of tissue; only the quality
is enhanced. Also, HBO is expensive, ranging up to $50,000 for a treatment sequence. There
are some contraindications to receiving hyperbaric oxygen, including optic neuritis, immune
deficiency states, and end-stage chronic obstructive pulmonary disease. It is therefore very
important to make a thorough assessment of the patient's medical history, pulmonary status,
and chest radiograph. Occasionally, pulmonary function testing and ophthalmologic evalua‐
tion are required.
2. Grafts
2.1. Free skin grafting

Healthy skin grafts usually retain the same color as the donor area and retain the texture and
Grafts
appearance
Free SkinofGrafting
normal skin (Figure. 1). Skin grafting to the oral cavity has been indicated for
the correction of periodontal
Healthy skin grafts defects,
usually retain minorcolor
the same andasmajor preprosthetic
the donor area and defects,
retain theand implant
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surgery, as well
appearance as forskin
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traumatic,
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has been tumor ablative
for the
surgery.
correction of periodontal defects, minor and major preprosthetic defects, and implant surgery, as
well as for the reconstruction of traumatic, congenital cleft, and tumor ablative surgery.
Figure
Figure1. Free skin graft
1. Free skinofgraft
the scalp.
of thescalp.
Free grafting of the oral mucosa was first described by Propper [23] and was later refined by
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described by Propper
Skin [23] and
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procedure. Thea
retroauricular location are chosen when a good color match is desired for facial reconstruction.
buttocks are also used as a donor site when cosmesis is a concern. Full-thickness skin grafts
For mucosal grafting, the cheek and palate are the two sites most widely used for oral
from a retroauricular
transplantation. location
Theoretically, theare chosen
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reconstruction. For mucosal grafting, the cheek and palate are the two sites
nature of that which was removed. For example, lost periodontal tissues would best be replacedmost widely used
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mucosa, as its thick keratinizedthe tissue
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Split-thickness of that which
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be harvested byFor example,
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the dermatome tissues
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would bestofbethe
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generally Split-thickness
dependent skin grafts
on the correct may be
adjustment onharvested by adjusting
the dermatome, manual
dexterity, pressure, advancement of the dermatome, and experience. A similar harvest can be
obtained using a scalpel and sharp dissection of the epidermis and dermis from the underlying
connective tissues. Oral mucosal grafts from the palate are taken free handed with a scalpel. A
Mormann mucotome with a 6-mm blade is also suited for instrumentation. Skin grafts are
preferably outlined before injection with a local anesthetic solution. In this way, the tissues are
not distorted with the infused solution. If using a dermatome, a donor site with evident capillary
bleeding from the dermal layer can be dressed with a Telfa cover sponge impregnated with
1:100,000 epinephrine solution and placed over the site for approximately 10 minutes for
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the dermatome to control the thickness of the graft and to confine the amount of donor tissue
being removed. The desired thickness of the graft is generally dependent on the correct
adjustment on the dermatome, manual dexterity, pressure, advancement of the dermatome,
and experience. A similar harvest can be obtained using a scalpel and sharp dissection of the
epidermis and dermis from the underlying connective tissues. Oral mucosal grafts from the
palate are taken free handed with a scalpel. A Mormann mucotome with a 6-mm blade is also
suited for instrumentation. Skin grafts are preferably outlined before injection with a local
anesthetic solution. In this way, the tissues are not distorted with the infused solution. If using
a dermatome, a donor site with evident capillary bleeding from the dermal layer can be dressed
with a Telfa cover sponge impregnated with 1:100,000 epinephrine solution and placed over
the site for approximately 10 minutes for hemostatic control. A dressing is then placed to
prevent infection and to promote rapid healing. Traditionally, a dressing with petroleum jelly
gauze over the donor site works well. There is no need for antibiotics unless there is clinical
evidence of infection. When using the free-hand technique for skin graft acquisition, the donor
site must be closed primarily, which is relatively easy in the lateral thigh, buttocks, and inguinal
regions. The subcutaneous tissues are undermined widely to allow for a tension-free closure.
Sutures are placed in the subcutaneous layer, as well as in the skin. There is no need for a drain,
provided that dead space has been eliminated using the layered closure. The graft is then
placed on a wet gauze towel, which helps prevent folding of the graft edges. A "mesher" can
be used to cut multiple slits in the graft to transform it into a lattice, which increases its area
two to three times its original size. A meshed graft also has greater pliability to follow irregular
contours. The use of slits also creates sites where blood and wound exudate can escape,
providing optimal healing conditions. In order for skin grafting to be successful, graft immo‐
bility is of primary importance, especially during the early healing phase of revascularization.
There have been various methods to achieve this goal: sutures, splints, wires, bone screws, and
fibrin adhesive. Stents can be produced in advance using conventional dental impression
materials and techniques. Ideally, graft immobility should be maintained for 5 to 7 days.
Essentially, a graft that is not protected has a greater likelihood of failure. The use of freeze-
dried allergenic grafts has been shown in studies to be comparable to skin grafts for main‐
taining vestibular depth. Lyophilized dura as a wound dressing after periodontal surgery was
reported to delay healing time, with subsequent hematoma formation. There have been many
similar studies comparing the effectiveness of allografts and xenografts with that of traditional
fresh autogenous skin grafts. At present, there are no benefits in using such materials for oral
and maxillofacial reconstruction.
2.2. Bone grafting
When faced with a patient who requires reconstruction of significant hard tissue losses of the
mandible, bone grafting is the most viable treatment option. The continuity defect must be
prepared with a graft that provides several functions. The principles of bone induction and
conduction have been studied extensively over the years. The graft must be able to provide a
source of viable osteogenic cells, such that it maintains sufficient osseous bulk and resists
resorption for subsequent prosthetic rehabilitation. It must also act as a precursor for bone
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production and maturation by the bone induction principle. The graft must physically correct
any facial form deficiencies resulting from underlying hard tissue losses.
2.2.1. Autogenous bone grafts
Autogenous bone is a viable treatment option. It can be particulate cancellous bone marrow,
cortical blocks, or a combination of corticocancellous blocks. Particulate bone and cancellous
marrow grafts contain numerous osteoprogenitor cells and allow a rapid revascularization.
However, owing to their particulate nature, they require some form of containment via either
soft tissue envelope-type pockets or rigid mandibular trays. The nonvascular corticocancellous
blocks provide structure and bulk. The most common sites for acquisition are the anterior and
posterior ilium, rib, and cranial bone. These types of grafts transplant more mineral content
rather than osteocompetent cells. When grafting autogenous bone for reconstruction, one must
pay close attention to the anatomic detail of the donor site as well as the amount, quality, and
contour of bone to be used.
The iliac crest is widely accepted because it provides the greatest absolute amount of cancel‐
lous bone volume, as well as providing a cortical plate with significant structure and contour.
When approaching the anterior ilium, the position and course of sensory cutaneous innerva‐
tion must be considered. The nerve most often affected in this dissection is the iliohypogastric
nerve, which courses over the area of the tubercle. The subcostal nerve traverses over the tip
of the anterior superior iliac spine. The lateral femoral cutaneous nerve provides cutaneous
sensory innervation to the lateral thigh region. It is located medially between the iliacus and
psoas major muscles and then dives deep to the inguinal ligament, piercing the tensor fascia
lata muscle. The incisions are therefore made lateral to the crest, avoiding the lateral femoral
cutaneous nerve, extending from 2 cm posterior to the iliac tubercle, away from the subcostal
nerve, to 1 cm posterior to the anterior superior spine. This places the incision away from the
belt and waistband area, preventing excessive impingement. The blood supply to the anterior
ilium is from terminal branches of the deep circumflex iliac artery. This lies medially and is
avoided in the dissection. A roll is placed under the supinepositioned patient to elevate the
iliac crest by lateral rotation at the hip. The patient is then prepped with povidone-iodine
(Betadine) soap and paint and draped in a standard sterile fashion. Before sharp dissection,
local infiltration of 1 % lidocaine with 1:100,000 epinephrine is used at the planned incision
site for its local anesthetic and vasoconstrictive properties. A No. 15 blade is used to make the
skin incision, extending to the subcutaneous tissues. Electrocautery is used to gain hemostatic
control. The incision can then be manipulated to be centered over the crest. A sharp dissection
is completed through the external and internal oblique musculature and periosteal layers to
gain access to the bony crest. A subperiosteal reflection of the iliac crest in the medial direction
is preferred, to avoid dissection of the tensor fascia lata muscles laterally, creating gait
disturbances. Elevation of the iliacus muscle on the medial aspect of the ilium allows adequate
access and visualization of the crest for retrieval of the desired bone graft. One must take care
in this medial dissection to avoid accidental perforation of the peritoneum and/or bowel.
Several osteotomy approaches, with either conventional mallet and osteotomes or air or
electrical-driven saw blades, have been described to gain access to the cancellous bone. For
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small quantities of particulate cancellous bone marrow (PCBM), the "clamshell" approach
requires an osteotomy in the midcrestal position to a depth just through the cortical plates.
The medial and lateral cortices can be "split" and greensticked apart to allow a route of entry
to the cancellous graft. The "trap-door" technique allows access by creating a midline osteot‐
omy and reflecting either medial or lateral cortices, pedicled on adjacent muscles. The
"hollowed crest" approach osteotomizes the crest in a horizontal fashion by "de-capping" the
crest and reflecting the crest cap laterally to gain access to the central marrow (e.g., Tschapp
approach). Finally, Tessier's approach attempts to maintain the contour of the crest by
performing oblique osteotomies off the lateral and medial aspects and retrieving the bone deep
to the crest itself. If a corticocancellous block is desired, full-thickness osteotomies are com‐
pleted on the medial aspect, detaching the block at the most medial aspect. Once cancellous
marrow has been found, bone can be harvested using a 3/8- or 1/2 inch bone gouge and series
of curettes. Upon maximal retrieval, closure of the donor sites begins. Any sharp edges are
smoothed with bone files. Hemostasis can be achieved with electrocautery of small perforating
vessels, placement of bone wax, or microfibrillar bovine collagen (Avitene) to tamponade
bleeding. A drain is usually required, exiting at a site away from the incision and suctioned at
a low intermittent strength to avoid continuous aspiration of marrow blood. Closure is
achieved primarily, first reapproximating periosteal layers with 2-0 Vicryl suture, muscular
layers with 4-0 Vicryl suture, subcutaneous tissues with 3-0 chromic gut suture, subcuticular
with running, pull-out, and skin with 4-0 nylon/praline suture. A pressure dressing is helpful
in the immediate postoperative setting and can be accomplished with cover sponges and foam
tape [24].
Rib harvesting provides an alternative source of autogenous bone (Figure 2).
At the present time, its primary indication is to reconstruct the mandibular articulation with
good adaptation to the temporal fossa and reestablishment of ramus height, and also to augment
an atrophic mandible. Depending on size and contour, fourth, fifth, and sixth ribs are best. The
sixth rib is most widely used because it can be accessed through an inframammary crease
incision. At this level, minimal muscle is transected, as the dissection is between the pectora‐
lis major and rectus abdominis muscles, thus preserving these for future muscle flaps. With the
patient in the supine position, an inframammary incision is made through the skin and
subcutaneous tissues until fibers from the pectoralis major muscle (from above) and rectus
abdominis muscle (from below) are seen attaching on the sixth rib. A periosteal incision is placed
at the greatest convexity on the lateral aspect of the rib, and with the use of periosteal eleva‐
tors, the rib is exposed from its costochondral junction anteriorly to a posterior length as much
as 18 cm. The length is limited posterolaterally by the latissimus dorsi muscle.Careful eleva‐
tion of the periosteum with Molt and Freer elevators is most effective in preventing small tears
in the pleura, as small projections of the pleural cortex may tear with the use of large eleva‐
tors. Once reflection is completed, the resection is begun at the cartilage site, taking only 3 mm
of cartilage medially in both adults and children. Including more than 3 mm increases the chance
for cartilage separation from bone, especially in children. Once the anterior end is separated
from the sternum, the rib can be elevated by placing an instrument on the undersurface of the
rib, protecting the parietal pleura as the posterior extent is reached. The posterior end is then
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cut, and the host end is smoothed with files. At this time, it is prudent to evaluate the pleura for
tears. This can be done either visually or with the use of saline irrigation; the latter produces air
bubbles if an air leak is present. Closure begins with periosteal approximation, followed by a
muscle layer, subcutaneous tissue layer, and skin. Drains are usually not indicated. In chil‐
dren, a full morphologically normal rib will regenerate within 1 year, whereas in adults, an
incomplete bone ossicle resembling a rib slowly forms over 1 to 3 years. [25]
Calvarial bone grafting for oral and maxillofacial surgery has progressed since its described
use by Harsha and colleagues [26]. It has been widely used for vertical augmentation of maxilla
and reconstruction of orbital wall and floor defects. It has a unique characteristic of early
revascularization, which is directly related to the numerous vascular systems. As a result, the
graft survives with little dimensional change. The paramedian portion of the parietal bone is
the most likely area for harvest because it is the thickest, it is away from any vital structures
(e.g., the superior sagittal sinus), and there is less chance that the scar will be visible in patients
with male pattern baldness. The approach to this area requires a hemicoronal or bicoronal
incision, posterior to the ear, and is carried through the five scalp layers (skin, subcutaneous
tissues, galea-aponeurotic layer, loose connective tissue, and periosteum). Bleeding skin
vessels are hemostatically controlled with Raney clips. The use of electrocoagulation may
destroy hair follicles and result in patchy alopecia. A bur is used to create the shape of the
desired graft in the outer cortex to the level of the cancellous marrow. Then, with the use of
curved osteotomes, the outer table can be cleaved from the inner table in the plane of the
interposed cancellous marrow. The incision is closed primarily in layers. Pressure dressings
with "crani-caps" are placed to allow adaptation of the elevated tissues to bony scalp.
Figure 2. Rib harvesting

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Rigid plate fixation [27] has resolved the problems with nonunion, but resorption continues
to occur due to the stress shielding. Branemark and colleagues [28] in 1975 first reported the
successful use of a block bone graft stabilized by a titanium plate in traumatic cases. Rigid
plates have been well adapted to the preselected mandible to achieve the functional contours
necessary for reconstruction. Li and associates [29] established a technique to maintain
mandibular position with respect to the temporomandibular joint. Before resection, the
mandible is placed in maximal intercuspation, with condyles seated firmly in the fossa.
Miniplates and screws are spanned bilaterally from the maxillary zygomatic processes to the
mandibular ascending ramus. The plate is then adapted to the contour of the existing mandible,
and the resection takes place. In this technique, the posterior facial height is maintained, as
well as accurate adaptation of the condyle to the fossa. Ardary [30] also commented on the
importance of adequately stabilizing the free bone graft with the use of a mandibular recon‐
struction plate in a report of nine consecutive cases with successful results. Absolute stability
promotes neovascularization of the graft by permitting vascular ingrowth while simultane‐
ously allowing for immediate postsurgical jaw function. Boyne [31] compared segmental
defects in dogs that were bridged together with block bone or stabilized with a plate or with
particulate bone and marrow within a Vitallium tray. He found significant resorption with the
block bone, whereas complete bony regeneration and union were evident when the PCBM and
tray were used. Dacron urethane mandibular trays were used with autogenous iliac crest bone
in one study that showed retention of 80% of bony height over a 3-year period, with little
alteration in the complication rate compared with standard reconstructive techniques [32]. The
Dacron tray is a lightweight, biologically inert structure that is easy to adapt to the mandible,
requiring a more limited access. Its radiolucency allows one to appreciate the radiographic
monitoring of the bone graft. And, finally, reconstruction of the bone graft with fixation plates
and metallic trays requires a second surgical procedure before endosseous dental implant
placement, whereas the Dacron tray does not require removal. Mandibular reconstruction with
reimplantation of resected mandibles that are hollowed out and function like a tray has been
studied by Jisander and coworkers [33]. The prepared segments act as a matrix for new bone
formation and as a carrier for transplanted cancellous bone. [34].
2.2.2. Allogenic bone grafts
Allogenic grafts are those taken from the same species but transplanted into a different
individual. [35]. The major disadvantage of FFB is the small risk of disease transmission. [36]
Bone substitutes, or alloplastic materials, have been used to recontour alveolar defects and as
extenders in bone graft systems for reconstruction of major continuity defects. One such
substitute is hydroxyapatite. It does not have the mechanical properties necessary for recon‐
structing major defects but provides a temporary matrix for future bone growth because of its
osteoconductive nature.
Xenografts of bone and cartilage such as bovine bone mineral have been used as fillers or
spacers in orthognathic and preprosthetic surgeries, as well as sinus grafting procedures
(Figure 3) and alloplastic trays are commonly used to bridge the gap and to carry PCBM to fill
mandibular defects. Its drawback is the risk of disease transmission. The Dacron-coated
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polyurethane crib is flexible, lightweight, biologically inert, easy to trim and adapt to the
mandible, and radiolucent, which allows assessment of postoperative bone graft healing. Its
disadvantages include its reliability in long-span mandibular defects, where intermaxillary
fixation or internal reinforced metal rods are used for added rigidity.
Figure 3. Polyurethane crib (left), alveolar bone grafting (right)
Metallic alloplastic trays have the ability to maintain the normal relationship of the residual
mandibular
11 segment without additional fixation, so the patient resumes normal functions
earlier.
The titanium tray is harder than the Dacron tray but softer than cobalt-chromium and
stainless steel trays. The disadvantages of metallic cribs are that they have very high flanges
in order to carry an adequate volume of bone, thus interfering with preprosthetic procedures
and dental prostheses. This leads to tray removal. A simple technique was recently reported
by Tayapongsak and coworkers [37] in designing a custom-made inferior border titanium crib
(IBTC). The disadvantages of the custom-made IBTC are the use of intermaxillary fixation and
its nonresorptive ability.
3. Flaps
Soft tissue flaps can be classified according to the method of movement (i.e., local or distant);
according to blood supply, such as axial or random pattern; and according to the composition
of the flap, such as cutaneous, myocutaneous, osteomyocutaneous, or fasciocutaneous.
Random flaps consist of skin with the underlying subcutaneous tissues and frequently muscle.
Their blood supply is provided by the plexuses from the dermal and subdermal regions. Axial
patterned flaps have their perfusion from dominant vessels present with the flap. They may
also contain secondary vessels to increase the flap's viability.
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3.1. Local flaps
3.1.1. Lingual tongue flap
The use of tongue flaps was described as early as 1909 by Lexer, for the repair of cheek defects.
Since then, tongue flaps have been described for facial and labial reconstruction [38]. Flaps
from the dorsum of the tongue are designed lengthwise, usually paramedian, with a posterior
or anterior base. Transverse flaps do not cross the midline of the body of the tongue, because
its blood flow would be compromised. The posteriorly based dorsal tongue flap relies on the
dorsal lingual artery for its survival. It usually runs the entire length of the tongue, from the
circumvallate line to its anterior tip. The thickness of the flap is approximately 8 mm and is
uniform, to avoid a wedge-shaped cross section. The flap includes mucosa and the adherent
stratum of the superior lingual musculature. The flap, once elevated, can be rotated laterally
and backward to repair the defect in the retromolar trigone or tonsillar region on the ipsilateral
side, or to repair a cheek defect. This donor region is closed by direct suture, with meticulous
attention to hemostasis. Dead space is eliminated by interrupted buried sutures, thus pre‐
venting hematoma formation and airway compromise. This closure does not affect the tongue's
lingual function.
The anteriorly based dorsal tongue flap offers greater mobility, because the pedicle is on the
free end of the tongue, and is thus more versatile. The tip of the tongue is supplied by the
anastomotic ranine arch, which is the terminal branch from the forward continuation of the
lingual artery. This vessel gives off numerous branches as it ascends to the tip. Thus the flap,
which appears delicate and friable, is more robust than imagined. This type of flap is indicated
mainly to repair anterior cheek and commissural defects. With outward rotation, it can be used
to replace the lining and vermilion of the lips. With downward rotation, it is able to repair floor
of the mouth defects in the anterior region, as well as anterior lateral defects when rotated
through a window in the median raphe of the tongue. And by forward reflection, it can cover
oronasal defects in cleft patients and excisional defects of the hard palate. As opposed to the
posterior-based flap, the anterior one requires second-stage surgery to divide the tongue at its
pedicle in order to maintain speech and swallow function.
The transverse dorsal tongue flap is usually created in bipedicle form, such that the flap is
transferred anteriorly from the tongue to the floor of the mouth or to the lip, and the donor
defect is closed primarily by approximation. The disadvantage is that tongue length is
diminished and blunting of the free end occurs. This type of flap is recommended in cases in
which length is not a factor.
The perimeter flap is developed by a vertical incision just inside and parallel to the border of
the tongue. These flaps are narrow and may be uni- or bipedicle in design. Their use is indicated
mainly for repair of lip vermilion defects, and variations in flap design are possible. Because
of the anastomotic ranine arch, there is no compromise of vascular supply.
Dorsoventral flaps are derived from the lingual tip by a horizontal incision, inside and parallel
to the edge, and are wider than they are long. They can be reflected dorsally on a posterior
base to reconstruct the lining of the upper lip. The flap can also be reflected ventrally on an
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anterior base for lower lip reconstruction. A combination of both types of flaps can be incor‐
porated to reconstruct vermilion and lining. The only drawback in creating these flaps is the
resultant shortening of the tongue, which may affect speech and swallow mechanisms.
Ventral-based flaps have been described for repairs of anterior floor of the mouth defects,
where two parallel lengthwise posterior-based flaps are reflected and rotated to the anterior
defect. The resultant donor site cannot be closed primarily because of obvious contraction of
the tongue. In this case, a skin graft can be placed to cover the donor site and is in fact well
tolerated, with minimal effect on tongue mobility. This flap also has good results for vermilion
reconstruction [38] (Figure 4)
Figure 4. Reconstruction of the lower lip with a pedicled tongue flap.
3.1.2. Nasolabial flap
Nasolabial flaps are more useful for intraoral reconstruction when they are based inferiorly.
With this design, floor of the mouth, tongue, and anterior mandibular defects can be recon‐
structed (Figure 5). In the dissection, it is important to include a thick portion of the underlying
subcutaneous tissues to provide adequate blood supply to the flap. Its primary supply is from
the branches of the facial artery. The flap can be based superiorly for upper alveolar or palatal
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Figure 4. Reconstruction of the lower lip with a pedicled tongue flap.
Nasolabial Flap
656 ANasolabial flaps areOral
Textbook of Advanced moreanduseful for intraoral
Maxillofacial reconstruction
Surgery Volume 2 when they are based inferiorly. With
this design, floor of the mouth, tongue, and anterior mandibular defects can be reconstructed
(Figure 5). In the dissection, it is important to include a thick portion of the underlying
subcutaneous tissues to provide adequate blood supply to the flap. Its primary supply is from the
resurfacing.
branches of Athe long, tapered
facial artery.flap
Theis flap
designed
can be on based
the hairless skin for
superiorly edge alongalveolar
upper the nasolabial
or palatal
fold.
resurfacing. A long, tapered flap is designed on the hairless skin edge along the then
The epithelium is removed at the base and tunneled through the cheek. It is sutured
nasolabial fold.
in theepithelium
The oral cavityisatremoved
the desired
at thesitebase
and and
to itstunneled
contralateral counterpart
through the cheek.asItthe flapssutured
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at the coverage
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its contralateral counterpart as the flaps lie side by side to
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Figure
Figure5. Nasolabial flap.
5. Nasolabial flap.
Cervical Island Skin Flap
3.1.3. Cervical island skin flap
For defects that include the oral mucosa, gingiva, and part of the mandible after excision of
gingival carcinomas, a cervical island skin flap has been described for reconstruction, along‐
side a bone graft for the hard tissue mandibular bony defect [39]. The cervical island flap was
first described by Farr and colleagues [40]. The size of the skin island depends on the extent
of the resected oral mucosa and gingiva, which in most cases is 2 to 2.5 cm in width and 4 to
5 cm in length. A skin margin of 3 mm is elevated to suture the skin of the flap to the oral
mucosa (Figure 6).
11

Figure 6. Cervical Island Skin Flap

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The flap is passed under the mandible and introduced medial to the mucosal defect. The
margin of the denuded distal part of the flap is sutured to the lingual edge of the cut surface
of the remaining mandible. The border of the skin island is sutured to the mucosa of the floor
of the mouth and the anteroposterior adjoining gingiva, thus forming a partition. The lateral
margin
Figureof6.the skin island
Cervical Islandis sutured to the buccal mucosa. This creates a pocket from the cervical
Skin Flap
flap. The pocket can then be filled with autologous PCBM or hydroxyapatite granules. The
The flap
study is passedand
by Tashiro under the mandible
associate and introduced
[39] showed medial
successful to the mucosal
reconstruction usingdefect. The margin
this technique.
of the denuded distal part of the flap is sutured to the lingual edge of the cut
Reconstructed mandibles lost approximately 8% to 22% of their bone height, with patients
surface of the
remaining mandible. The border of the skin island is sutured to the mucosa of the floor of the
wearing their prostheses comfortably. Minimal necrosis of the flaps was noted.
mouth and the anteroposterior adjoining gingiva, thus forming a partition. The lateral margin of
the skin island is sutured to the buccal mucosa. This creates a pocket from the cervical flap. The
3.1.4.
pocketBilobe
can skin
thenflap
be filled with autologous PCBM or hydroxyapatite granules. The study by
Tashiro and associate [39] showed successful reconstruction using this technique. Reconstructed
Bilobe flaps lost
mandibles are double transposition
approximately 8% toflaps
22%thatof share
their abone
singleheight,
base (Figure 7). Similar
with patients to single
wearing their
transposition flaps, bilobe
prostheses comfortably. flaps move
Minimal around
necrosis pivotal
of the points
flaps was located at their base and develop
noted.
standing cutaneous
Bilobe Skin Flapdeformities as they pivot. Since each flap or lobe moves around an
independent
Bilobe flaps pivotal point,
are double each lobe develops
transposition flaps thatand individual
share standing
a single base cutaneous
(Figure deformity.
7). Similar to single
transposition
The greater isflaps, bilobe
the arc flaps moveabout
of movement around pivotal
their points
pivotal located
points, at theirare
the larger base
theand develop
standing
standing cutaneous
cutaneous deformities as they pivot. Since each flap or lobe moves around an
deformities.
independent pivotal point, each lobe develops and individual standing cutaneous deformity. The
greater is the arc of movement about their pivotal points, the larger are the standing cutaneous
deformities.
Figure 7, Bilobed skin flap

Figure 7. BilobedFlaps
Regional skin flap
PEDICLED FACIOCUTANEOUS/MYOCUTANEOUS/MUSCLE FLAPS
The pectoralis major myocutaneous flap was first introduced by Ariyan [41] in 1979, and along
3.2. Regional flaps
with the forehead flap, it was the most commonly used flap for head and neck reconstruction in
the early 1980s. However, these flaps consisted of only epithelium and some subcutaneous tissue
3.2.1. Pedicled faciocutaneous/myocutaneous/muscle
and therefore were not appropriate for defects in whichflaps bulk had to be restored. The total scheme
of soft tissue reconstructive management is dependent on the type of pathology being treated. For
The pectoralis
example, major myocutaneous
the management flap was
of oral cancer first introduced
requires immediateby Ariyan
soft tissue[41] in 1979, and Also,
reconstruction. along in
with
areasthe forehead
where flap, it was
reconstructive bonetheplates
most are
commonly used
used, it is flap paramount
usually for head andto neck
have reconstruction
the plate covered
in the aearly
with muscle1980s.
flapHowever, these flaps adjuvant
when postoperative consistedradiotherapy
of only epithelium
will be and
used,some
whichsubcutaneous
helps prevent
tissue and therefore
skin dehiscence were the
overlying notbone
appropriate
plate. for defects in which bulk had to be restored. The
total scheme of soft tissue
Sternocleidomastoid reconstructive
Myocutaneous/ management
Muscle Flap is dependent on the type of pathology
The sternocleidomastoid (SCM) myocutaneous flap was first described by Owen [42] in 1955.
being treated. For example, the management of oral cancer requires immediate soft tissue
This type of flap has been reported in the literature for a variety of indications[43]. These include
reconstruction. Also, in areas where reconstructive bone plates are used, it is usually para‐
aiding in mucosal reconstruction by providing an epithelial lining; creating a facial cover to close
mount to have the plate covered with a muscle flap when postoperative adjuvant radiotherapy
will be used, which helps prevent skin dehiscence overlying the bone plate.

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3.2.2. Sternocleidomastoid myocutaneous/ muscle flap
The sternocleidomastoid (SCM) myocutaneous flap was first described by Owen [42] in 1955.
This type of flap has been reported in the literature for a variety of indications[43]. These
include aiding in mucosal reconstruction by providing an epithelial lining; creating a facial
cover to close orocutaneous fistula; releasing scar contractures, especially around the angle
and submandibular regions; providing additional tissue to allow for a passive, tension free
closure; and, when used as a muscle flap, obliterating dead space around a bone graft. It is also
a very vascular flap that, when used in an irradiated tissue bed, provides additional perfusion
to the bone graft material. This strap muscle originates at the medial third of the clavicle
(muscular) and near the manubrium (tendon). The SCM is innervated by a branch of the spinal
accessory nerve, which is found between the internal carotid artery and the internal jugular
vein, outside the carotid sheath, and enters the deep surface of the muscle. The dominant blood
supply is from branches of the occipital artery and corresponding vein. The muscle also
receives blood supply from the superior thyroid artery and vein, and the entire muscle and
overlying skin remain viable (Figure 8). The inferior third aspect of the muscle is supplied by
a branch of the inferior thyroid artery and a branch of the thyrocervical trunk, which may be
sacrificed if not contained in the desired flap design. The dissection begins by outlining the
skin paddle at the anterior and posterior borders with a scalpel and dissecting through skin,
subcutaneous tissues, and platysmal muscle until the SCM is reached. The myocutaneous flap
is then separated from the clavicular and sternal origins and deeply dissected to the level of
the carotid sheath. This dissection is carried superiorly, always taking care to avoid trauma to
the contents of the carotid sheath. At the level of the carotid bifurcation and anterior to the
muscle, the branches of the superior thyroid artery are found. Just below the level of the
bifurcation, the spinal accessory nerve enters the posterior dorsal surface of the muscle. It is
important that this nerve be preserved, to maintain the function of the trapezius muscle. Thus,
neuromuscular blocking agents are not recommended. The flap is developed until adequate
length to reach the recipient site without tension is achieved. One of the drawbacks of this flap
is the limited size and arc of rotation. For this reason, these flaps are not used for defects
involving the anterior floor of the mouth. Functionally, use of the SCM muscle for reconstruc‐
tive purposes does not lead to the inability to rotate the head to the contralateral side, as this
function is maintained by other muscles (splenius capitis, trapezius, and suprahyoid muscles
of the contralateral neck).
3.2.3. Temporalis muscle flap
Temporalis flap can provide abundant tissue for soft tissue reconstruction of the upper two
thirds of the face, as well as reconstruction of the oropharynx (Figure 9). Use of this flap has
been studied extensively. It was first described by Golovine, who used the flap for the
obliteration of dead space after orbital exenteration as cited by Huttenbrink [44]. It is used to
reconstruct composite defects of the maxilla, as well as areas of scar contracture and soft tissue
deficiencies. Cheung [45] described the use of the temporalis flap for intraoral defects after
maxillectomies in cats and the healing mechanisms of the flap in the oral cavity. He found a
biologic response similar to that of humans, with regeneration of smooth palatal mucosa,
this flap is the limited size and arc of rotation. For this reason, these flaps are not used for defe
involving the anterior floor of www.dentalbooks.co
the mouth. Functionally, use of the SCM muscle for reconstruc
purposes does not lead to the inability to rotate the head to the contralateral side, as this funct
is maintained by other muscles (splenius Reconstruction of the Face Following
capitis, trapezius, Cancer Ablation muscles
and suprahyoid 659 of
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contralateral neck).

Figure
Figure8. Sternocleidomastoid Myocutaneous/ Muscle
8. Sternocleidomastoid Flap
Myocutaneous/ Muscle Flap
without ruga formation.

Temporalis Anatomically, the fan-shaped, bipennate temporalis muscle is based
Muscle Flap
on the main vascular
Temporalis flap cansupply from
provide the anterior
abundant and for
tissue posterior deep temporal
soft tissue arteries,ofwhich
reconstruction the upper two th
arise from
of the the second
face, division
as well of the maxillaryof
as reconstruction artery.
the The anterior deep
oropharynx temporal
(Figure 9).artery
Use enters
of this flap has b
the muscleextensively.
studied approximatelyIt 1was
cm anterior to the coronoid
first described process, whereas
by Golovine, who usedthe posterior
the flap branch
for the obliteration
isdead
1.7 cmspace after orbital exenteration as cited by Huttenbrink [44].of Ittheisfascia,
posterior to the bony landmark. Thus, the mobilized flap, consisting used to reconstr
muscle,
compositeand pericranium,
defects of thecanmaxilla,
be split into
as anterior
well as and
areasposterior
of scarflaps.
contracture and soft tissue deficienc
Cheung [45] described the use of the temporalis flap for intraoral defects after maxillectomie
cats and the healing mechanisms of the flap in the oral cavity. He found a biologic respo
similar to that of humans, with regeneration of smooth palatal mucosa, without ruga formati
13

Figure 9. Temporalis muscle
An additional flap can be pedicled from the middle temporal artery, which arises from the
superficial temporal artery immediately superior to the zygomatic arch. Located immediately
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deep to the subdermal layer is the superficial temporal fascia, which is a thin, highly vascular
layer of moderately dense connective tissue. On its deep aspect, a very loose areolar tissue
separates it from the deep temporal fascia. A temporoparietal fasciocutaneous flap described
by Upton and colleagues [46] can be raised, as it is based on the superficial temporal artery. It
is a prefabricated flap, in that a full-thickness skin graft is placed on the temporoparietal fascia
2 weeks before reconstruction. Access to the temporal flap is via a bicoronal incision and flap.
It has the advantage of being very thin and quite sturdy and is suitable for the maxillofacial
region. The dissection extends to the deep temporal fascia until the entire muscle is exposed.
In this way, the temporal branch of the facial nerve (cranial nerve VII) is protected. In a
subperiosteal plane, the muscle is then stripped of the temporal bone. When used for recon‐
structing the oral cavity, passage to enter the mouth requires fracturing the zygomatic arch as
far posteriorly and anteriorly as possible and displacing it laterally, providing a tunnel into
the mouth. The flap can then be rotated by dividing the coronoid process carefully, so as not
to sever the vascular pedicle. Its ability to provide a large amount of tissue for reconstructing
facial defects results in a mild cosmetic deformity at the donor site (i.e., hollowing of the
temporalis fossa). However, with time, the depression may be hidden either by scar tissue or
by hairstyle. If only an anterior flap is being used, the posterior flap can be rotated to fill in the

prominent depression. Alloplastic materials, such as acrylic, have been used to fill in the defect.
used, the posterior flap can be rotated to fill in the prominent depression. Alloplastic materials,
such as acrylic, have been used to fill in the defect.
3.2.4. Forehead myocutaneous flap
The forehead
Forehead flap is a powerful
Myocutaneous Flap tool in nasal and surrounding area reconstruction and is
currently the method of choice for resurfacing large nasal defects [47]. It has evolved from
its
Theancient roots
forehead flapasisaabroad-based
powerful toolflap withand
in nasal significant donor
surrounding areasite morbidity and
reconstruction andexcessive
is currently
bulk to an elegant
the method of choiceprocedure using large
for resurfacing a narrow
nasal pedicle with Itadequate
defects [47]. length
has evolved fromand appropri‐
its ancient roots
ate
as thickness to achieve
a broad-based an esthetically
flap with significant pleasing result
donor site for both
morbidity andtheexcessive
patient and
bulksurgeon [48]
to an elegant
(Figure
procedure10).using a narrow pedicle with adequate length and appropriate thickness to achieve an
esthetically pleasing result for both the patient and surgeon [48]( Figure 10 ).

Figure
Figure10. 10.
Forehead Myocutaneous
Forehead Flap
Myocutaneous Flap
Advances
Advances ininunderstanding
understanding of ofthe
theanatomic
anatomicbasis
basisfor
forforehead
foreheadflaps have
flaps allowed
have allowed surgeons to to
surgeons
expand
expand the
the versatility
versatility of
of the
the pedicle
pedicle without compromisingviability.
without compromising viability.The
Themidline
midlineskinskinpaddle
paddlehas
has advantages,
advantages, whichwhich include
include a favorable
a favorable donordonor
site site
scar scar
[49].[49].
TheThe forehead
forehead flapflap is multila‐
is multilamellar,
consisting
mellar, of skin, of
consisting subcutaneous tissue, frontalis
skin, subcutaneous tissue, muscle,
frontalisand a thin,and
muscle, areolar layer.
a thin, Elevated
areolar as a
layer.
Elevated as a full thickness flap based on a paramedian pedicle, its supratrochlear vessels passthe
full thickness flap based on a paramedian pedicle, its supratrochlear vessels pass deeply over
periosteum at the supraorbital rim and travel vertically upward through the muscle to lie at an
almost subdermal position under the skin at the hairline. It is both a myofascial and axial flap, and
highly vascular [50] (Figure 11).
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deeply over the periosteum at the supraorbital rim and travel vertically upward through the
muscle to lie at an almost subdermal position under the skin at the hairline. It is both a
myofascial and axial flap, and highly vascular [50] (Figure 11).

Figure 11. Forehead Myocutaneous Flap
The use 11.

Figure of tissue expansion
Forehead in conjunction
Myocutaneous Flap with this flap has been an important, managing
factor for these
The use problems
of tissue (Figure
expansion 12). [51]
in conjunction with this flap has been an important, managing factor
for these problems (Figure 12). [51]

Figure
Figure12. Forehead Myocutaneous
12. Forehead Flap
Myocutaneous Flap
Temporoparietal Fasciocutaneous Flap

3.2.5.
OverTemporoparietal
the years, manyfasciocutaneous
uses have been flapfound for the well-vascularized and long-reaching pedicled
temporoparietal fascial (TPF) flap (Figure
Over the years, many uses have been found the well-vascularized and long-reaching
13).for
pedicled temporoparietal fascial (TPF) flap (Figure 13).
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Figure 13. Temporoparietal Fasciocutaneous Flap

Figure 13. Temporoparietal Fasciocutaneous Flap
It has been used for several reconstructive situations, including functional and esthetic
restoration of the extended maxillectomy; mandibulectomy; anterior skull base; oral cavity;
base ofIttongue;
has beenandused for several
pharyngeal, reconstructive
orbital, situations,
auricular, mastoid, including
scalp, functional
dura, cheek, and esthetic
lip, eyelid, and restoration
of the extended maxillectomy; mandibulectomy; anterior skull base; oral
brow deficits. It also provides excellent vascular inflow for cases of infection such as with cavity; base of tongue;
and pharyngeal, orbital, auricular, mastoid, scalp, dura, cheek, lip, eyelid,
osteoradionecrosis of the facial or mandibular bones, or coverage for carotid protection [51].
and brow deficits. It
also provides excellent vascular inflow for cases of infection such as with osteoradionecrosis of
When confronted with a head and neck defect following tumor resection or trauma, especially
the facial or mandibular bones, or coverage for carotid protection [51]. When confronted with a
in a chemoradiated field, one must call upon a hardy, reliable and flexible flap for reconstruc‐
head and neck defect following tumor resection or trauma, especially in a chemoradiated field,
tion, such as the TPF flap. Additionally, the TPF flap avoids the relatively awkward positioning
one must call upon a hardy, reliable and flexible flap for reconstruction, such as the TPF flap.
of free flaps and musculocutaneous flaps and still is richly vascular. There are several varia‐
Additionally, the TPF flap avoids the relatively awkward positioning of free flaps and
tions of the TPF flap, including the superficial temporal vessels-pedicled pericranial-galea flap,
musculocutaneous flaps and still is richly vascular. There are several variations of the TPF flap,
which including
can be used thein superficial
combination with an iliac
temporal bone graft to pericranial-galea
vessels-pedicled reconstruct the orbital
flap, floor,
whichandcan be used in
palate combination
in total maxillectomy
with an iliac bone graft to reconstruct the orbital floor, used
defects with globe preservation [51]. The TPF flap can be in
and palate in total
composite with outer-table
maxillectomy or full-thickness
defects with calvarial
globe preservation forThe
[51]. maxillectomy/
TPF flap can orbital
be usedfloor or
in composite with
mandibular deficits.
outer-table or This modification
full-thickness was originally
calvarial described orbital
for maxillectomy/ by Conley
floor[51]
or but with the deficits. This
mandibular
entire temporalis
modification muscle. This tissuedescribed
was originally also has been used as[51]
by Conley a free
butmicrovascular
with the entire flap.
temporalis muscle. This
tissue also has been used as a free microvascular flap.
3.2.6. Scalp myocutaneous flap
Scalp Myocutaneous Flap
The scalp consists of five layers: skin, subcutaneous tissue, galea aponeurotica, sub-
aponeurotic areolar tissue and pericranium. The three outer layers are closely joined, and
The scalp consists of five layers: skin, subcutaneous tissue, galea aponeurotica, subaponeurotic
function as a single entity. Skin thickness in this region ranges from 3 to 8 mm, making it
areolar tissue and pericranium. The three outer layers are closely joined, and function as a single
the thickest in the body. The adnexal tissues, nerves, lymphatics, and principal scalp vessels
entity. Skin thickness in this region ranges from 3 to 8 mm, making it the thickest in the body. The
are located in a dense layer of subcutaneous tissue underlying the skin. The paired
adnexal tissues, nerves, lymphatics, and principal scalp vessels are located in a dense layer of
occipitalis and frontalis
subcutaneous muscles
tissue are connected
underlying at theThe
the skin. vertex by theoccipitalis
paired galea aponeurotica which muscles are
and frontalis
is an elastic musculofascial layer supported by the areolar tissue in the subaponeurotic
connected at the vertex by the galea aponeurotica which is an elastic musculofascial layer
space. supported
This is byby farthe
theareolar
strongest and
tissue in most important
the sub- layer.space.
aponeurotic The primary function
This is by far the of the
strongest and most
subaponeurotic layer is to enable scalp mobility. It is comprised of loose, thin, connective
important layer. The primary function of the subaponeurotic layer is to enable scalp mobility. It is
tissue comprised
facilitating of
this movement.
loose, The pericranium
thin, connective is the innermost
tissue facilitating layer of The
this movement. the scalp.
pericranium is the
Generally, scalp flaps are elevated superficial to this layer. There are many
innermost layer of the scalp. Generally, scalp flaps are elevated superficial to this different types
layer. There are
many different types of rotation flap techniques that may be used for reconstruction of scalp
defects. The reconstructive surgeon has used rotation, sliding, and direct advancement bipedicled
flaps since the mid-twentieth century. Rotation flaps are used primarily for small defects.
Transposition flaps are used for larger defects (Figure 14).
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of rotation flap techniques that may be used for reconstruction of scalp defects. The
reconstructive surgeon has used rotation, sliding, and direct advancement bipedicled flaps
the mid-twentieth century. Rotation flaps are used primarily for small defects.
since
Transposition flaps are used for larger defects (Figure 14).
Figure 14. Scalp Myocutaneous Flap
The use of tissue expansion

14. ScalpinMyocutaneous
Figure scalp reconstruction
Flap has been an important in managing
problems (Figure 15).
The use of tissue expansion in scalp reconstruction has been an important in managing these
The use of tissue expansion in scalp reconstruction has been an
problems (Figure 15). important
problems (Figure 15).

Figure 15. Scalp
Platysmal Myocutaneous Flap Myocutaneous Flap
The platysmal Platysmal Myocutaneous

flap has been described asFlap
an axial flap used for soft tissue reconstruction
and maxillofacial surgery. It has significant advantages in reconstruction of the buccal m
after excision The platysmal
of lesions flapashassquamous
such been described as an axial the
cell carcinoma; flap flap
used isforclose
soft tissue
to there
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3.2.7. Platysmal myocutaneous flap
The platysmal flap has been described as an axial flap used for soft tissue reconstruction in
oral and maxillofacial surgery. It has significant advantages in reconstruction of the buccal
mucosa after excision of lesions such as squamous cell carcinoma; the flap is close to the site
of reconstruction, as well as being a thin and generally hairless tissue surface that is adequate
to line the buccal mucosa. Also, carcinomas of the buccal mucosa rarely require neck dissec‐
tions. In situations in which neck dissection is performed, the major vascular branch to this
flap, the submental branch of the facial artery, is likely to be sacrificed, therefore obviating the
use of this type of flap. The flap is not indicated in patients with previous irradiation, because
the small perforators supplying blood to the subdermal plexus may provide inadequate
perfusion to the flap. This type of flap is indicated for stage I and II gingival squamous cell
carcinomas that require oral lining. It can cover an exposed area of mandible where other types
of coverage, such as skin grafts, would not survive. It can be used as a bipedicle neck flap for
closure of a tight neck during bone graft reconstruction and as a random pattern flap for closure
of bone graft dehiscence. This muscle of facial expression originates from the skin just inferior
to the clavicle and inserts into the skin of the face superior to the body of the mandible. Its
motor function is supplied by cranial nerve VII (the facial nerve), and sensory innervation of
the overlying skin is by the cutaneous nerves of the cervical plexus (C2 and C3). Again, the
major artery for the pedicle is the submental branch of the facial artery. It also has a minor
pedicle that is supplied by the superficial branch of the transverse cervical artery. The overlying
skin is supplied by small perforators from these two main vessels. This is a technically easy
flap that can be harvested in the same operative field, providing a thin and pliable flap for
resurfacing deficiencies. The skin paddle is outlined by determining the size of the recipient
defect. The skin paddle is placed in the supraclavicular fossa when the site to be reconstructed
is located in the upper neck or oral cavity. Skin incisions are made over the anterior and
posterior aspects of the muscle or parallel to the midline and are carried down to the midline,
taking care to avoid cutting through the muscle. The deep aspect of the muscle is dissected
down to the investing layer of the deep cervical fascia. The flap is then undermined superfi‐
cially to the investing fascia and mobilized superiorly, where the submental branch of the facial
artery is coursing in a horizontal fashion over the submandibular gland. The dissection is
continued until adequate mobility of the flap is achieved to cover the defect [43]. Esclamado
and coworkers [52] described 12 consecutive patients undergoing reconstruction for T2 and
small T3 lesions of the oral cavity and oropharynx. They reported a flap survival rate of 92%,
whereas earlier studies had reported 80% to 85%. Their complications were related to skin
paddle loss, pharyngocutaneous fistula, and intraoral wound dehiscence, related to excessive
tension on the muscle pedicle as it was rotated to the recipient site. The apron flap is a
musculocutaneous flap incorporating the platysmal muscle. It can provide an adequate
amount of thin tissue to resurface defects involving the floor of the mouth. It is usually outlined
in the lower part of the neck. The base is frequently de-epithelialized in order to turn the flap
under the mandible and into the floor of the mouth in a one-step procedure. The donor site
can be closed primarily by undermining skin edges to achieve advancement of the adjacent
tissues of the cervical skin. This reconstruction provides a thin lining to the remaining mandible
and reconstructed floor of the mouth.
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3.3. Pedicled osteomyocutaneous flaps
In the development of mandibular reconstruction techniques, it was evident that nonvascular

bone grafting was a less reliable technique, because there was a high rate of infection secondary
to salivary contamination, and vascularity to the graft was limited by the vascularity of the
recipient bed in cases of previous irradiation. As a result, a poor success rate was obtained.
[53-60] Using vascularized bone implies the maintenance of an intact blood supply to the bone
during transplantation. This enables the donor bone to retain its original volume when
incorporated for mandibular defects. The additional blood supply also aids in resisting
infection and extrusion of the graft. The bone remains viable and does not need to be replaced
by "creeping substitution." The healing time is therefore shortened, and function is regained
earlier. An early study compared vascularized bone grafts with nonvascularized types and
concluded that free grafts undergo resorption but pedicled bone grafts have greater survival
[61-63]. Pedicled osteomyocutaneous flaps have the advantages of ease of flap harvest,
relatively short operative time, decreased resorption, improved healing, and decreased
infection rate. Their disadvantages include limited amount of bone for grafting, a variable
vascular supply, and limited maneuverability of the bone. These factors contribute to an overall
lower success rate compared with that of composite free tissue transfers, which is about 95%.
However, the latter flap designs require increased sophistication and expertise and prolonged
operative time. The following pedicled osteomyocutaneous flaps are clinically useful techni‐
ques for head and neck skeletal reconstruction.
3.3.1. Sternocleidomastoid osteomyocutaneous flap
Conley and Gullane [64] first described the SCM flap with a bone component for head and
neck repairs. It was further described by Siemssen and colleagues [65] in 1978 for reconstruc‐
tion of traumatic mandibular fractures, osteoradionecrosis, and mandibular defects following
cancer resection. Barnes and associates [66] in 1981 made further technical modifications and
cited a 3- year follow-up with no bone resorption. The SCM osteomyocutaneous flap was
recently used by Friedman and Mayer [67] for tracheal reconstruction using clavicular
periosteum with an SCM pedicle in cases of long-standing subglottic or tracheal stenosis. They
were able to conform the clavicular periosteum to that of the trachea, with resulting bone
formation to provide stability to the airway. The technique for raising an SCM osteomyocu‐
taneous flap is to use the contralateral muscle and bone for reconstruction. After tumor
resection, the clavicle is measured to obtain the desired segment to fill the mandibular defect.
The clavicle that is harvested must include its medial portion and at least two thirds of the
lateral clavicular body. Once the SCM muscle is dissected, preserving the clavicular attach‐
ments, the thyrocervical trunk, its blood supply, is identified and transected. The superior
thyroid trunk is preserved superiorly, as is the spinal accessory nerve. Once the clavicle is
released from all its attachments except for the SCM, it is rotated on the muscular pedicle across
the midline into the defect and fixated with conventional bone fixation systems. The intraoral
defect is closed primarily, the external skin flap is repositioned, and the neck is closed in a
standard layered closure. The primary problem with this type of flap is the tripartite blood
supply to the SCM muscle. The flap as described is a superior based one, which has the occipital
artery as the major supply to the superior aspect of the muscle only. Thus the skin component
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of the flap is unreliable. Other disadvantages include the exposure of the great vessels of the
neck after mobilization and a resulting contour deformity of the neck. However, the flap is a
rapid, technically easy flap to elevate for one-stage immediate reconstruction of oromandib‐
ular defects.
3.3.2. Pectoralis major-rib osteomyocutaneous flap
In 1979, the pectoralis myocutaneous flap was first introduced, and it has been modified over
the years. Cuono and Ariyan [68] first reported a case in which they used a rib graft for
mandibular reconstruction and proved its viability 3 months postoperatively. Multiple studies
have reported on the inconsistencies of this flap, with the primary limitations involving the
tenuous blood supply, which hinders manipulation and contouring of the transferred bone.
The size of the skin island is also limited, and it cannot be manipulated on the pedicle to achieve
the desired closure. Additional graft resorption occurs, as well as pectoralis muscle atrophy,
loss of cartilage, and separation of the graft from the mandible. Therefore, several other
modifications have been designed to overcome these limitations. The pectoralis osteomyocu‐
taneous flap has its dominant vascular pedicle based on the pectoral branch of the thoracoa‐
cromial artery, which is located beneath the clavicle at the midsuperior edge of the muscle.
Other vascular pedicles include that which contains the lateral thoracic artery and other
perforating arterial branches at the first through sixth intercostal spaces off the internal
mammary artery. The skin island is chosen to lie in a transverse axis over the fifth rib between
the nipple and sternum. Placement in the inframammary crease is an alternative site, especially
in female patients. The elliptic skin island is incised through skin and subcutaneous tissues to
the level of the pectoralis major muscle. The muscle is dissected from the inferior sixth, seventh,
and eighth ribs, and the dissection proceeds in a cephalad direction toward the fifth and sixth
intercostal spaces. Laterally, the pectoralis muscle is bluntly dissected off pectoralis minor
muscle to expose the vascular pedicle while maintaining the attachments to the fifth rib. The
intercostal muscles between the fifth and sixth ribs are divided, with reflection of the pleura
from the undersurface of the rib performed carefully. The rib is then sectioned at its lateral and
medial desired extent with rib cutters. This rib segment, along with its muscle attachments, is
released from the anterior chest wall, with increased mobilization of the flap gained by
dividing the humeral, sternal, and clavicular attachments. A segment of the clavicle may also
be excised to increase mobility. The flap is then transferred under the deltopectoral skin bridge.
The rib segment harvested with the skin pedicle is secured to the remaining mandibular
segment. The skin island can then be secured to the intraoral mucosa. The donor site is closed
primarily by undermining the adjacent wound margins. Advantages of this reconstructive
design include the technical ease of harvest and a versatile and durable flap that contains a
long pedicle. However, the rib segment does not provide adequate bone stock for reconstruc‐
tion, there is an increased risk of pneumothorax, and the limited vascular supply to the bone
segment may lead to long-term bone resorption and muscular atrophy.
3.3.3. Temporalis osteomuscular/ osteomusculofascial Flap
The temporalis osteomuscular flap is an option for reconstruction of maxillary and mandibular
deficiencies. Its advantageous location permits the arc of rotation of the flap to facilitate
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fixation materials, such as wires or plates. The wound is then closed in a two-layered fashion with
the appropriate use of drains (Figure 16).
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Figure 16. Temporalis Osteomuscular/ Osteomusculofascial Flap
Figure 16. Temporalis Osteomuscular/ Osteomusculofascial Flap
Free Flaps
reconstruction of the facial skeleton
Free Fasciocutaneous Flapsat all anatomic levels. [69] Conleys [70] designed an
osteomuscular
Radial Forearm flap incorporating the temporalis muscle and the underlying bone, using the
Flap
deep temporal
Originally artery and
developed its perforators
in China [73], thefor flap forearm
radial viability.flap
In 1984, McCarthy and
has developed into Zide
one of [71]the most
designed a composite flap for orbital and frontal reconstructions but encountered limited
utilized techniques for reconstruction. Initially, it was used for the correction of cervical skin
contracture in burn patients. It was then applied for reconstruction
mobility due to an anatomic obstruction by the intact zygoma and lateral orbital rim. The of total thumb defects using a
portion of the radial bone. In 1983, Soutar [74] introduced
dissection was modified to include division of the arch and removal of the coronoid process,this technique to oromandibular
reconstruction.
which Urken [75]
allowed maximal followed
mobility of the in 1989flap
muscle by re-innervating
by basing the pediclethe oral oncavity
the deep with modifications
temporal
of the flap design, using medial and lateral antebrachial
artery. The involvement of the membranous calvarial bone provides further advantages, cutaneous nerves of the forearm
anastomosed with the transected branches of the greater
including superior viability of bone (as compared with endochondral bone), greater bone
auricular nerve. This was a major
breakthrough in the restoration of sensory function in the oral cavity. The radial forearm flap with
availability, single operative field with minimal associated morbidity, and a cosmetic result.
or without incorporation of radial bone stock has many attributes that make it ideal for the
Weaknesses include the previously mentioned poor anterior mobilization, increased bulk of
reconstruction of intraoral defects. It is composed of a hairless surface that is relatively thin and
the flap, and a donor site volume defect that may affect jaw function and range of motion.
pliable and allows easy three-dimensional restoration of the oral cavity. There is flexibility in skin
Choung and colleagues
paddle design, allowing [72]
forrecently developed
the creation a bone-facial-periosteal
of independent skin islands flap, not using
to resurface muscle, defects.
intraoral
to overcome the aforementioned limitations. They successfully reconstructed
The vascular pedicle that can be obtained has a generous length and caliber, which facilitates zygomaticoor‐
bital complexes andespecially
revascularization, maxillary and mandibular
if recipient defects,
vessels are atincluding hemifacial
a distance. The rich microsomia.
vascularityThis of the flap
new design provides a long, thin pedicle that is easily
promotes rapid healing and minimizes wound-healing complications, and there is rotated into the defect, allowing
a potential for
simultaneous use of cranial
sensory reinnervation. bone.the
Finally, They
flapfound
can bea low incidence
harvested at of
thetemporal
same time volume loss and
as tumor ablation is
adverse
performed. Anatomically, the major blood supply to the flap is from the branches ofand
effects on jaw movements. The side that is ipsilateral to the defect is often chosen, the radial
the dissection
artery begins in
that course the supragaleal
along the lateralplane to expose the
intramuscular superficial
septum of thetemporal arterybetween
forearm, and the
vein. The pedicleand
brachioradialis mayflexor
be designed with themuscles.
carpi radialis use of a template,
There are such
9 tothat
17the center
septal of the pedicle
perforators that supply
isthe
overlying the vessels
deep forearm fasciawith sufficient to
superficial length to the
muscle andpedicle. The desired
the overlying skin. facial
Theisland
septalisperforators
incised and
to thedirect
the pericranium,
branches andofthetheparietotemporal
radial artery supplyfascia isthe
elevated to the
tendons oflimits of the designed bone
the brachioradialis, flexor carpi
and folded
radialis, over
and the bone.
palmaris The bone
longus is then
muscles. harvested,segments
Vascularized avoiding of thethesinuses
lateralwith bursof
cortex and
the distal
osteotomies,
radius can producing
be included full-inorthe partial-thickness
flap, based bone on a grafts. The muscle
periosteal is anchored
circulation supplied to theby direct

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zygomatic arch by the deep temporal fascia. Dividing these attachments allows anterior
mobilization of the flap. Again, the zygomatic arch may be divided, and the coronoid process
may be transected to provide maximal transposition of the flap. The muscle's arc of rotation
is thus increased, as it is isolated on its neurovascular pedicle. The flap can be used for external
reconstruction of maxillary and mandibular defects but can also be tunneled intraorally to
reach the ipsilateral canine region. The bone segment is fixed to the surrounding bone by
standard fixation materials, such as wires or plates. The wound is then closed in a two-layered
fashion with the appropriate use of drains (Figure 16).
4. Free flaps
4.1. Free fasciocutaneous flaps
4.1.1. Radial forearm flap
Originally developed in China [73], the radial forearm flap has developed into one of the most
utilized techniques for reconstruction. Initially, it was used for the correction of cervical skin
contracture in burn patients. It was then applied for reconstruction of total thumb defects using
a portion of the radial bone. In 1983, Soutar [74] introduced this technique to oromandibular
reconstruction. Urken [75] followed in 1989 by re-innervating the oral cavity with modifica‐
tions of the flap design, using medial and lateral antebrachial cutaneous nerves of the forearm
anastomosed with the transected branches of the greater auricular nerve. This was a major
breakthrough in the restoration of sensory function in the oral cavity. The radial forearm flap
with or without incorporation of radial bone stock has many attributes that make it ideal for
the reconstruction of intraoral defects. It is composed of a hairless surface that is relatively thin
and pliable and allows easy three-dimensional restoration of the oral cavity. There is flexibility
in skin paddle design, allowing for the creation of independent skin islands to resurface
intraoral defects. The vascular pedicle that can be obtained has a generous length and caliber,
which facilitates revascularization, especially if recipient vessels are at a distance. The rich
vascularity of the flap promotes rapid healing and minimizes wound-healing complications,
and there is a potential for sensory reinnervation. Finally, the flap can be harvested at the same
time as tumor ablation is performed. Anatomically, the major blood supply to the flap is from
the branches of the radial artery that course along the lateral intramuscular septum of the
forearm, between the brachioradialis and flexor carpi radialis muscles. There are 9 to 17 septal
perforators that supply the deep forearm fascia superficial to muscle and the overlying skin.
The septal perforators and the direct branches of the radial artery supply the tendons of the
brachioradialis, flexor carpi radialis, and palmaris longus muscles. Vascularized segments of
the lateral cortex of the distal radius can be included in the flap, based on a periosteal circulation
supplied by direct fascioperiosteal branches of the radial artery and musculoperiosteal vessels.
The maximal length that can be harvested is 12 cm, based on the pronator teres muscle insertion
proximally and the brachioradialis insertion distally. The sensory nerves, the medial and
lateral antebrachial cutaneous nerves, run in close proximity to the superficial veins of the
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forearm and can be incorporated by dissecting proximally to obtain adequate length to

anastomose to recipient vessels (Figure 17).
Figure 17. Forearm anatomy
The nondominant arm is usually selected for flap harvest, after documentation of adequate
palmar circulation by Allen's test. Under sterile conditions, the extremity is exsanguinated,
followed by application of a tourniquet. The skin paddle is then outlined, with its configuration
dependent on the size and shape of the defect. It is usually projected over the course of the
radial artery and one of the subcutaneous veins. The paddle is frequently outlined over the
distal radius to obtain a vascular pedicle of greatest length. A flap may also be designed to
provide a second, proximal skin island that is exteriorized in the lower neck to serve as an
external monitor of flap viability. Intervening tissue is often used to provide coverage to the
carotid vessels and augment soft tissue defects in radical neck cases. Once the distal incision
is made, the radial vessels are identified and ligated just lateral to the flexor carpi radialis
tendon. The incisions are carried through the deep muscular fascia, and flap elevation proceeds
deep to this plane and extends proximally toward the intramuscular septum of the forearm.
As the septum is approached, the septal perforators are encountered. The flap is then elevated
for the flexor muscles of the wrist, where care is taken to preserve the paratendon, as this
provides the vascularized bed for the healing of skin grafts. Once the intramuscular septum
is widely exposed, the radial vessels are elevated sharply from the groove between the flexor
carpi radialis and the brachioradialis muscles. The dissection continues proximally until the
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bifurcation of the brachial artery, which requires careful separation of the muscle bellies. At
this proximal aspect, the antebrachial cutaneous nerves are identified next to the cephalic vein.
The tourniquet is then released while the flap is still attached to its vascular pedicle, so the flap
is reperfused until ready for transfer to the donor site. If radial bone is to be used, a cuff of
muscle and periosteum is preserved along the anterior radial border in continuity with the
lateral intramuscular septum. The periosteum and muscle are carefully incised along the ulnar
border of the radius. Holes are drilled into the bone, which are subsequently joined by a fissure
bur, and the osteotomy is completed with a reciprocating saw. Only 40% of the anterior radius
can be harvested in full thickness. The bone is then lifted and segmentalized by greenstick
fractures in order to be adapted to the bony defect. Each segment is attached by a screw to a
precontoured titanium reconstruction plate [76]. The harvested fascia is then adapted to the
bony contours and sutured to provide a watertight seal. Following tissue transfer, the wound
is closed and bolstered with split-thickness skin grafts. Full-thickness skin grafts that are
defatted and taken from the abdomen provide an excellent alternative to the traditional split
thickness grafts, which are associated with complications [77]. An ulnar transposition flap may
be used to close a small residual donor defect. An ulnar immobilizing splint is then applied
for approximately 1 week. The wrist is in slight extension to eliminate dead space between the
brachioradialis and flexor carpi radialis muscles, where a hematoma may form. Radial forearm
flaps have been applied mostly to reconstruction of the oral cavity and pharyngeal defects.
They provide tissue with an independent blood supply capable of healing in a contaminated
and irradiated wound. It has been shown in many studies that an improved level of oral cavity
function occurs after skin graft reconstruction as opposed to using tongue or myocutaneous
flaps alone [78]. The radial forearm flap, without its bony counterpart, is well suited for the
reconstruction of tongue and floor of the mouth defects. A bilobed design has been used by
Urken and Biller [79] to restore shape and volume of the tongue with one lobe and to resurface
the floor of the mouth and gingiva with the second lobe. They reported that mobility, oral
alimentation, articulation, and sensory reinnervation occurred in the majority of their patients
(Figure 18).
In those cases in which tumor ablation involves segmental mandibulectomy, the radial forearm
flap with its radial bone, or in conjunction with bone stock from other sites such as iliac crest
free flap or scapular bone, achieves functional mandibular reconstruction with a sensate soft
tissue component. Nakatsuka and colleagues [80] described their experience using dual free
flap transfers combining the radial forearm flap with an osteocutaneous free bone flap. Despite
a high complication rate of 41 %, the technique is useful for obtaining good alveolar ridge
height. Circumferential defects of the hypopharynx or cervical esophagus can be restored with
the use of tubed radial forearm free flaps, allowing rehabilitation of the swallowing mecha‐
nism. Soft palatal defects can be reconstructed by using this flap design, folded over on itself
to provide lining for the oro- and nasopharynx. Utilizing the tendons, as incorporated in flap
design, allows total lip and chin reconstruction, with the palmaris longus tendon acting as a
sling to assist in maintaining the vertical height and support of the lip [81] Complications of
using the radial forearm flap include those encountered with other designs, such as flap
necrosis, delayed wound healing due to failure of the skin graft to take over the exposed flexor
tendons of the wrist, radial bone fracture, lack of sensation over the grafted donor site, vascular
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Figure 18. Radial Forearm Flap
Figure
18. Radial Forearm Flap
In those cases in which tumor ablation involves segmental mandibulectomy, the radial forearm
insufficiency of the bone,
flap with its radial hand,orstiffness or swelling
in conjunction withofbone
the wrist, reduced
stock from hand
other sitesorsuch
wrist
as length, andfree
iliac crest
sympathetic dystrophy.
flap or scapular Disfigurement
bone, achieves of the
functional forearm was
mandibular noted to be with
reconstruction acceptable in men
a sensate soft but
tissue
was not as well tolerated in women [82].
component. Nakatsuka and colleagues [80] described their experience using dual free flap
transfers combining the radial forearm flap with an osteocutaneous free bone flap. Despite a high
complication
4.1.2. rateflap
Lateral thigh of 41 %, the technique is useful for obtaining good alveolar ridge height.
Circumferential defects of the hypopharynx or cervical esophagus can be restored with the use of
tubedtype
This radial forearm
of flap was free
first flaps, allowing
described rehabilitation
by Baek [83] in 1983, of the
when swallowing
it was used mechanism. Soft palatal
for reconstruction
defects can be reconstructed by using this flap design, folded over on itself to provide lining for
of pharyngoesophageal defects, as well as for regions of skin contraction secondary to burn
the oro- and nasopharynx. Utilizing the tendons, as incorporated in flap design, allows total lip
contractures in the anterior neck. It has been described as a fasciocutaneous flap from the lower
and chin reconstruction, with the palmaris longus tendon acting as a sling to assist in maintaining
limb used primarily
the vertical for pharyngoesophageal
height and support of the lip [81] defects [84]. This flap
Complications of provides
using thearadial
more abundant
forearm flap
surface
includearea
thosethan any otherwith
encountered skinother
flap. designs,
The overlying
such asskin
flapinnecrosis,
women delayed
is frequently
wound thin, pliable,
healing due to
and hairless.
failure of theThe
skinmore
graftproximal aspect
to take over theofexposed
the flapflexor
is usedtendons
to provide bulk,
of the whereas
wrist, radial the thinner
bone fracture,
distal
lack ofaspect can be over
sensation used theto reconstruct the thin
grafted donor site,oral and pharyngeal
vascular insufficiencymucous membranes.
of the This or
hand, stiffness
isswelling
useful when
of thethere
wrist,is reduced
a subtotal lossor
hand ofwrist
the tongue
length,base
and and loss of the
sympathetic lateral pharyngeal
dystrophy. wall of
Disfigurement
the forearm
and wasThe
soft palate. noted to be acceptable
thicker portions ofinthe
menflapbutcan
wasfillnot
theastongue
well tolerated in women
defect with bulk, [82].
and the
Lateral Thigh Flap
thinner aspects can be used to reconstruct the pharyngeal wall and soft palate. In regions of
This type of flap was first described by Baek [83] in 1983, when it was used for reconstruction of
subtotal and total glossectomies, the flap can serve as a sensate fasciocutaneous flap, with the
pharyngoesophageal defects, as well as for regions of skin contraction secondary to burn
lateral femoral
contractures in cutaneous
the anteriornerve
neck.anastomosed with theas
It has been described glossopharyngeal
a fasciocutaneousorflap
lingual
fromnerves.
the lower
This flap also has a long vascular pedicle, which may lend itself to the repair of cranial
limb used primarily for pharyngoesophageal defects [84]. This flap provides a more abundant base
defects by incorporating fascia lata with the flap. The flap has also been used without its
surface area than any other skin flap. The overlying skin in women is frequently thin, pliable, skinand
hairless. The more proximal aspect of the flap is used to provide bulk, whereas the thinner distal
aspect can be used to reconstruct the thin oral and pharyngeal mucous membranes. This is useful
25

postoncologic mandibulectomy defect is unique, in that oral contamination, radiation changes,
and decreased blood supply hinder the use of nonvascularized tissues. Furthermore, rehabilitation
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of the dental arch is possible with the simultaneous use of vascularized osteocutaneous flaps and
osseointegrated implants, which results in improved postoperative masticatory function. A variety
of donor sites exist for oromandibular reconstruction, including the iliac crest, fibula, scapula,
radius, metatarsus, and rib [90]
Iliac Crest Osteocutaneous Free Flap
for a vascularized
Free facial
microvascular graft
flaps for facial augmentation,
in oromandibular as it has
reconstruction sufficient
have fatbe
proved to deposits
reliableand canface of
in the
beadverse
harvested while the patient
environmental remains[91].
conditions in theOf
supine position.
the sites thatThe lateral
have beenthigh flap offers
described, thelarge
iliac crest
vessel diameters,
composite which
free flap hasmake microvascular
distinguished itselfanastomosis
as being theeasier
most(Figure 19). and has become the
efficacious
principal reconstructive option (Figure 20).
Figure 19. The lateral thigh flap
This flap has not gained popularity largely owing to technical difficulties. However, for large
laryngopharyngectomies, it should be a first-line reconstructive choice.
4.2. Free osteomyocutaneous flaps
Primary mandibular reconstruction in patients treated with preoperative radiation therapy is

often unsuccessful, failing because of ineffective healing, lack of neovascularization, or
infection from salivary contamination. The use of vascularized free flaps has decreased the
morbidity and mortality, as well as the length of hospital stay, for patients who have undergone
oral cavity reconstruction. The use of myocutaneous vascularized flaps has been criticized,
because they result in bulky tissues in the oral cavity, which has a major adverse affect on
deglutition and articulation, and dental appliances often fail in these settings. Free vascular‐
ized bone flap transfers from distant sites have revolutionized mandibular reconstruction.
[85-89] The postoncologic mandibulectomy defect is unique, in that oral contamination,
radiation changes, and decreased blood supply hinder the use of nonvascularized tissues.
Furthermore, rehabilitation of the dental arch is possible with the simultaneous use of
vascularized osteocutaneous flaps and osseointegrated implants, which results in improved
postoperative masticatory function. A variety of donor sites exist for oromandibular recon‐
struction, including the iliac crest, fibula, scapula, radius, metatarsus, and rib [90]
4.2.1. Iliac crest osteocutaneous free flap
Free microvascular flaps in oromandibular reconstruction have proved to be reliable in the

face of adverse environmental conditions [91]. Of the sites that have been described, the iliac
crest composite free flap has distinguished itself as being the most efficacious and has become
the principal reconstructive option (Figure 20).
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Figure 20. Iliac Crest
Figure 20. Osteocutaneous
Iliac Free Flap
Crest Osteocutaneous Free Flap
The corticocancellous iliac crest yields sufficient bone for reconstruction, as well as providing
The corticocancellous iliac crest yields sufficient bone for reconstruction, as well as providin
the appropriate contour to parallel the mandible. The cancellous portion promotes rapid
appropriate contour to parallel the mandible. The cancellous portion promotes rapid he
healing, while the dense cortex maintains strength and contour and allows the use of rigid
while the dense cortex maintains strength and contour and allows the use of rigid fixation
fixation and restoration with osseointegrated implants. The soft tissue free flap provides
restoration
extensive with coverage.
soft tissue osseointegrated
With the implants. Theof soft
incorporation tissue oblique
the internal free flap provides
muscle, extensive soft
the oral
cavity can be lined, and articulation can be improved following glossectomy. Use of the iliac can be lined
coverage. With the incorporation of the internal oblique muscle, the oral cavity
articulation
crest can be
free flap allows forimproved
immediate following glossectomy.
reconstruction, thus preventingUse distortions
of the iliac in crest free flap allow
contour.
immediate reconstruction, thus preventing distortions in contour. This
This is accomplished by the use of fixation stabilization achieved before initial resection. This is accomplished by th
of fixation
approach stabilization
is also amenable to achieved
use of a dual before initial
surgical team, resection.
improvingThis approachofisharvest.
the efficiency also amenable to u
a flap
The dualcansurgical
be raised asteam, improving myo-osseous,
an osteocutaneous, the efficiency of harvest. Theflap.
or osteomyocutaneous flap can be raised a
Review
of Urken's report suggests a success rate of 96%. [29] This type of reconstructive option also report sugge
osteocutaneous, myo-osseous, or osteomyocutaneous flap. Review of Urken's
has limitations;
success rate for
of example,
96%. [29] it isThis
technically
type ofdifficult in obese patients.
reconstructive optionRemoval
also hasoflimitations;
a bicortical for example
block producesdifficult
technically significant donor site
in obese deformity
patients. and asymmetry.
Removal of a bicorticalEncroachment on the significant d
block produces
abdomen may occur,
site deformity producing
and asymmetry. weakness or hernia development.
Encroachment on the abdomenThe associated skin paddle
may occur, producing weakne
may be difficult
hernia to mobilize
development. Theand thus difficult
associated skintopaddle
orient and mayposition. The bulky
be difficult bony mass
to mobilize and thus diffic
often requires
orient and secondary
position. Therevision to improve
bulky or create
bony mass oftenideal contours.
requires Postoperative
secondary sequelae
revision to improve or c
include
ideal injury to the Postoperative
contours. lateral femoral cutaneous
sequelae and ilioinguinal
include injurynerves, which
to the can produce
lateral femoral cutaneous
ilioinguinal nerves, which can produce unpleasant dysesthesia and/or anesthesia. A numb
refinements have taken place over the years to prevent some of these adverse postope
sequelae. The split inner cortex iliac crest microsurgical free flap preserves the outer cort
anchor the abdominal wall musculature and fascia and produces a firm, dependable clo
preventing abdominal wall weakness and subsequent hernia formation. The advantag
liberating a single cortex are that it is technically easier, takes less time to harvest, reduces
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unpleasant dysesthesia and/or anesthesia. A number of refinements have taken place over the
years to prevent some of these adverse postoperative sequelae. The split inner cortex iliac crest
microsurgical free flap preserves the outer cortex to anchor the abdominal wall musculature
and fascia and produces a firm, dependable closure, preventing abdominal wall weakness and
subsequent hernia formation. The advantages of liberating a single cortex are that it is
technically easier, takes less time to harvest, reduces blood loss, and decreases the incidence
of hematoma or seroma formation. Of course, the amount of harvested bone is limited and less
reliable for contouring osteotomies, internal fixation, and osseointegration. However, the
breadth of the single cortex is comparable to that of the intact mandible. The iliac bone is
perfused by a number of vessels, including the deep, lateral, and superficial circumflex iliac
arteries; the superficial inferior epigastric artery; and the superior deep branch of the superior
gluteal artery. The osteomyocutaneous flap is based on the deep iliac artery as the principal
blood supply, with accompanying perforators to augment perfusion to the overlying skin.

Figure 21. Iliac Crest Osteocutaneous Free Flap
Figure 21. Iliac Crest Osteocutaneous Free Flap
Incorporation of the internal oblique muscle flap provides a source of oral lining to aid in the
reconstruction of compound deficiencies. Durable internal fixation of free vascularized bone
grafts is accomplished with reconstructive plating systems (e.g., THORP, AO). Placement of the
plates before initial resection maintains contour and eliminates the need for intermaxillary or
external fixation (Figure 22).
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Figure
Figure22. 22.
Iliac Iliac
Crest Crest
Osteocutaneous Free Flap
Osteocutaneous Free Flap
The deep circumflex iliac artery originates from the external iliac just proximal to the inguinal
ligament andFlap
Fibula Free courses toward the iliac spine in a plane deep to the transverse fascia and parallel
toAmong the freeligament.
the inguinal flap donor
In sites
this used
path, for
it ismandibular
crossed byreconstruction, the and
the ilioinguinal fibula is becoming
lateral femoral a
popular choice
cutaneous (Figures
nerves. 23). [92] begins with a skin incision parallel to the inguinal ligament
The dissection
in the direction of the anterior superior iliac spine. A vertical incision over the major femoral
vessels is made approximately 5 cm in length, forming a final inverted-L--shaped incision. The
deep circumflex vessels are identified and dissected to their origin. Care is taken to identify
the ascending branch of the deep circumflex artery, which takes off from the parent artery 1
cm before the anterior iliac spine. It is important to preserve this vasculature, as it is the major
supplier to the internal oblique muscle. If required, a skin paddle can be excised over the crest.
The skin, subcutaneous tissues, and fascia are elevated as one unit, with an adjoining 2.5- cm
protective cuff of muscle. The skin flap is then undermined to the superior border of the crest,
where the periosteum is divided in the midline of the crest. With adequate elevation of the
periosteum in the medial and lateral dimensions, the two cortices can be osteotomized with a
sagittal saw. The internal oblique muscle flap can then be fashioned, with the iliacus muscle
divided and dissected to a level below the deep circumflex artery. The medial cortical plate
can then be accessed for the osteotomy. The shape of the reconstructed mandible is dependent
on the sites of the osteotomy. The vascular pedicle follows behind the newly designed

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mandibular angle with a length sufficient to reach the external carotid system, where anasto‐
moses of the donor vessels will take place. The donor site is closed in layers, where the residual
internal oblique muscle is reapproximated with the residual periosteum, and the external
oblique muscle is anchored to the outer cortex of the iliac crest. Drains are frequently used in
the wound site and covered with fascia and skin. This donor site provides a long vascular
pedicle that can be fashioned to fit the defect precisely (Figure 21).
Incorporation of the internal oblique muscle flap provides a source of oral lining to aid in the
reconstruction of compound deficiencies. Durable internal fixation of free vascularized bone
grafts is accomplished with reconstructive plating systems (e.g., THORP, AO). Placement of
the plates before initial resection maintains contour and eliminates the need for intermaxillary
or external fixation (Figure 22).
4.2.2. Fibula free flap
Among the free flap donor sites used for mandibular reconstruction, the fibula is becoming a
popular choice (Figures 23). [92]
Figure 23. Fibula anatomy
It provides enough bone stock, with up to 25 cm of bone, and can maintain a consistent shape
throughout its length for shaping a mandibular defect. Its blood supply courses along with it,
in parallel, guaranteeing adequate vascularity to the osteotomized segments. The muscle
segment also parallels the bony segment, enabling the soft tissue defect to be filled in ade‐
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quately. It provides a rigid, strong, tubular-shaped cortical bone similar to the anatomic
structure of the mandible, and it is easily contoured without compromising vascularity [93].
Simultaneous reconstruction, both internally and externally, can be reliably performed with
an associated skin island based on the septocutaneous blood supply. Finally, the graft site is
located distally enough so that two teams can work simultaneously. Most anterior mandibular
reconstructions, where defects can exceed 12 cm and where external skin or floor of the mouth
defects mandate replacement, are accomplished primarily with fibula free flaps. Other
indications include hemimandibular defects with adjacent lateral floor of the mouth or buccal
mucosa loss. Carroll and Esclamado recently suggested the use of preoperative angiography
in all patients undergoing reconstructions using fibular osteocutaneous flaps [94]. They found
that subclinical and marked atherosclerotic disease may be detected in patients with clinically
benign lower extremity examinations, and that aberrant arterial anatomy exists in 5% to 7% of
the population. However, a dominant peroneal artery occurs in a very small number of patients
in a population, and an angiogram is not justified. Moreover, a diseased peroneal artery can
be safely used for microvascular anastomoses. But if the peroneal artery must be used in the
free flap transfer, adequate foot runoffs must be present. Primary reconstruction provides the
optimal setting for obtaining the best surgical result. Graft shaping is easily accomplished
when the resected segment is directly visualized. In secondary reconstruction, distortion of
the anatomy, secondary to soft tissue contracture, makes the reconstruction a "mystery." Before
tumor ablation, miniplates are easily contoured to the existing mandible. They provide a high
degree of precision, without the bulk of AO reconstruction plates. When planning on which
donor leg to use, the ipsilateral fibula is generally used [95]. When the same side is used, the
flexor hallucis longus muscle lies under the fibula to aid in filling in the soft tissue defect. The
skin island can then be easily rotated up and over the fibula to reach the oral cavity and
reconstruct a mucosal defect. The skin island is designed to run along the length of the fibula
to preserve all its septal blood supply. The long axis is centered over the fibula's posterior
border, such that the septal blood supply is captured. The width of the island is approximately
4 cm on average, which usually allows primary closure of the donor site (Figure 24).
A larger skin island requires some type of skin graft closure. Dissection begins from a lateral
approach, with the skin incised anteriorly. The lateral compartment, separated from the
anterior by the intramuscular septum, is divided, and muscles from both groups are divided,
with the use of electrocautery to gain hemostasis. A cleft posteriorly between the soleus and
flexor hallucis muscles is created by blunt dissection, and the soleus is separated with elec‐
trocautery from the fibula (Figure 25).
Osteotomies are performed at the proximal neck of the fibula and at a distal site 4 to 6 cm
proximal to the lateral malleolus. The peroneal vessels and the flexor hallucis longus muscle
are divided distally. At the distal site, traction on the bone outward exposes the posterior
tibialis muscle and its median raphae; the former is then divided along the latter in a distal to
proximal direction. The peroneal and tibial vessels are usually safe as long as the muscle is
divided along the raphae. The recipient vessels are dissected in preparation for a microvascular
transfer. The facial artery and external carotid artery are used most frequently, and the superior
thyroid artery is used as an alternative. However, the external jugular vein is generally
and over the fibula to reach the oral cavity and reconstruct a mucosal defect. The skin isl
designed to run along the length www.dentalbooks.co
of the fibula to preserve all its septal blood supply. The lon
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Figure 24. Free fibula flap
A larger skin island requires some type of skin graft closure. Dissection begins from a
preferred, because it is more superficial and has an ideal diameter for anastomosis. In general,
approach, with the skin incised anteriorly. The lateral compartment, separated from the a
to prevent lengthy ischemia times, the fibula is shaped as much as possible before the pedicle
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and over the mandible into the oral cavity. The flexus hallucis longus muscle can be used to
fill in the submental soft tissue loss. Postoperatively, graft monitoring can be difficult unless
intraoral reconstruction was done. The intraoral skin island can be followed for any color or
capillary refill change. The peroneal artery patency can be followed with Doppler examination.
The successful grafts can then be recipients for osseointegrated implants to complete the
functional reconstruction. Wells [96] stated that the fibula flap is more technically difficult to
elevate but is an excellent reconstructive modality, because it provides superior bone stock for
mandibular reconstruction. Another disadvantage is insufficient height to restore the mandi‐
ble, but this has been corrected with the use of a double fibula graft (i.e., the double barreled
flap). Sensibility can be restored using this neurocutaneous fibular free flap by repairing the
lateral cutaneous nerve of the calf to the lingual nerve. A vascularized jump graft can be
accomplished by using the sural communicating nerve to bridge the inferior alveolar nerve
defect [97]. There has been ongoing controversy regarding the reliability of the skin island

associated with the fibular osteocutaneous flap in mandibular reconstruction. Jones and

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coworkers [98] recently addressed this topic by studying a new flap design in 60 cadavers.
They found that a major perforator through the soleus muscle or flexor hallucis muscle can
provide perfusion to the skin flap, without the need to incorporate portions of the muscle. The
reliability of the skin island is based on the design's more distal location (that is, it is placed
more distally over the distal third of the lower leg); preoperative identification of the perfo‐
rators with Doppler mapping so as not to sacrifice them during dissection; and protection of
the septocutaneous perforators that traverse the posterior periosteum when performing wedge
osteotomies of the fibula. Violations of this design may be responsible for the poor outcomes
previously reported regarding the reliability of the fibular osteocutaneous flap for mandibular
reconstruction (Figure 26).

Osteotomies are performed at the proximal neck of the fibula and at a distal site 4 to 6 cm
proximal to the lateral malleolus. The peroneal vessels and the flexor hallucis longus muscle are
divided distally. At the distal site, traction on the bone outward exposes the posterior tibialis
muscle and its median raphae; the former is then divided along the latter in a distal to proximal
direction. The peroneal and tibial vessels are usually safe as long as the muscle is divided along
the raphae. The recipient vessels are dissected in preparation for a microvascular transfer. The
facial artery and external carotid artery are used most frequently, and the superior thyroid artery is
used as an alternative. However, the external jugular vein is generally preferred, because it is
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Figure 26. Free fibula flap reconstruction
Figure 26. Free fibula flap reconstruction
Other Free Flaps in Head and Neck Reconstruction

4.3. Linked
Other free flaps
Free in head and neck reconstruction
Flaps
The goal of reconstructive surgery is to replace bone and soft tissue in a manner such that
4.3.1. Linked free
functional andflaps
aesthetic problems are minimized. For this reason, a large number of pedicled
myo-osteocutaneous flaps and free tissue transfers have been developed. Patients who have
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myo-osteocutaneous flaps and free tissue transfers have been developed. Patients who have
35

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http://dx.doi.org/10.5772/59746
undergone previous surgery and radiation develop poor recipient beds. In these cases,
vascularized bone has become a viable treatment option. In cases in which complex soft tissue
and bony defects have resulted from tumor extirpation, multiple head and neck surgical
operations, and past irradiation, limited recipient vascularity requires reconstructive modal‐
ities other than a single osteocutaneous flap. Because of their limitations, linking of free flaps
has become a preferred method of reconstruction for complex composite head and neck
defects. The use of sequentially linked free flaps is best suited to cases of composite defects
that cannot be adequately restored by a single flap, large through-and-through head and neck
defects, limited native vasculature from either previous surgical excisions or preoperative
radiation, lack of availability of local or regional flaps, and defects that require both adequate
bony stock and a thin mucosal lining for intraoral coverage. [99-117]
Wells and coworkers [118] described their technique for using the radial forearm flap in
conjunction with a free fibular transfer. Similar experiences were shared by Camilleri and
associates [119] reporting survival rates of 98%. Elevation of the flaps occurred simultaneously
and independently of each other, as described earlier. The peroneal vessels and vein from the
contoured fibular flap and the radial artery vessels and cephalic vein were anastomosed in an
end-to-end fashion, respectively. The long pedicle of the forearm flap allowed for primary
anastomosis of the linked flaps without the use of intervening vein grafts. The radial artery
was then anastomosed end to end to a branch of the external carotid artery, and the cephalic
vein was anastomosed to the external or internal jugular vein in an end-to-end configuration.
This technique is advantageous because there is no ideal osteocutaneous free flap that provides
both an unlimited amount of bone and a reliable cutaneous component. The fibula provides
ample bone stock to reconstruct the entire mandible, and the forearm furnishes a thin, reliable,
hairless sensate flap for intraoral lining. The potential disadvantage is the risk of proximal
thrombosis, which results in the loss of two free tissue transfers. Also, extra operative time is
involved in the microvascular reconstruction. However, if the two donor sites are appropri‐
ately spaced, the use of two surgical teams may reduce operative time. Penfold and colleagues
[120] described the combination serratus anterior-rib flap with the latissimus dorsi myocuta‐
neous flap for mandibular reconstruction. Their technique accesses both flaps through a single
skin incision placed along the anterior border of the latissimus muscle. After elevating this
muscle, the lower part of the serratus anterior muscle is exposed. A segment of rib (either sixth
or seventh in this location) with its associated periosteum and a cuff of muscle above and below
is elevated on the serratus muscle pedicle. The superior part of the latissimus dorsi muscle is
then divided, and the combined flap is transferred on a common pedicle of the thoracodorsal
vessels. The donor site is closed primarily. The vascular anastomosis can then be performed
in an end-to-side fashion to the external carotid artery and vein, or to the facial artery and vein.
The amount of tissue provided by the latissimus dorsi muscle flap for transfer is ideal for
reconstructing large mandibular defects, which are often associated with extensive soft tissue
losses involving the floor of the mouth. The disadvantages of using such a combined flap
include those associated with serratus-rib composite flaps, such as insufficient bony stock to
allow for placement of osseointegrated implants. Even though bulky tissue is required for
reconstructing extensive soft tissue defects, the combined flap may provide excessive tissue
bulk in the neck, resulting in poor cosmesis. Another variation in flap design is the combined
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V-shaped scapular osteocutaneous and latissimus dorsi myocutaneous flap, used for primary
or secondary reconstruction of the mandible, intraoral mucosa, and external skin. The design,
reported by Yamamoto and coworkers [121], is based on the vascular network including the
angular branch from the thoracodorsal artery, the dorsal scapular artery, the circumflex
scapular artery arising from the subscapular artery, and the suprascapular artery. They
reported seven cases in which this reconstructive option was employed, citing six successful
cases. The fact that this combined flap is nourished by the angular branch allows the graft to
have an independent long arc of rotation. The V shape of the grafted bone has a reliable blood
supply from the vascular network. Combining this bone graft with a myocutaneous compo‐
nent, the latissimus dorsi flap, allows the reconstruction of large soft tissue losses in the oral
floor or submandibular region. The latissimus dorsi muscle may also restore tongue volume
when large tongue defects coexist. As already mentioned, the main disadvantage of using the
latissimus dorsi flap in conjunction with a scapular bone flap is the necessity of patient
repositioning for flap harvest. Thus, the operation is usually prolonged. Also, the quality of
bone retrieved from the scapula is not adequate to accept dental reconstructive implants,
unless the lateral border or inferior angle of the scapula is obtained.
5. Site specific reconstruction problems
5.1. Mandibular reconstruction
Mandibular reconstructive procedures have conventionally consisted of bone graft replacing

the resected defect. Historically, Macewen [122] discussed the reconstruction of defects using
a tibia harvested graft. Blocker and Stout [123] described the use of iliac crest in the mandible.
Development of other donor sites was sought, with disappointing results. Metallic cribs and
mesh trays to contain the grafts were designed but were suboptimal for primary reconstruc‐
tion. Furthermore, in patients who had been irradiated or who presented with extensive soft
tissue defects, successful reconstruction was difficult to achieve, as there was a greater chance
of postoperative infection due to diminished blood circulation, ingress of oral flora, and an
absent blood supply to the grafted bone. One technique that would provide increased
resistance to infection was to use pedicled grafts. Conley [124] and Snyder [125] published the
first case reports using osteomyocutaneous flaps in the immediate reconstructive setting.
Numerous other flaps followed, with minimal reliability and poor success rates. They were
subsequently considered unacceptable for primary mandibular reconstruction. Because the
defect site is plagued with soft tissue loss, oral contamination, and compromised irradiated
tissues, free vascularized grafts were thought to be the ideal choice. McKee [126] and Daniel
[127] were the first to report the outcomes of free vascularized composite rib flaps in a large
series of patients. Success rates have increased for microvascular free tissue transfers using
iliac crest and scapular free flaps, reaching 96% [128]. With the recent development of rigid
fixation systems, reconstruction of the mandible with a combination of metallic plate and
pedicled osteomyocutaneous flap or microvascular free tissue transfer has been advocated.
Essentially, reconstruction of the mandible with bone grafting must be dimensionally and
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structurally stable, capable of withstanding the functional demands of prosthesis. The graft
must be able to maintain a correct arch form and continuity, with significant bone height and
osseous bulk for full prosthetic rehabilitation and an acceptable facial form. The primary goals
of mandibular reconstruction are to achieve primary wound closure and to achieve adequate
range of motion with a stabilized, repetitive occlusion, dependent on the maintenance of
physiologic condylar position. Bony reconstruction is of importance when acceptable facial
aesthetics are required. If a defect in the anterior symphysis or chin region were not addressed,
an "Andy Gump" deformity would result, with posterior and inferior collapse. Lateral defects
stabilize jaw symmetry and contour. Functionally, masticatory difficulties result from poor
bony reconstructive efforts. Inadequately repaired regions result in jaw deviation and inability
to fabricate an acceptable prosthesis. Soft tissue attachments to the mandible are also affected
(i.e., lip, floor of the mouth, tongue, hyoid musculature). Thus, poor restoration of a mandib‐
ular defect results in oral incompetence and difficulties with speech, mastication, and swal‐
lowing functions. Bony mandibular defects are classified by the amount of hard tissue loss
specific to an anatomic region. For example, class I mandibular defects involve the alveolus,
but with preservation of mandibular continuity; class II defects involve loss of continuity distal
to the canine; class III involves loss up to the mandibular midline region; class IV deficiencies
involve the lateral aspect of the mandible but are augmented to maintain pseudoarticulation
of bone and soft tissue in the region of the ascending ramus; class V involves the symphysis
and parasymphyseal regions only, augmented to preserve bilateral temporomandibular
articulations; class VI is similar to class V, except that mandibular continuity is not restored.
Similar functional deficits can occur with inadequate soft tissue reconstruction. For example,
inadequate mucosal replacement can create restricted tongue mobility and insufficient space
for dental reconstruction.
5.2. Reconstruction of symphysis, condyle, and ramus
Symphyseal mandibular defects resulting from cancer ablation continue to be a surgical

problem. Many techniques using autologous bone grafts, osteomyocutaneous regional and
free flaps, and alloplastic and allogeneic materials have been described in the literature, with
variable results. As in all reconstructive surgical cases, the primary goals are restoration of
function and cosmesis. Recently, distraction osteogenesis has been used in mandibular
reconstruction. In essence, a vascularized bony segment is stretched, or distracted, across a
defect, inducing new bone formation from the native bone. This process has been well
described in the orthopedic surgical literature for the reconstruction of long bones in lower
extremities. Bony defects of the symphysis create a great cosmetic and functional problem.
Annino and associates [129] created iatrogenic mandibular symphyseal defects in the canine
model and reported great success with the use of a trifocal distraction osteogenetic appliance.
Mandibular body segmental defects were also reconstructed by distraction osteogenesis, and
biomechanical testing revealed the newly generated bone to have approximately 77% the
strength of the native bone. Owing to the complexity of applying this device, it is not recom‐
mended for the reconstruction of mandibular condylar or ramus regions.
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5.3. Reconstruction plates
The AO stainless steel plate has been available for many years as an effective means of
mandibular replacement. Mignogna and colleagues [130] commented on their experiences
using the AO reconstruction plate with a sternal osteomyocutaneous flap in primary mandib‐
ular reconstruction. They replicated the mandible with a malleable pattern before excision and
transferred its shape to an AO reconstruction plate, which was then positioned to the unre‐
sected portions of the mandible with drilled pilot holes. Once resection takes place, the
pectoralis myocutaneous flap is harvested, and the sternum is split to the size of the defect.
The osteocutaneous flap is placed at the defect site, and the AO plate is rigidly fixed into
position using noncompression screws. Closure of the myocutaneous portion of the flap is
carried out meticulously to prevent oral contamination. Mignogna and colleagues believe that
the increased operative time, high failure rate, frequent need for operative rescue, and need
for specialized training, care, and facilities make reconstruction with vascularized free flaps
an impractical option for reconstructive surgeons. In the titanium hollow screw system
(THORP), hollow screws integrate at the surface level and permit ingrowth of bone that locks
each screw in place. Before resection, the plate is bent and shaped to the existing contours of
the mandible [131]. The resected mandible may also serve as a template for plate bending and
hole drilling. The plate is generally contoured to the inferior border of the mandible to avoid
tooth roots, maintain facial contour, leave space for osseointegration, and keep it well away
from the oral mucosa to lessen the chance of intraoral exposure. Metallic fatigue and plate
exposure are some of the complications that require removal and replacement. Intraoral
exposures are frequently associated with granulation tissue that heals in the immediate
postoperative period. Nonetheless, it remains an excellent method of fixing a vascularized
bone graft.[132] The plates, in general, provided better cosmetic results than autogenous bone
grafting, because there is greater flexibility in contouring a metal plate as opposed to a linear
bone strut. Alloplastic metallic plates provided a more rapid postoperative oral rehabilitation
and have become a viable reconstructive option. Cordeiro and Hidalgo [133] studied the effects
of soft tissue coverage for titanium reconstructive plating systems. They compared patients
who received pectoralis major flaps with those who received soft tissue-free flaps. Forty-four
percent of the patients with pectoralis flaps had extrusion of the hardware, requiring its
subsequent removal. They commented that the excessive tension placed on the flap, from the
shoulder-based pedicle; create this high risk of failure. Moreover, despite the increased
operative time to acquire free tissue for transfer, as well as the complexity of its harvest; free
flap patients had shorter hospital stays, higher overall success rates, and fewer additional
procedures. Their data suggest that a free flap provides more reliable soft tissue coverage of
reconstruction plates than does a pectoralis flap.
Recently, Blackwell and colleagues [134] looked at the outcomes of using various soft tissue
free flaps in conjunction with mandibular reconstruction plates. Even though the added
morbidity associated with harvesting free vascularized bone grafts is higher than that for
harvesting soft tissue alone, they found a high rate of delayed failure (40%) using metallic
reconstruction plates and soft tissue. Thus, they advocate the practice of using vascularized
bone-containing free flaps or a combination of free flaps for patients who are undergoing
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primary reconstruction of lateral mandibulectomy defects. Kudo and associates [135] evalu‐
ated the use of various mandibular reconstructive techniques. They commented on the
excellent long-term results when using AO-type reconstruction plates, citing successful
reconstruction lasting over 10 years, provided sufficient soft tissues exist. When there is a lack
of soft tissue, avoidance of plate exposure is best handled by using a myocutaneous flap.
Immediate reconstruction of the posterior region of the mandible was most appropriately
treated with a metallic plate or a myocutaneous flap and bone graft. Anterior mandibular
regions that were immediately reconstructed with autogenous bone grafts resulted in post‐
operative infection. The authors recommended delayed bone grafting after immediate fixation
using a metallic plate to bridge the mandibular defect. An extensive defect of the anterior
region requires immediate reconstruction with a myocutaneous flap and bone graft.
5.4. Reconstruction of maxillary and midfacial defects
Tumors of the midface account for a small subset of head and neck cancers. Malignancies of
the paranasal sinuses make up 0.2% of the total number of malignancies and 3% of all cancers
in the aerodigestive tract. Tumors of the palate are uncommon, representing 8% of all oral
cancers and 5% of all aerodigestive carcinomas. The goal in treatment and reconstruction of
these cancers is extirpation in toto and cure of the patient with restoration of aesthetic form
and function [136]. In many situations, the surgical resection results in a significant functional
loss, causing feeding and speech developmental problems with oral-antral communication
and velopharyngeal incompetence. Loss of the orbital floor and Lockwood's ligament may
result in the loss of orbital support, with ensuing exophthalmoses and orbital dystopia.
Reconstructive options are determined primarily by the extent of the midfacial skin deficit, the
extent of maxillary buttress resection, the size of the palatal defect, and the loss of orbital
support (Figure 27).
Type I defects are those with loss of midfacial skin of the cheeks and lips only. The underlying
bony skeleton is not affected. These cutaneous defects can be restored with standard soft tissue
reconstructive techniques, from simple primary closure in areas of lax surrounding soft tissue
to skin grafts and use of cervicofacial flaps. Larger tissue deficits require regional or distant
flaps, such as, latissimus dorsi, temporalis, or forehead flaps. Larger aesthetic units may
require resurfacing with free tissue transfers.
Type II and III defects result from partial maxillectomy procedures in which the palate is
complete or a portion of the palate is lost, respectively. Traditionally, these midfacial defects
are satisfactorily restored by fabrication of a maxillofacial prosthesis in which the denture and
palatal obturator close the oral antral fistula and provide projection of the midface. The only
requirement for success is that there is an adequate residual palatal arch with enough sur‐
rounding soft tissues to support the prosthesis. The impression is taken of the defect well after
swelling has subsided, approximately 3 to 4 weeks. The silicone prosthesis constructed from
the impression is custom made and attached by previously inserted integrated fixtures and
abutments. Other patients may benefit from reconstruction with autogenous tissues, with the
use of ipsilateral or bilateral temporal muscle flaps or facial artery musculomucosal flaps,
which are often used to reconstruct small oroantral fistulae and palatal defects.
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Figure 27. Maxillary tumor reconstruction
Type IV defects that result after total maxillectomy with a concomitant palatectomy are best
served by reconstruction with autogenous tissue via regional or distant flaps. The aforemen‐
tioned pedicled flaps and free tissue transfers are all indicated to redrape defects in the middle
third of the face. The bony component is addressed with vascularized bone with its cutaneous
counterparts, or bone combined with separate free soft tissue flaps used as linked flaps. For
example, by combining the bony reconstruction with scapular and parascapular paddles,
massive defects of the midface can be reconstructed with primary closure of the donor site. In
this case, the muscular portion of the transfer can be used to obliterate the dead space of the
maxillary sinus defect, and the cutaneous aspect can be used to resurface the face and palate.
Type V defects are type IV defects that extend into the orbital floor. Tumors that require
exenteration of the orbit should be followed by reconstructive procedures that obliterate the
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orbital cavity and restore facial contour. Orbital support procedures, described by Ilankovan
and Jackson [137], include split-thickness vascularized calvarial bone pedicled on either the
temporalis or the superficial temporalis muscle to reconstruct the orbital floor. A temporo‐
parietal facial flap has been used for orbital and eyelid reconstruction. Free transfer flaps are
advocated for this reconstructive challenge, as there are no limitations with
rotation and the goals of maintaining facial structural stability and contour are upheld. Sadove
and Powell [138] described a one-stage reconstruction of the subtotal maxillectomy and
hemimandibulectomy with a free fibular osteocutaneous flap. After harvesting a vascularized
fibular bone flap, multiple osteotomies allow the surgeon to shape the bone and simultane‐
ously apply the segments to the maxilla and mandible. The technique applied was taken from
Jones and colleagues [139]. In their "double-barreled" bone graft, transverse osteotomies
produce two vascularized bone struts that can be folded parallel to each other and connected
by the periosteum and muscle cuff pedicle. Here, three bone struts were employed; the distal
end of the fibula was rigidly fixed to the small remaining portion of the maxilla, and a
transverse osteotomy allowed a 90-degree turn of the segment. A second osteotomy was then
performed to allow fixation to the remaining zygomatic fragment, and all osteotomies were
rigidly fixated with miniplates and screws. A third osteotomy in the remaining third portion
of the harvested fibula allowed removal of a 3- cm segment, which would account for the
distance between the maxilla and mandible. The remaining vascularized bony segment was
then rotated and used to bridge the mandibular bony defect, and rigid fixation was similarly
applied. The accompanying peroneal vessels were anastomosed end to side with a radial
artery, from a radial artery forearm flap. The combination of radial forearm and fibular
fasciocutaneous flaps offers excellent versatility to meet the extreme three-dimensional
demands of reconstruction of massive injuries to the face.
5.5. Lip reconstruction
The overall survival rate for carcinomas involving the lip has increased over the past 30 years
to 85% to 90%. Because regional spread is uncommon in the behavior of lip cancers, recon‐
struction after tumor ablation becomes paramount in these patients. Most neoplastic processes
occur in the lower lip, and almost all lesions are epidermoid or squamous cell carcinomas.
Upper lip malignancies are almost exclusively basal cell cancers. The primary function of the
lip is oral competence, along with its role in speech, deglutition, and beauty. The competence
is provided by the sphincter muscles, the orbicularis oris muscle, and a number of elevator
and depressor muscles. Its primary blood supply is from the superior and inferior labial
arteries, which are direct branches of the facial artery. When performing lip reconstruction,
one must attempt to retain the sphincter muscle function, obtain a watertight oral seal, and
allow sufficient opening for daily dietary habits. In defects of 30% to 65%, upper lip tissue may
be transferred by a pedicle flap based on the labial artery [140]. The oral commissure is
preserved when using this in conjunction with the Abbe technique or when the flap is rotated
around the commissure using the Eastlander method. The flap on the upper lip is designed
with the medial incision on the philtrum ridge to allow closure of the donor site on this natural
landmark. The largest flap that can be designed is approximately 2 cm, and one fourth of the
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upper lip can be excised and closed primarily. The Karapandzic technique also uses lip tissue
by advancing and rotating segments of skin, orbicularis muscle, and mucosa. However, the
principal disadvantage is the creation of microsomia. Local flaps are preferable to regional
flaps for closing defects of less than two thirds of the lip width because of their skin color and
texture match and the availability of mucous membrane for internal lining. Defects greater
than two thirds of the entire lip are best reconstructed using adjacent cheek flaps. Large defects
of the upper lip may be reconstructed by excising crescent-shaped peri-alar cheek tissue and
advancing the flaps medially. For larger defects, between 65% and 80%, the cheek tissue can
be advanced as in the Webster-Bernard approach. This technique, however, has led to the
development of chronic tension, resulting in a poorly functioning lower lip. Karapandzic lip
rotation has been used, without inevitable microstomia. This approach requires dissection of
the remaining lower lip segment, the modiolus bilaterally, and the lateral upper lip tissue, and
then advancement of these components to reconstruct the lower lip deficiency. Defects greater
than 80% to 85% have been reconstructed with inferiorly based nasolabial flaps. Massive
defects of the lip, chin, and mandible are reconstructed with the use of distant flaps, transfer‐
ring composite flaps of skin and bone revascularized by microvascular techniques. The radial
forearm flap, incorporating the plantaris tendon, provides excellent support to the circumoral
structures (Figure 28).

Figure 28. Total reconstruction of the lower lip
Figure 28. Total reconstruction of the lower lip
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This has yet to be demonstrated clinically. The temporal forehead flap can be used for total upper
lip reconstruction, but a secondary cosmetic deformity precludes its common use. More recently,
the pectoralis major myocutaneous flap has been used for lip reconstruction; it has the advantage
of being an axial myocutaneous flap that may be elevated as a strip of muscle, and a portion of the
flap may be turned on itself to provide tissue for the inner aspect of the lips or anterior floor of the
mouth [141]. The development of microvascular techniques has allowed reconstruction of
concomitant defects of the lip, chin, and anterior mandible by transferring free composite
osteomyocutaneous flaps, providing vascularized bone grafts for mandibular reconstruction.
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extended muscle pedicle including the cervical branch of the facial nerve would greatly
improve its motor function. This has yet to be demonstrated clinically. The temporal forehead
flap can be used for total upper lip reconstruction, but a secondary cosmetic deformity
precludes its common use. More recently, the pectoralis major myocutaneous flap has been
used for lip reconstruction; it has the advantage of being an axial myocutaneous flap that may
be elevated as a strip of muscle, and a portion of the flap may be turned on itself to provide
tissue for the inner aspect of the lips or anterior floor of the mouth [141]. The development of
microvascular techniques has allowed reconstruction of concomitant defects of the lip, chin,
and anterior mandible by transferring free composite osteomyocutaneous flaps, providing
vascularized bone grafts for mandibular reconstruction.
5.6. Tongue reconstruction
Reconstruction of hemiglossectomy requires a thin-tissue flap. Many flaps have been advocat‐
ed for this purpose. The forearm flap is easily retrieved, but the donor site must receive skin
grafting coverage. Because this is an area of daily exposure, its appearance may not be well
tolerated by patients. The forehead flap is also easy to harvest, but one of the complications is
facial nerve palsy from damage to the temporal branch of the facial nerve. In order to restore
the tongue's sensation, a neurovascular radial forearm flap and lateral arm flap could potential‐
ly fulfill a sensory function if anastomosed to the lingual or inferior alveolar nerve (Figure 29).

Figure 29. Tongue reconstruction
Figure 29. Tongue reconstruction
The dorsalis pedis flap has recently received attention, as it is thinner than the lateral forearm
The dorsalis
flap. The donor pedis
site is well flap and
covered, has its
recently received
distal location attention,
allows as it is harvest
simultaneous thinnerand
than
the lateral
The donor site is well covered, and its distal location allows simultaneous harvest
The only functional disturbances are related to slight sensory alterations, which have
to improve over time. No motor deficits or impairments have been reported. Initially,
angiography was recommended, but a Doppler flowmeter is able to detect dorsalis
patency. The largest skin island that can be obtained is approximately 9 by 8 cm
designed to include the dorsalis pedis artery and the first metatarsal dorsal artery. Dis
is elevated and the dorsalis pedis artery is located laterally to medially. The exte
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ablation. The only functional disturbances are related to slight sensory alterations, which have
been shown to improve over time. No motor deficits or impairments have been reported.
Initially, preoperative angiography was recommended, but a Doppler flowmeter is able to
detect dorsalis pedis artery patency. The largest skin island that can be obtained is approxi‐
mately 9 by 8 cm. The flap is designed to include the dorsalis pedis artery and the first
metatarsal dorsal artery. Distally, the flap is elevated and the dorsalis pedis artery is located
laterally to medially. The extensor hallucis brevis tendon should be cut because it crosses the
first metatarsal artery. If a long pedicle is desired, the inferior extensor retinaculum is incised
to elevate the tibialis anterior artery and dorsalis pedis artery. The donor site is then covered
by a split-thickness skin graft [142].
5.7. Nasal reconstruction
The most common causes of nasal defects are wide surgical excisions of nasal tumors, fol‐
lowed by trauma and infection. Most nasal skin tumors are basal cell carcinomas, with squamous
cell carcinomas accounting for up to 50% of all aggressive tumors. Frequently, treatment of these
neoplastic processes requires hemirhinectomy or total rhinectomy to achieve cure. Historical‐
ly, the use of a nasal prosthesis attached to spectacles was cosmetically acceptable but could be
troublesome and lead to patient noncompliance. In fact, more patients have opted for immedi‐
ate reconstruction [143]. The principles of nasal reconstruction are to replace the lost mucosal
lining, reconstruct the skeletal framework, and achieve adequate external skin coverage. The
mucosal lining is best replaced by folding full thickness adjacent nasal skin or by using nasolabial
flaps or a fold-down median forehead flap (the Kazanjian flap) (Figure 30). [144]

Figure
Figure30. Nasal reconstruction
30. Nasal using tissue expansion
reconstruction using tissue expansion
The
Theskeletal
skeletalframework
framework provides
providessupport to prevent
support sagging
to prevent of overlying
sagging tissues,
of overlying whichwhich
tissues, can can lead
lead to nasal stenosis and a poor cosmetic result. The framework can be made
to nasal stenosis and a poor cosmetic result. The framework can be made by advancing the by advancing
the remainingseptal
remaining septalcartilage
cartilage or
orusing
usinga composite
a compositeconchal graft, cartilage
conchal xenograft,
graft, cartilage Silastic Silastic
xenograft,
prosthesis,
prosthesis, or cantilever bone graft, which is usually a strut of rib bone graft fixedbase
or cantilever bone graft, which is usually a strut of rib bone graft fixed at its at its base to
to thenasal
the nasalor
or frontal
frontal bones
bonesbybyosteosynthesis
osteosynthesis wires or plates.
wires The problem
or plates. arises when
The problem arisestrying
when trying to
match color and texture to replace the external skin covering. This has led to the development of
many types of flap designs, including median forehead flaps, based on the supraorbital and
supratrochlear vessels, and the scalping forehead flap, which resembles the nasal skin in color and
texture and is based on the superficial temporal artery. Primary closure of these forehead flaps can
be accomplished with the use of tissue expanders. This, however, requires multiple staged
procedures, which may affect patient willingness. The retroauriculotemporal flap, or Washio flap
[145], is based on the anastomosis between the posterior branches of the superficial temporal and
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to match color and texture to replace the external skin covering. This has led to the development
of many types of flap designs, including median forehead flaps, based on the supraorbital and
supratrochlear vessels, and the scalping forehead flap, which resembles the nasal skin in color
and texture and is based on the superficial temporal artery. Primary closure of these forehead
flaps can be accomplished with the use of tissue expanders. This, however, requires multiple
staged procedures, which may affect patient willingness. The retroauriculotemporal flap, or
Washio flap [145], is based on the anastomosis between the posterior branches of the superficial
temporal and retroauricular vessels. Its advantage is that the donor site is hidden and com‐
posite skin and conchal cartilage are available. Distant pedicled flaps from the arm or neck
have been used but require prolonged periods of immobilization and often have poor cosmetic
results. Free microvascular tissue transfer can also provide tissue coverage, as well as bony
support (Figure 31).

Figure 31. Free flap nasal reconstruction
Figure 31. Free flap nasal reconstruction
For example, in the dorsalis pedis osteocutaneous flap, skin is taken from the dorsum of the
For example, in the dorsalis pedis osteocutaneous flap, skin is taken from the dorsum o
foot, associated with a vascularized bone graft from the second metatarsal bone.
associated with a vascularized bone graft from the second metatarsal bone.
Reconstruction of the Buccal Mucosa

Cancers occurring in the buccal mucosa account for only 10% of all oral cavity carcinom
is a higher distribution in the southeastern United States, where "snuff dipping" is a
practice. These lesions tend to occur along the occlusal plane or just below it, and
mandible more than the maxilla. These types of lesions are readily treated with surgic
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5.8. Reconstruction of the buccal mucosa
Cancers occurring in the buccal mucosa account for only 10% of all oral cavity carcinomas.
There is a higher distribution in the southeastern United States, where "snuff dipping" is a
common practice. These lesions tend to occur along the occlusal plane or just below it, and
affect the mandible more than the maxilla. These types of lesions are readily treated with
surgical ablative surgery, followed by reconstructive efforts to restore the defect. Smaller
lesions can be successfully treated with local and buccal flaps. When larger defects are left from
surgical excision of larger tumors, more substantial flap designs are required. The buccal cavity
allows for expansion of the oral cavity during opening and chewing. Limitation in this region
affects jaw function and vestibular loss. Because the buccal mucosa requires a thin, soft, pliable
flap for its reconstruction [146], a deltopectoral flap is an ideal choice. It is, however, a two-
stage procedure that gives a significantly better result than simple myocutaneous flaps. A thin
flap reconstruction can also be achieved with a microvascular free tissue transfer of jejunum
used as a patch graft, or with a radial forearm flap. Large full-thickness defects have historically
been reconstructed using forehead flaps, temporalis muscle flaps, or pectoralis, latissimus, or
trapezius muscle flaps [147]. The operative combination of lower lip splitting incisions and
composite anterior oromandibular reconstruction creates a predisposition to increased lip
and labial sulcus deformities related to abnormal wound healing, which is commonly caused
by extensive anterior floor of the mouth and oral lining defects combined with partial skin
paddle necrosis, inadequate intraoral lining replacement, closure under excess tension, over
projection of mandible reconstruction, and improper draping of the soft tissues of the chin to
the reconstructed mandible. The lower lip deformity is called a reverse whistling deformity
[148]. It is a vertically short lip with central notching associated with oral incontinence and an
inadequate lower labial sulcus. To repair this cosmetically displeasing complication, the scar
contractures are released with excisions, and vertical musculomucosal turnover flaps are
combined with bilateral lip advancement to improve the deficient lip height and labial sulcus.
The blood supply to these flaps is based on inferior labial artery and submental artery
distributions, which are branches of the facial artery.
5.9. Craniofacial reconstruction
Large resections during cranial surgery produce severe disfigurement and emotional anguish,
with significant functional impairment for the patient. After surgical management of skull-
based malignancies, the reconstructive surgeon is faced with the extensive task of not only
restoring the anatomic defects but also preventing potentially life-threatening complications,
such as ascending meningitis from the close proximity of the paranasal sinuses and nasophar‐
ynx to the dura. Reconstructions may be immediate or delayed. Although immediate recon‐
struction after extensive resection of aggressive or recurrent tumors has been recommended,
it is not routinely practiced, because extensive immediate reconstruction may lead to delayed
detection of early recurrence. Also, the ideal reconstructive option, which is usually the first
major reconstruction, would be sacrificed. The two indications for immediate reconstruction
are to prevent ascending infection from an open nasopharynx or to close the frontal sinus, and
to prevent exposure of brain and/or bone. Historically, many cranial base defects were treated
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with the use of local flaps through a "patch" design. Myocutaneous flaps were then developed,
with the pectoralis major and latissimus dorsi flaps becoming the most widely employed.
Finally came the advent of free tissue transfer for larger defects requiring well-vascularized
tissue with bulk, not restricted by pedicles. As experience with free flap harvest has been
gained, complication rates have dropped. The correct selection and application of these
reconstructive methods require that the surgeon appreciate the capabilities of each technique.
Often a combination of techniques is required for optimal reconstruction. The most common
combination is an internal fixation device and a bone graft. In the reconstruction of cranio-
orbital defects, the following goals are addressed: achieve a tight dural seal to isolate the
intracranial contents from the aerodigestive tract, obliterate dead spaces in the sinuses to
remove potential sources of infection, suspend and support neural structures, provide bone
and soft tissue coverage, maintain function, and achieve optimal cosmetic result [149]. The
likelihood of recurrence of the disease and its concealment by the reconstruction has been a
major deterrent to midface reconstruction. Calvarial grafts, having a membranous bony quality
with delayed resorption, are excellent replacements for the orbital floor and nasal dorsum.
Stability is maintained with rigid fixation. When combined with the temporoparietal fascia, a
calvarial graft provides an excellent source of vascularized tissue for enhancing soft tissue
reconstruction to the orbit and maxilla. However, because it is based on a pedicle, its arc of
rotation limits its flexibility. Free tissue transfer using microvascular anastomosis has allevi‐
ated this problem. The scapula, radial forearm, and dorsalis pedis osteocutaneous flaps all
have fairly long pedicles and can carry both skin and bone reliably. The deep circumflex iliac
artery flap has a short pedicle, thick skin, and little mobility, making it more difficult to
maneuver. A modification of the scapular flap using the angular artery, which supplies the
entire lateral border of the scapula, can increase the pedicle from 4 to 9 cm to 13 to 18 cm; this
allows the skin and bone to have much longer, independent arcs of rotation, so that they can
be used in different parts of the reconstruction, such as skin for the palate and lateral nasal
wall and bone for the infraorbital rim, with the two segments supplied by the same subscapular
pedicle [150]. Preoperative planning for osseous reconstruction begins with a careful and
thorough history and physical examination. Radiographic imaging with standard cephalo‐
metric radiographs and CT with three dimensional reconstructive images are very useful.
Reconstructions of the cranial base are divided by their anatomic designs. Classifications by
Jones and Jacksons have been widely used to integrate the anatomic boundaries with tumor
growth patterns in different regions. Region I corresponds to defects extending from the
anterior midline to the posterior wall of the orbital cavity, but including an extension down
the clivus to the foramen magnum. This region houses tumors from the maxilla, maxillary
antrum, parotid gland, and midfacial skin. Initially, reconstruction was aimed at covering the
exposed dura with the use of nonvascularized split-thickness skin grafts, such as tensor fascia
lata grafts. Failures would occur in 50% of the cases in which dural leaks of cerebrospinal fluid
occurred [151]. Thus, covering the defect with a vascularized tissue seemed appropriate.
Forehead flaps, glabella flaps, pericranial flaps, and galea flaps have all been advocated.
Defects of the anterior cranial fossa can be covered by using a laterally positioned temporalis
muscle flap. Myocutaneous flaps have also been used and provide a number of distinct
advantages. They are well vascularized, provide additional bulk that aids in eliminating dead
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space, and provide acceptable soft tissue contouring and aesthetic results. The pectoralis major
flap is used to reach the orbital region, but it must be exteriorized to reach this site, thus adding
a second operation. The latissimus dorsi muscle flap can access the orbit without a subsequent
exteriorization procedure, but the patient must be repositioned for its harvest. A trapezius flap
is also available, but its use must be carefully assessed in a previously irradiated patient or one
in whom a radical neck dissection was performed. Again, this technique requires repositioning
of the patient. In larger defects, free tissue transfer provides a well-vascularized, bulky tissue,
without the restrictions of a pedicle. The most frequently used is the rectus abdominis free
flap; simultaneous ablation of the tumor and flap harvest by two surgical teams reduces
operative time and patient mortality. Region II defects essentially include the boundaries of
the middle cranial fossa. It comprises the infratemporal and pterygomaxillary fossae and the
overlying segment of the skull base. Tumors of this area include basal and squamous cell
carcinoma of the external ear and scalp, invasive parotid tumors, and tumors of the middle
ear. Access to the middle cranial vault is primarily through an infratemporal approach but
may also be combined with a mandibulotomy, lateral mandibulotomy, anterior mandibulot‐
omy with swing, or anterior displacement of the mandible. Also, via a hemicoronal incision,
a transtemporal approach can provide access to the tumor. The location and the size of the
defect dictate which reconstructive option is used. Historically, large scalp rotation flaps [152]
and deltopectoral flaps have provided adequate restoration. Smaller defects can be repaired
with temporalis muscle flaps. However, when larger defects may be inadequately treated with
these local flaps-that is, when communications between the nasopharynx and dura persists-
free flaps become the procedure of choice, specifically, the rectus abdominis free flap.
Region III includes the posterior segment of the middle cranial fossa, as well as the entire
posterior section. The most common tumors encountered here are glomus tumors and
schwannomas. Through a transtemporal approach, tumors are readily excised, and small
defects can be closed with local flaps such as temporalis, deltoid, and sternocleidomastoid.
Larger defects are more definitively reconstructed with latissimus dorsi flaps or the rectus
abdominis free flap. Eye socket reconstruction requires not only a mucosal lining but also
supportive tissue to mimic the tarsus. Traditionally, full- or split-thickness skin grafts without
any supportive tissue failed owing to severe contracture formation. Millard [153] in 1962 used
a composite nasal cartilage-mucosa graft. In 1985, Siegel [154] discussed the use of the palatal
mucosa for reconstruction of the eyelid. The palatal mucosa is thick and rigid tissue that has
been used for the reconstruction of the lip, gingiva, nasal vestibular lining, and tracheal wall
defects. The "socket plasty" described by Yoshimura and coworkers [155] uses a palatal mucosa
graft to maintain the dimensions of the socket to accept an orbital prosthesis. The palatal
mucosa is sutured to deepen the fornix and keep the maximal dimensions of the graft for at
least 10 to 14 days. An artificial eye or Silastic rubber ball is inserted to maintain the newly
formed socket during the initial healing period. The donor site usually heals unremarkably,
with little patient discomfort. Orbital floor defects have been treated with many materials,
including autografts, allografts, xenografts, and alloplasts. The ideal material is fresh autoge‐
nous bone, but this requires a second surgical procedure. Harvested auricular cartilage
provides an excellent source of autogenous tissue for repairing orbital floor defects. This fresh
cartilage maintains adequate structure and volume many years after transplantation [156] In
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fact, less resorption occurs if the perichondrium is left intact. Two approaches to auricular
harvesting have been described: patients susceptible to keloid formation benefit from a
posterior approach, and others undergo the anterior approach. The anterior approach involves
a semicircular incision made through skin and perichondrium within the edge of the concha
bowl to hide the scar. The skin-perichondrial flap is elevated anteriorly with blunt dissection
to expose the graft conchal cartilage. Once the desired amount is excised with its associated
perichondrium, the donor site can be closed with single-layer closure. The graft can then be
sculpted to its desired shape, thus allowing it to be custom fitted. The posterior approach uses
a posterior auricular incision to expose the posteromedial aspect of the concha. Using blunt
dissection with a Freer elevator, the cartilage is accessed and excised from its native site. The
auricular wound is closed in a similar fashion as that described for the anterior approach. Both
techniques require a pressure dressing to prevent hematoma formation. This procedure is
quick, is in the same location as the recipient site, and has minimal associated morbidity [157].
Shestak [158] described the reconstruction of combined midfacial and palatal defects with the
use of a latissimus dorsi musculocutaneous free flap with separate skin paddles to reconstruct
multiple tissue surfaces. After tumor excision, the recipient vessels of free flap are selected in
the ipsilateral neck. The latissimus dorsi flap is harvested in a standard fashion, with the
proximal end of the inscribed skin paddle designed at least 5 cm below the tip of the scapula
to allow an ample length of the thoracodorsal artery and vein. The palatal inset is performed
first using everting horizontal mattress sutures to obtain a watertight seal. An area of the skin
is then de-epithelialized to accept remnants of facial skin and lip segments. The vascular
pedicle is passed through a tunnel to the recipient vessels in the neck. Revascularization occurs
by microvascular anastomosis. Because of the latissimus dorsi's accessibility, pedicle length,
reliability of skin paddles, and ample available tissue, this flap is a viable treatment option for
soft tissue reconstruction of complex craniofacial defects. Shestak reported 12 reconstructions
using the same technique with satisfactory functional and aesthetic outcomes.
6. Implants in reconstruction
After extensive ablation of maxillofacial tumors, reconstruction of the head and neck region is
attempted to restore the external cosmetic and functional deficits. However, masticatory
function continues to be a problem in the rehabilitation of these patients. Without dental
implants, the area of reconstruction does not allow placement of a dental prosthesis. Implants
eliminate the requirement for adjacent natural soft tissue support for the prosthesis. Endo‐
sseous implants placed in bone grafts have been shown to stimulate bone growth and minimize
its resorption. Therefore, when one reconstructive option is chosen over another, not only the
quantity but also the quality of the bone that will ultimately receive endosseous implants
should be a consideration [20]. Implants can be placed after a reconstruction has been per‐
formed or at the time of immediate reconstruction [159] Stoler and Hill [160] were the first to
report a case in which oromandibular reconstruction was performed for a patient who had
undergone ablative surgery for fibrous dysplasia using a combination of both free cranial and
microvascular iliac crest grafts, as well as osseointegrated implants placed in vitro and then
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grafted onto the reconstructed mandible. The advantages of immediate placement are the ease
of access and ability to avoid any adjacent alloplastic materials, such as bone plates and screws.
One possible problem associated with immediate placement is improper position of the
implant. A delayed placement has the advantage of providing better control for placement in
the correct position. However, disadvantages of the delayed technique are the necessity for a
secondary surgical procedure, the need to deal with abnormal intraoral soft tissues, and the
need to be aware of the position of the vascular pedicle as it relates to the reconstructed
mandible [161]. Moscoso and associates [162] analyzed the effect of osseointegration in various
donor sites for vascularized bone used for oromandibular reconstruction. The results of the
study confirmed that the iliac crest is the most uniform implantable source of vascularized
bone for the reception of osseointegrated implants. This was followed by scapula, fibula, and
radius. They also pointed out some gender differences. Male fibulas were statistically equiv‐
alent to the iliac crest in terms of implantability. In females, however, only one third of proximal
scapulas and 50% of proximal to midfibulas would allow implant placement. The long-term
stability of a successfully osseointegrated implant is dependent on implant dimension, the
structural integrity of the bone to withstand functional loading, and allowances for loss of
marginal bone height [163] In cases in which the iliac crest is not accessible owing to previous
bone grafting attempts or disruption of vascular anatomy from previous groin vascular
surgery, or when the excessive tissue bulk associated with the osteomyocutaneous iliac flap is
not desired, an alternative is to use osseointegrated implants in free vascularized radial bone
grafts. The radial bone graft provides the ideal mucosal replacement tissue from the associated
forearm skin paddle. Radial bone was previously reported as being too thin to accept implants.
Mounsey and Boyd [164] reported their experiences using implants placed in vascularized
radial bone flaps.
They showed that for small, straight, bony defects, the radius is a good alternative. In larger
defects, the contoured iliac crest is a better option. However, the radial bone may be osteo‐
tomized to attempt to create the desired mandibular contour. They reported excellent results
following implant placement in small- to moderate-size lateral defects, as well as small anterior
or anterolateral defects. Further reports using radial bone and dental implants were made by
Martin and colleagues [165], with similar success. They do not advocate one-stage reconstruc‐
tion and primary implant placement because of the possibility of jeopardizing its periosteal
blood supply. The microvascular free fibular transfer is an excellent option for reconstruction
of large mandibular defects. Its bicortical nature mimics that of the native mandible and seems
to be ideal for inserting implants as primary stabilization is achieved [166]. However, dental
restoration with traditional removable oral appliances has failed owing to diminished denture-
bearing regions as tongue dysfunction. Zlotolow and associates [167] studied the use of the
fibular free flap with osseointegrated implants. They reported seven successful cases and
concluded that with microvascular bony reconstruction with osseointegrated implants, the
quality of life is greatly enhanced by bringing the patient closer to the predisease state.
In 1994, Donovan and coworkers [168] described a new technique combining calvarial onlay
bone grafts with osseointegrated implants-more specifically, the Branemark system. The use
of such membranous grafts stemmed from previous reports stating that less resorption is seen
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with membranous bone grafts, compared with endochondral onlay grafts [169]. After har‐
vesting the outer cortical table of calvarial-parietal bone in strips, two grafting techniques are
used. The vertical technique is used primarily in the atrophic maxilla, and the graft is secured
to the lateral aspect of the remaining maxillary bone or alveolar processes with a rigid screw
system. This is followed by a period of healing, approximately 6 to 8 months, before definitive
placement of dental implants. They reported an 86% success rate with this onlay procedure,
attributing possible failures to varying degrees of soft tissue ingrowth, as well as the cortical
strip of bone being further away from its source of blood supply. The horizontal technique,
which enjoyed a 98% success rate, places the calvarial bony strips in a horizontal fashion in
the anterior maxillary region, where the nasal spine is separated from its most inferior bony
attachment. The cortical struts are then placed in a horizontal fashion superiorly at the level
of the nasal floor as well as inferiorly, augmenting the height of the maxillary ridge. The
"sandwiched" maxilla is then stabilized with its grafts with the placement of osseointegrated
implants from one canine eminence to the other. These implants, in contrast to those used in
the vertical technique, have bicortical stabilization and are placed close together to aid in stress
load distribution. These success rates are comparable to those seen when reconstructing the
anterior mandible. All patients were restored with implant-supported prostheses, resulting in
good function, a stable prosthesis, lack of donor site morbidity, early ambulation, and a short
hospital stay.
6.1. Maxillofacial prosthodontics
The demand for maxillofacial prosthodontic devices for the rehabilitation of patients with
postsurgical defects has intensified in recent years. The extensive surgical procedures neces‐
sary to eradicate cancer of the head and neck often leave extremely large physical defects that
may not be amenable to surgical reconstruction. The prosthodontist can provide surgical
stents, radiation carriers and shields, intraoral cone stents, palatal augmentation prostheses
for glossectomy patients, and immediate transitional and definitive prostheses, as well as
extraoral prostheses to replace ears, nose, and facial defects. Thus, the maxillofacial prostho‐
dontist must have knowledge of the disease, etiology, diagnosis, treatment, and rehabilitation
in order to be a member of the team that is responsible for enhancing the patient's quality of
life [170]. Prosthetic and prosthodontic appliances are required for realignment and fixation
of mandibular fragments in adequate dental occlusal relationships with the teeth of the
opposing jaw; as obturators for the occlusion of defects of the palatal region; for the mainte‐
nance of facial form and contour so as to prevent contracture of the tissues during the healing
period; as a temporary or transitional modality before or during surgical treatment; and for
the restoration of facial features, such as the nose, auricle, or orbital region [171]. The maxillary
defects that result from ablative cancer surgery vary in complexity, but prosthetic rehabilita‐
tion may provide a functional and aesthetic result. The purpose of the obturator prosthesis is
to re-establish the normal contour of the oral cavity to allow normal speech and swallowing.
The size of the defect determines the size of the obturator, or bulb portion that closes the
surgical defect. The loss of this supporting tissue can be offset by gaining retention from the
peripheral tissues. The maturity of the defect also determines how the obturator is tolerated.
The more mature the defect, the more readily it is tolerated. A skin graft can provide a firm
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tissue base that resists abrasion and reduces mucus secretion, minimizing poor hygienic
environments. The opposing mandibular ridge is important to the stability of the obturator.
Prosthetic rehabilitation of the maxillectomy patient is performed in three phases. Stage one
starts with the placement of the surgical packing and surgical obturator, which is retained for
5 to 7 days by screw or wire fixation. This helps re-establish oral contours and allows the patient
to start a liquid diet almost immediately postoperatively, bypassing the need for nasogastric
feeding. In the second stage, the surgical obturator is removed and modified with a tissue
conditioner. As the obturator is modified, the patient learns how to swallow less forcefully,
and leakage around the prosthesis decreases. The third stage can be anywhere from 3 months
to over a year after maxillectomy, when the definitive obturator prosthesis is fabricated [172].
In maxillectomy patients, osseointegrated implants may be placed in the residual alveolar
ridge or horizontal palate. An edentulous maxillectomy defect has the poorest prognosis for
accepting an obturator. It is impossible to achieve retention of a complete maxillary denture.
Thus, endosseous implants may aid in retention, stability, and support of the obturator
prosthesis; a bar and clip, magnet, and ball-0-ring gasket-type keeper are widely used in these
situations. The bar and clip assembly provides the obturator prosthesis with improved stability
and retention. For patients with significant extraoral tissue loss, the facial prosthesis also has
limitations related to retention and stability. The extraoral application of implants has been a
significant advance in maxillofacial prosthetics (Figure 32).

Figure
Figure 32. Orbit prosthesis 32. Orbit prosthesis
For example, implants placed in the

For example, mastoid placed
implants bone or in
the the
temporal bones
mastoid alloworanthe
bone auricular
temporal bones a
implant to be fixated via bar splinting. A nasal prosthesis can use a similar retention technique
implant to be fixated via bar splinting. A nasal prosthesis can use a similar reten
and have its fixtures placed
have its infixtures
the floorplaced
of the nose. Andfloor
in the in situations
of theinnose.
which And
tumorin ablation
situations in whic
included the orbit,included
implants can be placed in the supraorbital rim region [173]. As with intraoral
the orbit, implants can be placed in the supraorbital rim region [173]
dental implants, extraoral sites require
dental implants, proper hygiene
extraoral practices
sites require to ensure
proper tissuepractices
hygiene health. to ensure tissue
Pediatric Reconstruction
Mandibular reconstruction and rehabilitation in a 7-year-old with osteosarco
reported by Richardson and Cawood [174]. They made every effort to maint
matrix so as not to disturb the normal growth processes of the face. After tum
partial mandibulectomy, immediate reconstruction with a titanium mesh tra
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7. Pediatric reconstruction
Mandibular reconstruction and rehabilitation in a 7-year-old with osteosarcoma were recently

reported by Richardson and Cawood [174]. They made every effort to maintain the functional
matrix so as not to disturb the normal growth processes of the face. After tumor ablation with
a partial mandibulectomy, immediate reconstruction with a titanium mesh tray was performed
without bone graft. This technique allowed the tray to function as a space maintainer. When
the patient approached the onset of puberty, the tray was removed and a composite circumflex
iliac crest free flap was used to restore the continuity and soft tissue deficiencies. Microvascular
anastomosis of the donor and recipient sites was used. Two years later, osseointegrated
implants were placed, with a subsequent vestibuloplasty with a split-thickness skin graft. They
concluded that the multidisciplinary approach to the care of this patient, along with the
introduction of revascularized free tissue transfer with osseointegrated implants, revolution‐
ized the reconstruction of pediatric orofacial defects following extensive tissue losses.
8. Postoperative evaluation
The postoperative care and management of complications require an understanding of osseous

wound healing and the potential causes of failure. Loss of skeletal stability as a result of loss
of fixation allows for motion at the wound interface, with secondary impairment of vascula‐
rization. Early recognition of flap compromise is associated with improved chances of flap
salvage. The ideal flap monitoring technique should be reliable, reproducible, easily inter‐
pretable, inexpensive, noninvasive, rapidly responsive to changes in microcirculation, and
able to provide continuous monitoring in the immediate postreconstructive period. The
clinical examination should focus on capillary refill time (>3 seconds is the cutoff), which
provides information on the adequacy of the arterial supply. Early venous outflow obstruction
results in capillary refill that is too brisk. The color of a flap can also provide information about
arterial insufficiency. A pale flap signifies poor flap perfusion, whereas one with outflow
obstruction is congested and hyperemic. Skin temperature can assess the adequacy of circu‐
lation in digits but is of little use when applied to flaps for reconstruction, as changes in ambient
temperature affect the measured surface temperature readings. The most invasive monitoring
method is blood flow from the flap. Flow of oxygenated blood, from a needle puncture,
indicates good perfusion, whereas dark red blood or sluggish flow is a prognostic indicator.
Buried flaps, or flaps used for pharyngoesophageal reconstruction, require some other form
of monitoring technique, because direct visualization is not possible. Flexible fiberoptic
telescopes have been used, but this method cannot be performed on a continual basis. To
visualize a segment of jejunum used for pharyngeal reconstruction, a sheet of silicone rubber
(Silastic) is placed over the segment of jejunum and the skin is left open to provide a "window"
to allow a direct view of the jejunum. A flap can be designed with a segment externalized so
that the surgeon can readily visualize it. The cutaneous part can often be partially externalized
and incorporated in the wound closure to serve as an indicator of graft survival; this also
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decreases wound tension. Tissue that is unnecessary for reconstruction and is supplied by the
vascular pedicle can be externalized and observed for impairment of blood supply.
There are a number of adjunctive monitoring devices that can be used to assess the adequacy
of tissue perfusion. An electromagnetic flowmeter determines the absolute blood flow in a
vessel by electromagnetic induction and allows immediate and continuous readings to see
slow or rapid changes. The ultrasonic Doppler flowmeter has been in clinical use for more than
30 years and is useful if one is certain that the flow signal heard is from the vascular pedicle.
Arterial thermometry is a system that measures temperature difference across a vascular
anastomosis with implanted thermocouple probes. Fluorescein has been used to identify flaps
with inadequate perfusion; when injected intravenously, it diffuses out to the capillaries into
the interstitial fluid. The staining can then be visualized under ultraviolet illumination. The
more intense the staining, the better the perfusion, and vice versa. The dermofluorometer
enables the clinician to quantify minute degrees of fluorescence and uses smaller doses of the
drug to prevent allergic reactions. Radioisotope washout of xenon 133, sodium pertechnetate
Tc99m, iodine 131, and sodium 24 has been used to indicate the adequacy of perfusion; after
administration of an isotope, clearance from the flap is monitored and correlated with flap
perfusion (i.e., greater clearance equals greater flap perfusion). Pulse oximetery can detect
pulsatile blood flow until the artery is 95% occluded. Laser-Doppler velocimetry is currently
the best tool for objective monitoring of flaps. It must be in place when the flap is known to
have good perfusion, because changes in this initial value are the important parameter. The
laser-Doppler velocimeter can provide an accurate, easily interpretable readout of tissue
perfusion that is rapidly responsive to changes in perfusion. Duplex Doppler ultrasonography
is capable of identifying and characterizing blood flow from small, superficially located
vessels, similar to those involved with microvascular surgery. Different shades of gray are
assigned to stationary areas, whereas color is assigned to areas of motion such as blood flowing
within a vessel. Vessels as small as 1 mm in diameter can be identified. Transcutaneous oxygen
monitoring is also an option, where Po2 is measured directly to assess the state of microcir‐
culation. Finally, changes in interstitial fluid hydrostatic pressures can reflect changes in blood
flow [175]. Radiologic literature on bone graft evaluation is sparse. Follow-up assessment of
skeletal reconstruction with plain radiographs and cephalometric studies in the immediate
postoperative period is needed to document the position of bone segments and the location of
hardware. However, data on the evaluation of primary bone tumors and bone allografts stress
the role of plain film radiography. In 1992, Soderholm and colleague [176] studied the
effectiveness of using plain film radiography in the follow-up and prognosis of non-vascular
bone grafting used in mandibular reconstruction. They concluded that narrow-beam radiog‐
raphy and spiral tomography are excellent tools for the evaluation of bone resorption and bony
healing of mandibular grafts. Panoramic radiographs are able to visualize the whole mandib‐
ular bone and are used for a general assessment; tomography is used for specified, selected
diagnostic tasks, such as to visualize bone resorption within the graft and under the plate.
After reconstruction of large defects in the oral cavity or the oropharynx with myocutaneous
or free microvascular flaps, physical rehabilitation by a therapist trained in speech and
swallowing is of paramount importance, as these reconstructive procedures cannot fully
restore the patient's ability to masticate, swallow, or speak. The major aims of physical therapy
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http://dx.doi.org/10.5772/59746
are to decrease the amount of facial deformity and to limit the loss of oral opening. Oral opening
exercises are initiated as soon as the patient can tolerate them. Stretching exercises three to
four times a day are adequate home regimens. A specialized therapist may use the Therabite
mouth opener (Therabite Co., Bryn Mawr, PA) to improve maximal opening. Also, those
patients who have had neck dissections require physical therapy for shoulder pain and
trapezius weakness. Range-of-motion exercises are necessary to prevent frozen shoulder and
worsening pain.
Author details
Ata Garajei1,2,3*, Ali Arabkheradmand2, Mohammad Hosein Kalantar Motamedi4,5,

Alex E. Pazoki6 and Ashkan Rashad7
*Address all correspondence to: atagarajei@tums.ac.ir
1 Department of Oral and Maxillofacial Surgery, School of Dentistry, The Cancer Institute,
Tehran
2 Department of Head and Neck Surgical Oncology and Reconstructive Surgery, The Cancer
Institute, Tehran, Iran
3 Craniomaxillofacial Research Center, Tehran University of Medical Sciences, Tehran, Iran
4 Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
5 Department of Oral and Maxillofacial Surgery, Azad University of Medical Sciences, Den‐
tal College, Tehran, Iran
6 Department of Oral and Maxillofacial Surgery, Johns Hopkins University, Baltimore, USA
7 Department of Oral and Maxillofacial Surgery, Bremerhaven Hospital (Reinkenheide);

Bremerhaven, Germany
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teocutaneous and latissimus dorsi myocutaneous flap for composite mandibular re‐
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[126] Macewen W: The Growth of Bone. Glasgow, J Mackhose, 1912.
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[130] McKee K: Microvascular bone transplantation. Clin Plast Surg 1978;5:283.
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[132] Urken ML: Composite free flaps in oromandibular reconstruction: Review of the lit‐
erature. Arch Otolaryngol Head Neck Surg 1991;117:724.
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mandibular symphyseal defects. Arch Otolaryngol Head Neck Surg 1994;120:911.
[134] Mignogna FV, Rankow R, Garay KF: A-0 reconstruction plate and sternal osteomyo‐
cutaneous flap in primary mandibular reconstruction. Am J Surg 1993;166:416.
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omandibular reconstruction. Clin Plast Surg 1994;21:69.
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tanium hollow screw reconstruction plate: Evaluation of 51 cases. Plast Reconstr Surg
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[137] Cordeiro PG, Hidalgo DA: Soft tissue coverage of mandibular reconstruction plates.
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soft-tissue free flaps and plates. Arch Otolaryngol Head Neck Surg 1996;122:672.
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following resection of malignant tumors of the oral region. J Oral Maxillofac Surg
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one free osteocutaneous flap. Plast Reconstr Surg 1993; 92:141.
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1983;1:61.
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salis pedis flap. Acta Otolaryngol Suppl 1996;525:30.
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Surg 1972;50:160.
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Surg 1995;22:91.
[152] Wagner JD, Ress A, Coleman JJ: Repair of midline vertical lower lip deficiency after
mandible reconstruction. Am J Surg 1996;172:625.
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1995;22:71.
[154] Coleman JJ: Osseous reconstruction of the midface and orbits. Clin Plast Surg
1994;21:113.
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sections for tumors of the paranasal sinuses. Am J Surg 1966;112:591.
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[157] Millard DR Jr: Congenital nasal tip retrusion and three little composite ear grafts.
Case report. Plast Reconstr Surg 1971;40(5):501.
[158] Siegel RF: Palatal grafts for eyelid reconstruction. Plast Reconstr Surg 1985;26(3):411.
[159] Yoshimura Y, Nakajima T, Yoneda K: Use of palatal mucosal graft for reconstruction
of the eye socket. J Craniomaxillofac Surg 1995;23:27.
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1990;17:527.
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1994;21:107.
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[163] Sclaroff A, Haughey B, Gay WD, et al: Immediate mandibular reconstruction and
placement of dental implants: At the time of ablative surgery. Oral Surg Oral Med
Oral Pathol 1994;78:711.
[164] Stoler A, Hill T: Parts I, II. Mandibular reconstruction: Combined intra-oral and in vi‐
tro placement of osseointegrated implants into a free and vascularized bone graft. J
Oral Implantol 1992;18(1):38.
[165] Taylor TD, Rieger WP: Alloplastic implants: Their role in reconstruction of the man‐
dible. Clin Plast Surg 1994;21:79.
[166] Moscoso JF, Keller J, Genden E, et al: Vascularized bone flaps in oromandibular re‐
construction. Arch Otolaryngol Head Neck Surg 1994; 120:36.
[167] Albrektsson T: A multicenter report on osseointegreated oral implants. J Prosthet

Dent 1988; 60:76.
[168] Mounsey RA, Boyd JB: Mandibular reconstruction with osseointegrated implants in‐
to free vascularized radius. Plast Reconstr Surg 1994; 94:457.
[169] Martin IC, Cawood JI, Vaughan ED, et al: Endosseous implants in the irradiated
composite radial forearm free flap. Int J Oral Maxillofac Surg 1992;21:266.
[170] Reychler R, Ortabe JI, Pecheur A, et al: Mandibular reconstruction with a free vascu‐
larized fibula flap and osseointegrated implants: A report of four cases. J Oral Maxil‐
lofac Surg 1996;54:1464.
[171] Zlotolow IM, Huryn JM, Piro JD, et al: Osseointegrated implants and functional pros‐
thetic reha bilitation in microvascular fibula free flap reconstructed mandibles. Am J
Surg 1992;165:677.
[172] Donovan MG, Dickerson NG, Hanson LJ, et al: Maxillary and mandibular recon‐
struction using calvarial bone grafts and Branemark implants: A preliminary report. J
Oral Maxillofac Surg 1994;52:588.
[173] Peer L: Transplantation of Tissues, vol 1. Baltimore, Williams & Wilkins, 1955.
[174] Skinner FA: Maxillofacial prosthodontics: An aid to the oncology patient. J Med As‐
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gery, ed 2. Philadelphia, WB Saunders, 1990.
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[179] Stepnick DW, Hayden RE: Postoperative monitoring and salvage ofmicrovascular
free flaps. Otolaryngol Clin North Am 1994;27:1201-1217.
[180] Soderholm AL, Hallikainen D, Lindqvist C: Radiologic follow-up of bone transplants

to bridge mandibular continuity defects. Oral Surg Oral Med Oral Pathol 1992;73:253
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Chapter 29
Virtual Surgical Planning in Craniomaxillofacial

Reconstruction
Eric Zielinski, Ryan J. Jacobs, Eric Barker,

Kate Rodby and Anuja K. Antony
http://dx.doi.org/10.5772/59965
1. Introduction
Craniomaxillofacial reconstruction poses inherent and unique challenges due to the three-
dimensional configuration of the proposed construct and the critical importance to restore
speech, swallowing, mastication and symmetrical facial contour. Additionally, reconstruction
results are often inconsistent and learning curve dependent.[1-43] Until recently, the overall
success in bony reconstruction of the craniomaxillofacial skeleton has relied mainly on the use
of surgical trial-and-error and 2D imaging modalities. Virtual surgical planning (VSP) and
computer aided design (CAD) / computer aided modeling (CAM) is an exciting new technol‐
ogy that presents advantages in complex craniomaxillofacial reconstruction, with potential to
transform the approach and execution of challenging head and neck reconstructions.[30]
Among the reported benefits of VSP- CAD/CAM are increased reconstructive accuracy,
reduced OR and graft ischemia time, improved patient satisfaction and ease of use.[1, 9, 19]
VSP- CAD/CAM is gaining traction in craniomaxillofacial reconstruction applications and
offers opportunity for increased accuracy, improved efficiency, enhanced outcomes and ease
of use.[34, 43] To illustrate this point, the usage of this technology in different applications is
presented in subsequent sections with an emphasis and case study example for an oncologic
indication.
2. Applications
VSP- CAD/CAM is a novel technology which has been described for a range of surgical
applications ranging from trauma to oncologic reconstruction. Widening utilization in
craniomaxillofacial reconstruction is largely due to its unique capability that allows the
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surgical team to visualize and manipulate patient-derived virtual and stereolithographic

models in three dimensions during the virtual pre-operative planning phase. Due to refine‐
ments in pre-operative planning, many studies, though limited, have reported improved
outcomes through CT evaluation of actual verses planned height and width dimensions,
volumes, osseous graft overlap, and aesthetic outcomes.[24] For these reasons, VSP-
CAD/CAM has been of benefit for the following applications:
Craniomaxillofacial / Orthognathic procedures–VSP-CAD/CAM is a useful technology to

address craniofacial anomalies or maxillofacial deficiencies. Until recently, traditional imaging
methods only allowed for 2D images in a single plane to visualize the irregular and uniquely
shaped donor-graft and recipient sites.[3] While multiple imaging studies may aid in forming
a pre-surgical plan, the outcomes of movements outside the plane of imaging cannot be reliably
predicted. Therefore, complex reconstructions requiring correction for craniofacial and
maxillofacial applications can induce asymmetry since the traditional radiological studies
cannot plan movements in three dimensions; a capability that VSP-CAD/CAM offers.[23] In
addition, pre-made guides for harvesting and transplanting autografts as well as customized
allograft materials (e.g. pre-bent plates) facilitate achieving a result consistent with the
craniofacial reconstructive plan.[23, 43] In maxillofacial procedures, VSP-CAD/CAM elimi‐
nates several other sources of error when planning midline correction by allowing the surgeon
to account for the natural yaw, pitch, roll of a head position, and assessing heights and widths;
virtual manipulations of the patient model to millimeter precision can be performed to achieve
accurate maxillofacial balance and appropriate orthognathic relationships. Pre-bent fixation
plates further promote accurate translational movements intraoperatively that are pre-
planned in the virtual environment. When compared to the ‘classic’ method of building acrylic
intermaxillary occlusal splints using plaster models, VSP-CAD/CAM was shown to be superior
when evaluating post-operative maxillary position and centrality of the condyles in the
temporomandibular joint.[43]
Trauma–VSP-CAD/CAM has been utilized for reconstruction of traumatic facial injuries,

including comminuted mandible and panfacial fracture reduction and repair. Three-dimen‐
sional modeling of craniomaxillofacial injuries facilitates precise intraoperative reduction of
displaced bone fragments, while CAD/CAM produces occlusal splints that allow superior
restoration of facial symmetry, appearance, and function to those fitted intraopertively.[35]
Avulsed or necrotic areas can be replaced with grafts or covered with custom implants.
Additionally, implementation of VSP-CAD/CAM offers use of pre-manufactured cutting
guides for improved accuracy and reduced trial-and-error when harvesting and shaping
autologous implants, thus helping to ensure optimal bone-to-bone contact and aesthetic
outcome. Pre-bent fixation plates decrease intraoperative time and limit the extent of subper‐
iosteal dissection, thus minimizing avascularization of bony fragments.[35] Utilization of VSP-
CAD/CAM starting at initial presentation of traumatic facial injury does not result in increased
time to reconstruction and has been shown to better preserve facial height and width.[6, 35]
TMJ reconstruction – Traditional temporomandibular joint (TMJ) reconstruction is a two-

stage approach beginning with gap arthroplasty followed by postoperative CT to plan implant
design and fabrication. A subsequent procedure is then required to inset the pre-designed TMJ
implant. VSP-CAD/CAM however, enables single-stage reconstruction of the TMJ as gap
arthroplasty simulation and TMJ implant pre-fabrication can be performed on a virtual 3D
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model.[23] Planning and simulation of TMJ movements and jaw occlusion can also be assessed
on stereolithographic models prior to implant in-setting resulting in improved functional
outcomes and reduced postoperative complications.[23]
Mandibular Atrophy –In a case series of seven patients, VSP-CAD/CAM was utilized to repair
atrophic mandibular alveolar crest defects in patients after all other treatment modalities had
failed.[28] A free iliac crest transplant was harvested and anastamosed to the thoracodorsal
artery and vein in the axilla. Grafts were harvested three months later, after having developed
a whitish tissue layer on the bone, which was used as a mucous membrane following fixation
to the mandible. All grafts fit the mandible as predicted in the initial pre-reconstructive
planning phase and no implants were lost after 7 years of follow up.[28]
Oncologic resection and reconstruction–Craniomaxillofacial reconstruction using free fibula

flaps, as first described by Hidalgo, has traditionally relied on surgical skill, judgment, and
intra-operative trial and error to create the neomandible.[2, 3] Reconstruction of the mandible
and maxilla has therefore been considered to be learning curve dependent, often with
inconsistent results during the skill acquisition phase.[1] Furthermore, preoperative planning
and communication between the oncologic and reconstructive teams has been limited by the
lack of data regarding the anatomy of the lesion, precise margins of resection, and anatomy of
the graft recipient site, which prior to use of VSP-CAD/CAM, are only revealed in the operating
room.[6] Thus,for a procedure requiring a high degree of precision for optimal orthognathic
and aesthetic outcomes, craniomaxillofacial reconstructive success has historically been
hindered by prolonged intraoperative time and suboptimal reconstructions.[12] VSP-
CAD/CAM offers significant benefits for use in complex oncologic osseous head and neck
reconstruction by providing enhanced cooperation between surgical teams, pre-operative
planning, and the ability to customize models to patient’s individual characteristics, which
offers potential for considerable intraoperative time saving.[1]
VSP-CAD/CAM allows for a cooperative team approach to plan the resection and reconstruc‐
tion by synergistically facilitating pre-operative collaboration between the extirpative and
reconstructive teams, maximizing chances for tumor-free resection margins.[1, 3, 20] Addi‐
tionally, as the extirpative surgeon is provided with pre-operative 3D CT visualization of the
lesion borders and a comprehensive plan from the reconstructive team, he may be more
inclined to plan liberal resection margins initially; thus potentiating decreased local recurrence
rates and intraoperative time.[1] Similarly and in reciprocal fashion, reconstructive planning
may be better realized for the reconstructive surgeon with advance knowledge of the resection
plan. As refinements in the VSP-CAD/CAM interface have become progressively more user-
friendly for both the extirpative and reconstructive surgeon, adoption of this technology and
coordinated pre-operative planning has continued to increase.[30]
3. Process
Computer-assisted craniomaxillofacial surgery is based on four specific, well-described

phases, which are all necessary in order to achieve predictable outcomes: planning, modeling,
surgery, and evaluation.[3, 19] these steps are detailed as follows[24]:
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The first phase, planning, begins with a high-resolution computed tomographic (CT) scan of
the craniofacial skeleton and the possible donor sites, (e.g. lower extremities) if considered
necessary. A 3D reconstruction of the CT images is performed and then forwarded to the
desired modeling company. A web-based teleconference is then held between the surgical
teams and a biomedical engineer to allow participation from remote locations. During this
phase, the resection and reconstruction is virtually planned, with key parameters including
resection margins, osteotomies, placement of the vascularized bone graft in oncologic recon‐
struction, accurate reduction of the fractured bony segments for traumatic injuries, and the
staged virtual movement of the jaws in orthognathic procedures.
Figure 1. Overlay of the planned reconstruction with the native diseased mandible after virtual planning of the osteot‐
omies.
The modeling phase begins Based on the virtual surgical plan. Stereolithographic models are
manufactured of the area of the craniomaxillofacial skeleton of interest, along with specific
cutting guides for both the resection and the vascularized bone graft that will be used for
oncologic bony reconstruction (e.g. fibula), if indicated. In orthognathic procedures, pre-
bending of plates allows for accurate translation of the osteotomized segments for advance‐
ment/ setback and precise execution of the pre-operative plan (e.g. LeFort I, Bilateral Sagittal
Split Osteotomy). In oncologic reconstruction, this also allows for manufacturing of a recon‐
struction plate or plate-bending template; the specific guides and templates can be tailored to
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Figure : Overlay of the planned reconstruction with the native diseased mandible after virtual planning
http://dx.doi.org/10.5772/59965
of the osteotomies.
Figure : Positioning
Figure 2. Positioning of the designed
of the designed neomandible
neomandible adjusted adjusted
to optimize bonyto optimize bony contact and restore
contact and restore the anticipated man‐ the
dibular defect. Note the osseous segments to be produced via guided cuts of the free fibula graft.
anticipated mandibular defect. Note the osseous segments to be produced via guided cuts of the free
fibula graft.
the surgeon’s preference and the stereolithographic models can help to create pre-bent plates
The modeling phase begins Based on the virtual surgical plan. Stereolithographic models are
prior to reconstruction[17,
manufactured of the 19]
area of the craniomaxillofacial skeleton of interest, along with specific cutting
Figure 3. Virtual positioning of the pre-manufactured graft osteotomy guides on the fibula (A), extirpative osteotomy
guides on the diseased mandible (B), and fibula grafts secured to the pre-bent reconstruction plate aligned to the na‐
tive mandible.
During the surgery phase plate-bending templates and pre-bending of plates also expedites
the fixation step. Osteotomies are made in the mandible or maxilla based on the cutting guides,
typically after maxillomandibular fixation is achieved. In the case of oncologic reconstruction,
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the harvested osseous flap is also cut and osteotomized in-situ based on the cutting guides and
typically fixed to the reconstruction plate before the composite unit is secured into the
maxillofacial/mandibular defect. With the bony foundation restored, the soft tissue recon‐
struction can be carried out synergistically.
Figure 4. Intraoperative placement of osteotomy guide to fibula facilitating guided cuts for the neomandible.
The evaluation phase begins in the post-operative period, with a repeat high-resolution CT
scan performed, based on the same preoperative protocol.[17] While the method of evaluation
varies between institutions, a postoperative CT scan allows for a quantitative evaluation of the
surgical outcomes and can complement subjective assessments by the surgeon and patient of
restored oral and maxillofacial function. 3D models of the post-operative results are overlaid
with the pre-operative plan to determine accuracy and success of reconstruction including
actual mandibular angle and margins of bony contact in addition to accuracy of the VSP- CAD/
CAM plan including: bony segment overlap (repeatability) and mean service deviation, overall
positioning, osteotomy site differences, and reconstructive plate overlap.[3, 9, 25, 20] Clinical
parameters can then be correlated in the evaluation phase with functional parameters includ‐
ing occlusion, mastication, and speech, in addition to overall aesthetic outcome, and patient
satisfaction.
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Figure 5. Intraoperatively, the fibular grafts are secured to the reconstruction plate.
Figure 6. Overlay of the designed neomandible (blue segments) with the actual postoperative mandibular reconstruc‐
tion (green segments) evaluated by 3D CT.
Oncologic Case – A 61-year-old male patient presented to an oral surgeon for evaluation of
the right posterior mandible for potential chronic osteomyelitis. He stated that he had felt a
“dull pain” since nine months prior. Teeth #31 and #32 were extracted 16 and 9 months ago,
respectively. Since extraction, the patient had completed multiple courses of antibiotics, most
recently Augmentin 500mg.
On exam the patient displayed normal facial symmetry with a non-tender movable lymph
node <1cm right Level 1b without erythema, discharge or skin changes. The right mandible
was slightly tender to palpation with only minimal expansion, with slight "crepitus" appreci‐
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ated upon opening, concerning for osteolysis. Radiographic appearance on panorex was
notable for significant bone distraction appreciated on the right mandible involving the body
to the inferior border. Initial workup of the patient included an incisional biopsy and curettage
of the area under local anesthesia in order to rule out osteomyelitis. The pathology report
described a well-differentiated squamous cell carcinoma of right posterior mandible. The
patient was referred to oral-maxillofacial surgery for extirpation of the affected region of the
mandible with adequate margins and concomitant right free fibular osteocutaneous flap
reconstruction of the mandible by plastic and reconstructive surgery. High-resolution CT scans
were performed and sent to an outside company for modeling via CAD/CAM software.
Figure 7. Overlay of the virtual planned multiple fibular graft segments to reconstruct the mandible (blue segments),
over the diseased mandible (green).
After rendering the virtual models, the extirpative and reconstructive teams formulated a
surgical approach and consulted the modeling company for manufacturing of the desired
guides.
The virtual three-dimensional model of the craniofacial skeleton was first used to plan the
resection of the lesion and then the subsequent reconstruction of the defect by the extirpative
and reconstructive teams respectively in a joint teleconference facilitated by the biomedical
engineer from the modeling company. During the surgical phase, the oral-maxillofacial team
first excised the diseased mandible as planned using the prefabricated cutting guides. The
fibular osteocutaneous flap was then harvested by the reconstructive team; prefabricated
templates and guides were used by both the extirpative and reconstructive teams to ensure
the precise location and angle of osteotomies. The harvested, osteotomized flap was fixed to
the pre-bent plate in-situ and subsequently inset to the mandibular defect. The free condylar
end of the graft was contoured to fit the articular disk of the temporomandibular joint and the
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Figure 8. Positioning of the designed neomandible in the expected right hemimandible defect after virtual planning of
the osteotomies with positioning of the planned reconstructive plate.
graft placed into position. After successful fixation of the plate and graft to native bone, the
donor cutaneous flap was tailored for use in reconstruction of the oral mucosa. The flap
vasculature was then anastamosed, adequate circulation ensured, and both sites were closed
in a layered fashion.
After surgical completion, a high-resolution CT scan was obtained and sent to the original
modeling company for evaluation of reconstructive success. Comparisons were made between
the anatomical dimensions of the pre-operative and post-operative skull and mandible.
Reconstructive plate overlap was considered to be acceptable and the patient achieved
excellent functional and aesthetic results. The evaluation phase allowed for review of surgical
outcomes in a multidisciplinary fashion to further refine the technique.
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Figure 9. Virtual placement of the pre-manufactured extirpative osteotomy guide on the patient’s native mandible and
resection /osteotomy guide on the patient’s fibula for creation of the neomandible.
Figure 10. Intraoperative comparison of the virtual surgical planned reconstruction model with the fibular osteomyo‐
cutaneous flap segments secured to the pre-bent reconstruction plate (left). Placement of the plate secured fibula graft
to the native mandible (right).
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Figure 11. Post-operative evaluation by 3D CT of the virtually planned neomandible (blue segments) with the actual
mandibular reconstruction (green segments)
4. Advantages
Heightened aesthetic outcomes and reconstructive accuracy are realized with the multi-stage
implementation of virtual surgical planning throughout the four phases of computer-assisted
craniomaxillofacial surgery and the use of cutting guides, stereolithographic models and pre-
fabricated plates. In particular, the surgical course with VSP-CAD/CAM implementation,
specifically in the oncologic reconstruction of the mandible and maxilla, has been favorably
altered when compared to intraoperative planning and in-situ plate bending.[2, 23] More
pervasive use of the technology throughout the reconstructive process reduces translational
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error due to human error.[24] The virtual model data allows manufacturing of cutting guides,
plate bending templates, prefabricated reconstruction plates, and also stereolithographic
models to facilitate an accurate execution of the virtual plan in the operating room.[11, 13] Pre-
operative simulation of the maxillo-mandibular relationship facilitates proper alignment of
the graft for proper dental occlusion and proper orthognathic relationships.[4, 10] As the
majority of the planning of this process has occurred pre-operatively, total operating time is
also reduced concordantly.
While achieving reconstructive success was previously reliant on the surgeon’s experience and
intra-operative trial-and-error using 2-D imaging, VSP-CAD/CAM offers cited benefits over
traditional methods which include increased bone-to-bone contact, better dental alignment,
improved aesthetic contour, reduced complication rates and decreased intraoperative time.
[10, 13] In our review of surgeon-reported benefits, increased reconstruction accuracy in 92%
of cases proved to be a major perceived advantage demonstrated by this technology.[24]
Furthermore, a future direction of the VSP-CAD/CAM technology includes planning of
osseointegrated implants for mandibular reconstruction at the initial virtual planning session
to greater improve functional outcomes.[31, 34]
Quantifiable patient satisfaction surveys, subjective outcome evaluations, and clinical assess‐
ment can help to measure functional and aesthetic outcomes.[1, 11, 20, 21, 32, 33, 36] Likely
Results from more true-to-plan reconstructions attained by use of this technology, VSP-CAD/
CAM has been purported to translate to increased patient satisfaction. In a 2012 study
comparing VSP-CAD/CAM with conventional surgery, patients were asked to report satis‐
faction on a scale of 0-100. Patients who underwent virtually planned surgery reported an
average score of 88 compared to an average score of 68 by those patients undergoing traditional
reconstruction.[21]
The technical accuracy achieved as a consequence of VSP-CAD/CAM utilization can be

enumerated with evaluation of the final reconstruction with the virtual plan via comparison
of pre-operative and post-operative three-dimensional CT scans. Performing osteotomy with
use of cutting guides has been shown to assist in more accurately designed free flaps, while
use of pre-manufactured reconstruction plates versus hand-bent reconstruction plates has
been shown to promote true-to-plan reconstructive results.[4],`[9, 2] Àdditionally, a noted
decreased difference in the overall positioning between the native and reconstructed mandi‐
bles was found in VSP-CAD/CAM aided reconstructions when comparing standard technique
reconstructions.[9] Thus, improved reconstructive accuracy via the reduction of human error
can be achieved with pre-manufacturing of the reconstructive plates and implementation of
VSP-CAD/CAM more pervasively throughout the reconstructive process.[24] It follows that
application of VSP-CAD/CAM to refine preoperative planning, intraoperative contouring, and
postoperative orthodontic relationships in each surgical step can improve functional and
aesthetic outcomes.[22] With completion of the VSP process to the final evaluation phase, 3D
comparison imaging not only permits assessment of the reliability of the technology, it allows
the collaborative discussion between surgical teams to assess technique and identify areas for
improved performance.[25]
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Figure 12. Overlay of the virtually planned reconstruction (blue segments) with the native mandible demonstrating
translational error using a hand-bent plate (top). Post-operative overlay demonstrating improved match between ac‐
tual and virtual segments using a pre-bent reconstructive plate (bottom).
Pre-operative planning of the resection and reconstructive segmental osteotomies results in

enhanced operative time efficiency so that the extent of surgical time required is optimized to
precisely execute the previously developed plan.1Intraoperative surgical planning is thereby
converted to a preoperative event so that substantial savings in intraoperative time and
reductions in the surgical learning curve may be realized.[1] Such savings may be further
realized in reduced surgeon fatigue and concomitant reduced surgical error. Decreased
operative time and increased accuracy have been noted in multiple reconstructive series,
further illustrating the utility of VSP-CAD/CAM in dealing with complex head and neck
reconstruction for various surgical indications.[6, 28, 35] in mandibular reconstructions using
fibula free flaps, Hanasono reported a significant decreased mean intraoperative time when
utilizing VSP- CAM/CAD.[8] While Seruya et. al did not find a significant decrease in operative
time; they described a decrease in mean ischemic time in CAD assisted mandibular recon‐
structions.[29] Reduced ischemia time has been shown to result in decreased flap loss and
overall post-operative complications.[27, 29] Enhancing overall intra-operative efficiency is
facilitated by the use of pre-manufactured cutting guides and models which enables faster and
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more accurate osteotomies and graft placement. [7, 31] Use of manufactured pre-bent recon‐
structive plates can also significantly decrease the total operative time; total reconstructive
operative time was reported in one case to be less than 90 minutes.[3, 19, 31]
5. Disadvantages
With regard to the current economic climate in healthcare, potential limitation of widespread
incorporation of VSP-CAD/CAM technology is its added cost and the resultant financial
burdens that may be placed on the patient and medical system.[8, 17, 28, 34] Given the
economic healthcare constraints, the improved patient outcomes seen with VSP-CAD/CAM
have to be balanced against the cost of the technology.[24, 39] Potential costs are further
increased with the use of the manufactured pre-bent reconstruction plates. Given the qualita‐
tive nature of many benefits of VSP-CAD/CAM and the paucity of data currently available,
the total value added and cost efficiency of VSP-CAD/CAM utilization has not been formally
evaluated and still remains the subject of future studies.[24] As previously discussed, reduc‐
tions in ischemia and/or overall operative time is a potential source of cost reduction. Addi‐
tionally, the decreased complications and patient morbidity, and generalized improved
outcomes seen signify cost savings that may offset the technological costs.[24] However, the
clinical implications and economic benefits have yet to be formally analyzed with the added
cost of VSP-CAD/CAM in the context of various expanding clinical applications including
trauma, temporomandibular joint reconstruction, cancer, and skull base surgery.[6, 28, 35,
38] In head and neck cancer reconstruction, patient lifespan, risk for tumor recurrence and
disease progression, and quality of life are additional factors that add complexity to the cost-
benefit evaluation of the technology in an oncologic setting.
6. Summary
VSP-CAD/CAM is a novel technology that holds potential to consistently and predictably

advance reconstructive outcomes, both aesthetically and functionally. This technology is
suited for use in spatially complex reconstructive cases due to its ability to visualize and
virtually manipulate 3D configurations of the craniomaxillofacial skeleton in a collaborative,
synergistic fashion. Its applications are expanding for cases of varying levels of complexity
that require precise millimeter precision particularly in trauma, orthognathic procedures and
oncology to obtain optimized function and aesthetic outcomes. Implementation of VSP-CAD/
CAM into each stage of the reconstruction affords the opportunity to reduce human transla‐
tional error and facilitates intra-operative decision-making with expedition of the surgical
phase.[1, 10, 11, 13, 21, 24] VSP- CAD/CAM technology is attaining acceptance across the
multiple surgical disciplines as efforts towards validating its use are increasing, thereby
holding promise as an mainstay, innovative solution in the management of challenging head
and neck reconstruction cases.
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http://dx.doi.org/10.5772/59965
Author details
Eric Zielinski1, Ryan J. Jacobs1, Eric Barker3, Kate Rodby2 and Anuja K. Antony3*
*Address all correspondence to: akantony@uic.edu
1 University of Illinois at Chicago, USA
2 Mount Sinai Medical Center, USA
3 Rush University Medical Center, USA
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Chapter 30
Reconstruction
of Maxillofacial Osseous Defects
with Computer-Aided Designed/Computer-Aided
Manufactured Devices
Jan Rustemeyer
http://dx.doi.org/10.5772/58955
1. Introduction
Over the past years, virtually planned surgery has been increasingly utilised in maxillofa‐
cial reconstructive surgery. The concept of computer-aided surgery uses surgical simula‐
tion and three-dimensional (3-D) computer-aided designed/computer-aided manufactured
(CAD/CAM) tools such as cutting guides and jigs rather than relying exclusively on
intraoperative manual approximation for facial reconstruction [1].
The advantage of virtually planned surgery over conventional surgery has indisputably less
deviation between reconstructed and natural bony landmarks [2]. Nevertheless, the amount
of time saved by using the CAD/CAM approach is subject to controversy. On the one hand,
microsurgical craniofacial reconstruction using computer-assisted techniques, such as for
fibula-flap harvesting, has yielded significantly shorter ischemia times even with a larger
number of osteotomies compared with conventional techniques [3]. On the other hand, the
time savings should be considered in light of the additional time needed to complete the
preoperative virtual modeling session, which can take up to an hour. So if saving time were
a means of recouping the added cost of the CAD/CAM technique, the overall operative
time should not be different from that of the conventional technique [4]. However, no
differences between the techniques exist with respect to perioperative and long-term
outcomes, length of hospital stay, recipient-site infection, partial and total flap loss, or rate
of soft-tissue and bony-tissue revisions [3].
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We report herein our experiences using CAD/CAM techniques in five separate cases and
discuss them on the basis of recent criteria for the usage of CAD/CAM techniques given
in the literature.
2. Materials and methods
2.1. Classification systems of osseous maxillofacial defects

Osseous defects of the maxillofacial region are described using international classification
systems. The applied classification of mandibular defects refers to the HLC classification
described by Boyd et al. [5]. The H represents a defect compromising a lateral segment of any
length containing a condyle and not substantially crossing the midline, L stands for the same
defect but without a condyle, and C represents the anterior segment between the incisor
foramina. The classification of maxillopalatine defects refers to the classification given by Okay
et al. [6]. Class Ia summarizes defects with no involvement of the tooth-bearing alveolus; Class
Ib, preservation of both canines; Class II, resection of one canine or less than 50% of the hard
palate; Class III, resection of both canines or greater than 50% of the hard palate.
2.2. CAD/CAM technique

The CAD/CAM technique was applied for the reconstruction procedures. An exemplary
operational sequence of virtual osseous reconstruction with CAD/CAM technique is given in
Figure 1. Planning was performed on 3-D images generated from high-resolution, helical
computed tomography (CT) scans of the maxillomandibular region and the chosen donor site,
respectively. The patient’s natural anatomy was restored virtually by mirroring the unaffected
side (case 1 to 4). The mirroring protocol is not possible in defects involving both sides of the
mandible or maxilla. Therefore the solution is having a database from other patients which
can be imported as a reference (case 5). The selected osseous donor site was virtually harvested,
trimmed, and inset using the tools contained in the appropriate planning software of the CAD/
CAM tools-providing company (case 1 to 4: MedX, Xilloc Medical B.V., Maastricht, The
Netherlands; case 5: ProPlan CMF, Synthes/Materilise, Leuven, Belgium). Patient-specific
cutting guides for the donor site, as well as for the recipient site (if applicable), were created
using a 3-D printer. The prepared cutting guides should ensure the accurate segmentation and
implementation of the harvested bone.
2.3. Subjects
All patients were recruited and treated at the Department of Oral and Maxillofacial Surgery
and Plastic Operations. In all cases of applying the CAD/CAM technique, the bony recon‐
struction was intended to provide a basis for implant loading and prosthetic rehabilitation of
the patient. Subjects gave written informed consent to publish their medical records and
accompanying images. An overview of the presented cases with applied CAD/CAM technique
for maxillofacial reconstruction including their histories, chief complaints, affected sites and
types of reconstruction is given in table 1.
Case Age Gender History Chief complains Affected site Class Reconstruction
SCC of the lateral floor of the
Missing bony width
1 72 M mouth and alveolar ridge, L Free iliac crest
and height

partial mandibular resection
Chronic osteomyelitis,
Recurrent facial Vascularised iliac crest
2 54 F mandibular continuity L
pain and swelling and ASIS
resection
SCC of the lateral floor of the Vascularised two-

Deviation and
mouth, ORN of mandible, segment
3 72 F severe scaring of LC
mandibular continuity osteomyocutaneous
lower face
resection fibula flap

Double Flap technique:
Wide opening of vascularised
Maxillary ACC,
4 43 F maxillary sinus and III osteomyocutaneous
hemimaxillectomy
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nasal cavity double-barrelled fibula

flap and RFF

Vascularised three-
Wide opening of
Toxic induced subtotal segment
5 45 M maxillary sinus and III
maxillary osteonecrosis osteomyocutaneous
nasal cavities
fibula flap
Table 1. Overview of cases with applied CAD/CAM technique for maxillofacial reconstruction.
SCC = Squamous Cell Carcinoma, ASIS = Anterior Superior Iliac Spine, ORN = Osteoradionecrosis, ACC = Adenoidcystic
Carcinoma; RFF = Radial Forearm Flap
Table 1. Overview of cases with applied CAD/CAM technique for maxillofacial reconstruction.
http://dx.doi.org/10.5772/58955
Reconstruction of Maxillofacial Osseous Defects with Computer-Aided…
735
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Figure 1. Exemplary operational sequence of virtual osseous reconstruction with CAD/CAM technique. (a) Initial find‐
ings in 3-D CT, (b) and (c) Mirroring the unaffected side for virtual reconstruction, (d) Selecting a proper harvesting
site by precisely superimposing the virtually reconstructed side, (e) and (f) Virtually harvesting, trimming and inset‐
ting of the osseous transplant, (g) and (h) Designing patient-specific cutting guides for 3-D printing.
3. Clinical case studies
3.1. Case 1
A 72-year-old male was admitted to our centre with squamous cell carcinoma (SCC) of the left
lateral floor of the mouth and the adjacent alveolar ridge. He underwent tumour resection
including partial resection of the left mandible with scarifying of the ipsilateral canine,
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premolars, and molars, leaving a Class L defect. No mandibular resection in continuity was
necessary. Hence, it was possible to preserve the inferior alveolar nerve (IAN) and the base of
the mandible to ensure stability without osteosynthesis.
One year after primary surgery, reconstruction of the mandible was virtually planned to
augment the missing bony width and height (Figure 2). An additional soft tissue transfer was
not necessary since the residual soft tissue would provide a sure and tensionless wound
closure. Within the intraoperative use of a CAD/CAM cutting guide for harvesting a left iliac
crest bone part, the anterior superior iliac spine (ASIS) could be preserved. Using an intraoral
approach, we inset the harvested free iliac crest bone and rigidly anchored it with two
osteosynthesis platelets (2.0 mm system, Stryker Corp, Freiburg, Germany). On the anterolat‐
eral aspect, a space of 1.5 mm was left between the transplant and the preserved alveolar ridge
of the mandible. Therefore, it was necessary to bridge this gap with cancellous bone. Both,
postsurgical wound healing and further recovery were uneventful.
3.2. Case 2
In a 54-year-old female, chronic osteomyelitis of the left mandible from the premolar region
up to the ascending ramus was detected with bone scans consisting of scintigraphy using
single-photon-emission computed tomography (SPECT) and CT scans (Figure 3). A recurrent
intravenous antibiotic regime with piperacillin 3 × 2 g and sulbactam 3 × 1 g and local decor‐
tication did not lead to an enduring remission.
We consequently decided to resect the involved mandibular segments, achieving a Class L

defect, and to perform an immediate osseous reconstruction in one operative session. The IAN
was already compromised, leaving an anaesthetic area of corresponding ipsilateral skin,
mucosa, and lower lip. Virtual planning revealed that the best reconstruction could be obtained
using the ipsilateral ASIS and accompanying parts of the iliac crest.
At surgery, CAD/CAM cutting guides were used for mandibular resection, and iliac bone
harvesting ensured an exact fit of the osseous reconstruction. Vascular, pedicled iliac bone was
harvested, inset, and fixed with osteosynthesis platelets before microvascular anastomoses
were done. Following resection of the mandible, the condyle-bearing portion of the mandible
immediately rotated clockwise and was repositioned upon inset of the iliac bone flap. No
further augmentative features were necessary because the intraoperative findings were in strict
accordance with the planned situation. No complications occurred during the postoperative
course and no further episodes of inflammatory osteomyelitis were realised during a follow-
up of 6 months.
3.3. Case 3
A 72-year-old female suffering from SCC had tumour resection of the anterior and right lateral
floor of the mouth. Soft tissue reconstruction was performed with a radial forearm flap (RFF).
Postsurgically, necessary radiotherapy led to severe osteoradionecrosis (ORN) of the mandi‐
ble, compromising the area of the contralateral canine region up to the ipsilateral mandibular
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Figure 2. Case 1. (a) 3-D CT shows the left mandibular defect. (b) and (c) Virtual reconstruction of osseous defect. (d)
Virtual iliac crest with planned cutting guide and transplant. (e) Intraoperative positioning of the cutting guide. (f)
Harvesting of the iliac crest bone. (g) The transplant inset and fixed. (h) Postoperative 3-D CT findings with iliac crest
for mandibular augmentation.
angle. The affected parts of the mandible were completely resected without further recon‐
struction, leaving a class LC defect.
During follow-ups, the patient complained about ipsilateral deviation of the lower face after
muscle contraction and scar formation. No applicable prosthetic solution could be devised.
After 1 year and without any further evidence of ORN, mandibular reconstruction was
planned using CAD/CAM tools for harvesting a vascularised osteomyocutaneous fibula flap
(Figure 4). Intraoperative cutting guides for the mandibular stumps were used to assure
straight osteotomy lines. Another cutting guide was needed to produce a two-segment fibula
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http://dx.doi.org/10.5772/58955
Figure 3. Case 2. (a) SPECT shows osteomyelitis of the left mandible. (b) and (c) Virtual resection and reconstruction of
mandible. (d) and (e) Intraoperative positioning of the cutting guides on the mandible and the iliac crest and ASIS. (f)
Vascularised iliac bone flap inset and fixed. (g) and (h) Postoperative 3-D CT showing incorporated iliac bone flap.
to reconstruct the mandibular angle, corpus, and the anterior part. A skin paddle containing
two septocutaneous perforators was placed extraorally over the chin area to provide volume
for the resulting skin defect after dissolving the scars and repositioning the soft tissue chin in
the facial midline. Intraorally, the former RFF provided stable soft tissue coverage. The
segmented fibula was stabilised and fixed to the prepared mandibular stumps with osteosyn‐
thesis platelets before microvascular anastomosis was carried out. The fitting was in accord‐
ance with the planned situation, including repositioning both condyles. No trimming or
application of cancellous bone was necessary. The wounds healed primarily and the further
postsurgical course was uneventful.
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Figure 4. Case 3. (a) Initial mandibular defect in the 3-D CT. (b) and (c) Virtual reconstruction with a two-segment fibu‐
la flap. (d) Intraoperative positioning of the fibular cutting guide. (e) Inset of the prepared and osseous segmented os‐
teomyocutaneous fibula flap. (f) and (g) Postoperative 3-D CT of reconstructed mandible. (h) Complete wound healing
after 4 weeks.
3.4. Case 4
In a 43-year-old female, an adenoidcystic carcinoma of the left maxilla and hard palate was
histologically confirmed. Tumour surgery consisted of a hemimaxillectomy up to the zygo‐
matic arch and resection of the left and part of the right hard palate to achieve clear margins.
The maxillary sinus, nasal cavity, and septum were widely exposed, comprising a Class III
defect. No primary reconstruction was carried out. Radiotherapy was applied postsurgically,
as suggested by the tumour board.
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One year after initial therapy and with no evidence of recurrence, reconstruction was virtually
planned and realised by performing a double-flap technique for covering the soft and hard
tissue defects (Figure 5). During one operation, a fibula flap, with a wide muscular cuff to
provide bulkiness, was harvested. The fibular bone was then segmented using a CAD/CAM
cutting guide and prepared as a double-barrelled fibula by folding upward a precisely
determined distal portion of the fibula. This technique was chosen to apply the necessary bony
height to fill the osseous maxillary resection defect. After osteosynthesis between both fibular
parts and between the fibula and the preserved maxilla, microvascular anastomosis was
carried out. In the next step, an RFF was harvested to cover the muscle cuff of the fibular flap
and to provide adequate soft tissue coverage for the palatal defect. The postoperative course
was uncomplicated and both flaps were successfully incorporated.
3.5. Case 5
At first presentation, a 44-year-old male complained of chronic facial pain and nasal outflow
of fluid and food for at least two years. Clinical inspection revealed a desolate intraoral
situation with osteonecrosis of the nearly edentulous upper jaw and palate with oroantral and
oronasal fistulas. After careful inquiry, the patient admitted chronic abuse of alcohol, nicotine
and of the illicit drug methamphetamine (MA) for at least 25 years. For the past 20 years, he
had synthesized MA for his own consumption and for illegal disposal in his home country.
Furthermore, he confessed to extracting teeth himself since he became addicted to MA. After
further investigation, a history of bisphosphonate intake for any reason or radiation of the head
and face was definitely ruled out. In the last year the patient had successfully completed a drug
intervention and rehabilitation program and he was successfully cured of his addiction to toxic
substances and illegal drugs.
Upon hospitalization, an intravenous antibiotic regime with piperacillin 3 × 2 g and sulbactam

3 × 1 g was initiated. Bone scans consisting of SPECT and 3-D CT of the head and neck showed
extensive bony destruction of the maxilla and an accompanying osteomyelitis up to the
zygomatic arches. The surgical treatment comprised a step-by-step approach. In the first step,
the affected necrotic parts of the maxilla were resected to achieve clear margins. During
surgery, the infraorbital and zygomatic region showed bleeding spots and vital solid bone.
The diagnosis of osteonecrosis was confirmed by histopathology. In a second step two weeks
later, reconstruction of the maxilla was performed using a vascularized osteomyocutaneous
fibula flap from the left side (Figure 6).
To imitate the natural maxillary arch in the planning sessions, the fibula was divided into three
segments and folded in the transverse plane. After inset of the osteomyocutaneous fibular flap
and subcutaneous tunneling of the preauricular region, microvascular anastomoses were
carried out using the left superficial temporal artery and vein as recipient vessels for the
peroneal artery and the accompanying dominant vein. Surgery and postsurgical course were
uneventful and a remarkably good accordance between the virtually-planned and the real
outcome was recognized on postoperative CT scans. Immediately after surgery, nasal outflow
ceased and facial pain was remarkably minimized.
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Figure 5. Case 4. (a) Initial finding of the maxillopalatine defect in the 3-D CT. (b) Virtual reconstruction with a double-
barrelled fibula flap. (c) Positioning of the fibular cutting guide. (d) and (e) Prepared double-barrelled fibula flap inset
into the defect area. (f) Inset of radial forearm flap for intraoral cutaneous covering. (g) and (h) Postoperative 3-D CT
findings with incorporated fibula flap for osseous reconstruction.
4. Discussion
In this clinical study, we presented five different cases bearing for us some indications for the
application of CAD/CAM techniques. Our report included a regional mandibular defect after
tumour ablation (Case 1), extensive loss of mandibular continuity as a result of chronic
osteomyelitis and ORN (Cases 2 and 3), and maxillopalatine defects (Case 4 and 5). Recent
literature provides somewhat different criteria compared with ours for the application of CAD/
CAM technique for osseous reconstruction [7-9]. The former comprise the requirement of
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Figure 6. Case 5. (a) and (b) Extensive osteonecrosis and extensive bony destruction of the upper jaw. (c) and (d) Virtu‐
ally restored native anatomy and virtually inset of fibula bone to imitate the natural maxillary arch. (e) Cutting guide
for the three-segment fibula. (f) Prepared osteomyocutaneous fibula flap before inset. (g) and (h) Postoperative 3-D CT
and total soft tissue covering of the former subtotal maxillary defect.
multiple osteotomies for an osseous flap, the need for multiple simultaneous free flaps, history
of ORN or radiation therapy to the head and neck, and high-velocity ballistic injury with
significant tissue loss. However, it is remarkable that no evidence-based studies covering these
criteria are available and mostly refer to anecdotal case studies.
Keeping this in mind and following the criteria given above, only three of our presented cases
should be appropriate for the CAD/CAM technique. These cases comprise osseous recon‐
structions obviously more complex because of having to produce segmented bone flaps (Cases
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3 to 5) and employ a two-flap technique (Case 4). The two cases not meeting the criteria include
the harvesting of a free iliac bone flap (Case 1) and a vascularised iliac bone flap (Case 2).
Indeed, the latter cases were simpler with respect to the literature criteria and compared with
Cases 3, 4 and 5. However, our experience was that the CAD/CAM technique facilitated finding
and harvesting bone segments that closely duplicated the shape of the natural mandible in
even less complex cases of osseous reconstruction. Without the CAD/CAM technique and
cutting guides, surgery might have required further trimming and blurring of the osseous
transplant without improving accuracy. At worst, it might have resulted in unnecessary
scarifying of the ASIS in Case1 with further comorbidity.
However, the latter case was the only one in which compromises were necessary with respect
to the accuracy of the anterolateral junction of the osseous transplant and the residual man‐
dibular bone. Besides, the discrepancy between virtual planning and the actual finding was
within the scope of a reported distance between the real and virtual osteotomies of 1.30 ± 0.59
mm [1]. Retrospectively, the source of this error is difficult to detect. Possible reasons for this
inaccuracy are purely hypothetical, including movement artefacts during CT scans, metallic
artefacts from filled teeth, too much play of the oscillating saw in the slots of the cutting guides,
calculation errors, or simply being unfamiliar with a new method. Further studies are war‐
ranted to clarify these hypotheses.
While performing surgery with CAD/CAM devices, we experienced in Cases 2 and 3 an

additional helpful aspect. After we resected the aforementioned mandibular part in Case 2,
including parts of the ascending ramus, the condyle-bearing stump rotated clockwise as a
result of contraction of the temporal muscle tendon. Hand-setting alone would have resulted
in considerable bias when repositioning the condlye. However, by seamlessly insetting the
osseous transplant, we were able to replace the condyle exactly in its initial position without
further effort. Accordingly in Case 3, initial findings showed that the ascending rami were
pathologically rotated medially and the condyles laterally. During virtual planning, the rotated
parts were derotated and the segmented fibula flap was planned for the new position. Within
the inset of the prepared fibula we achieved the planned derotation of the condyles by setting
the residual mandibular stumps and fibula in a strictly axial and seamless bone-to-bone
contact. Hence, the outcomes of these cases suggest that the CAD/CAM technique presents
both the opportunity to accurately reconstruct osseous parts of the maxillofacial region and to
solve arising or existing pathological conditions.
5. Conclusion
Our case report has fulfilled the challenge in the literature to improve upon traditional shaping
methods, especially to justify the added costs [4, 10]. Furthermore, our report suggests that the
possible applications of CAD/CAM techniques have not yet to be exhausted. At the current
state of the art, we believe that the application of CAD/CAM techniques for osseous recon‐
struction in the field of maxillofacial surgery should not be restricted to obviously complex
reconstructions.
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Author details
Jan Rustemeyer
Department of Oral and Maxillofacial Surgery, Plastic Operations, Klinikum Bremen-Mitte,

School of Medicine of the University of Göttingen, Bremen, Germany
References
[1] Roser SM, Ramachandra S, Blair H, Grist W, Carlson GW, Christensen AM, Weimer
KA, Steed MB. The accuracy of virtual surgical planning in free fibula mandibular re‐
construction: comparison of planned and final results. J Oral Maxillofac Surg
2010;68(11) 2824-2832.
[2] Hanasono MM, Skoracki RJ. Computer-assisted design and rapid prototype model‐
ing in microvascular mandible reconstruction. Laryngoscope 2012; 123(3) 597–604.
[3] Seruya M, Fisher M, Rodriguez ED. Computer-assisted versus conventional free fibu‐
la flap technique for craniofacial reconstruction: an outcomes comparison. Plast Re‐
constr Surg 2013;132(5) 1219-1228.
[4] Matros E, Disa JJ. Discussion: Computer-Assisted versus Conventional Free Fibula
Flap Technique for Craniofacial Reconstruction: An Outcomes Comparison. Plast Re‐
constr Surg 2013;132(5) 1229-1230.
[5] Boyd JB, Gullane PJ, Brown DH. Classification of Mandibular Defects. Plast Reconstr
Surg 1993;92(7) 1266-1275.
[6] Okay DJ, Genden E, Buchbinder D, Urken M. Prosthodontic guidelines for surgical
reconstruction of the maxilla: a classification system of defects. J Prosthet Dent
2001;86(4) 352-363.
[7] Saad A, Winters R, Wise MW, Dupin CL, St Hilaire H. Virtual surgical planning in
complex composite maxillofacial reconstruction. Plast Reconstr Surg 2013; 132(3)
626-633.
[8] Ghazali N, Collyer JC, Tighe JV. Hemimandibulectomy and vascularized fibula flap
in bisphosphonate-induced mandibular osteonecrosis with polycythaemia rubra ve‐
ra. Int J Oral Maxillofac Surg 2013; 42(1) 120-123.
[9] Tepper OM, Sorice S, Hershman GN, Saadeh P, Levine JP, Hirsch D. Use of virtual 3-
dimensional surgery in post-traumatic craniomaxillofacial reconstruction. J Oral
Maxillofac Surg 2011;69(3) 733–741.
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[10] Hanasono MM, Jacob RF, Bidaut L, Robb GL, Skoracki RJ. Midfacial reconstruction
sing virtual planning, rapid prototype modeling,and stereotactic navigation. Plast
Reconstr Surg 2010; 126(6) 2002–2006.
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Chapter 31
Contemporary Rhinoplasty Techniques
Payam Varedi and Behnam Bohluli
http://dx.doi.org/10.5772/59811
1. Introduction
Rhinoplasty has evolved during the past two decades. The popular trend to have a smaller
nose is gradually changing to having a normal looking nose. Nowadays, functional consider‐
ations are an integral part of any treatment plan. A major effort is usually made to detect any
deficits in the nasal airway before aesthetic surgery to be solved or improved by a proper
treatment plan. Grafting and suturing techniques have replaced some older destructive
techniques. This chapter gives an overview of current concepts in rhinoplasty; we also present
logical approaches in case selection and evaluation.
2. Preoperative evaluations
Like any other aesthetic procedure, a comprehensive preoperative evaluation, may directly
affect the final outcome of the operation. The first step is usually started by a thorough
psychological assessment, and then functional assessment of the nose is performed. Structural
and aesthetic evaluations are usually the last stages followed by the treatment plan and finally
operation [1].
2.1. Psychological evaluation
Psychological assessment of the rhinoplasty candidates is the first step to build up a proper
treatment plan. Unrealistic demands and personality disorders are best detected at this stage.
An open discussion with the patient may clarify many potential problems. Any previous
psychological medications or therapies should be clarified. Patient may be asked to bring up
their ideal nose models; computerized simulation is another modality that may help the
surgeon communicate with the patient and seek their real demands and expectations. It is clear
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that an ideal surgery with perfect results in an unsatisfied patient is a big failure and is best
prevented in this preoperative phase [2-3].
2.2. Functional evaluation
The human nose bears a complex physiologic and functional role in breathing and smelling.
For this reason it is logically expected that this delicate organ be preserved and even improved
during aesthetic surgery. This evaluation usually starts with verbal interview with the patient.
Any breathing problems may be easily detected. Exacerbating factors or problems are usually
best described by the patient, and then the evaluation continues with direct inspection of the
nose. Any deviation or deformity should be observed and documented. To assess the septum
and turbinates sufficient light and a nasal speculum are necessary. A few drops of a vasocon‐
strictor such as phenylephrine in each nostril may be applied for better visualization [4-7].The
final step is to check the valve. The Cottle test is a known method to assess the internal nasal
valve. The patient is asked to take a deep breath through the nose, and then inhalation is
repeated while the patient is retracting his/her nasal side wall. If a considerable improvement
occurs (positive Cottle test), this means a serious weakness exists in the internal nasal valve
(Figure1). [8].It is clear that a reinforcement or total reconstruction of the internal valve should
be considered in treatment planning. This test should be done on both sides and documented
properly.
Figure 1. Cottle test.
To assess the external valves the patient is asked to tilt the head backward and take a deep.
The nose is closely observed by the surgeon. This test may be documented by simple standard
photography. Excessive medial movements of the nostrils and/or collapse means that some
kind of reinforcement technique needs to be considered in the rhinoplasty procedure [9-10].
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3. Additional diagnostic techniques
Water’s view radiograph is commonly used to evaluate the maxillary sinuses and nasal
septum. In case a complex deformity or deviation is found, CT scan may help the surgeon
better analyze the problem.
Lateral nasal view may help the surgeon measure the length and height of the bony vault
though measurement, palpation and tactile sensation may easily provide the same data for the
surgery.
CT scans are commonly used to assess internal compartments of the nose. Septal deformities
and spicules are easily detected and documented. Nasal turbinates and paranasal sinuses are
also clearly observed on CT scans. Nasal valve diameters are sometimes measured and
documented as well.
4. Structural assessment
Structurally the nose is formed from cartilage, bone, muscle, connective tissue and skin. It is
clear that the quantity and quality of these components play a determining role in the outcome
of aesthetic nasal surgery. For structural evaluation, the nose is gently palpated by the surgeon.
The quality and thickness of the overlying skin is size and length of the bony vault is grossly
measured and then subtle finger pressure is applied over the tip to determine the strength and
support of the cartilage framework. Then, the patient is asked to smile. Excessive drooping of
the nose or unpleasant widening may be an indicator of muscular hyperactivity or structural
weakness that both may be easily corrected with a thorough treatment plan.
5. Basic techniques in rhinoplasty
5.1. Incisions
Open approach rhinoplasty needs two basic incisions namely, skin incision and rim incisions.
These two incisions are connected to each other and skeletonization is started.
5.2. Skin incisions
The skin incision is placed in the mid-columellar skin. An inverted-V (Figure 2) or stair-step
(Figure 3) design will provide a longer incision line and logically better healing and less visible
scar. On the other hand, the geometric incision may help the surgeon return the flap to its exact
position thus, distortion or deformities are prevented.
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Figure 2. Inverted-V incision
Figure 3. Stair-step incision

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5.3. Rim incision
The rim incision is an intranasal incision along the caudal edge of the lower lateral cartilages
(Figure 4).Care should be taken to remain close to the cartilage edge. In this way a proper
incision will follow the normal anatomy of the lower lateral cartilages. For this reason, the
incision line will be close to the nostril margins in the dome area and will move caudally as it
is continued along the border of the lateral crural cartilage.
Figure 4. Rim incision
5.4. Skeletonization
Skeletonization is usually done to gain access to cartilaginous and bony framework of the nose.
To do so, columellar and marginal incisions are connected to each other and with delicate
scissors the skin flap is reflected gradually. Care is usually taken to move close to the cartilage
and bone during dissection (Figure 5). A deeper plane will provide a skin coverage that will
conceal subtle irregularities while intradermal dissections may lead to color changes or surface
irregularities.
5.5. Tip-plasty
Tip-plasty is a combination of many reductive, suturing and grafting techniques that are done
to refine or shape a malformed asymmetric tip. Basic techniques are usually enough in most
cases. Though in some complicated noses such as revision or cleft noses some advanced
methods may be applied that require skill and training.
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Figure 5. Skeletonization is completed.
Figure 6. Cephalic trimming.
5.6. Cephalic trimming
In this technique, a narrow strip of lateral crural cartilage is marked, incised and separated
from underlying skin. The main purpose of cephalic trimming is to refine the tip and make
enough space for tip rotation (Figure 6). [11].
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5.7. Salient points
This technique is potentially destructive and may weaken the tip. Vigorous cartilage resection
may result in severe pinch deformities and external nasal valve incompetency. As a rule all
respective techniques must be done conservatively and is best avoided in narrow or weak
lower lateral cartilages.
5.8. Tip spanning suture
Tip spanning suture is a mattress suture that is done on each dome. This suture will make a
sharper dome on each side and as result more definition of the tip will be apparent (Figure 7).
Figure 7. Tip spanning suture
5.9. Common mistakes
Big suture bites over the dome area or over-tightening of the tip spanning suture may lead to
a pinch deformity or tip destruction. Gentle tightening of sutures and use of delicate suture
material (PDS 6-0) is enough to shape the structure of the lower lateral cartilages.
6. Interdomal suture
Interdomal suture is a simple suture that approximates the two lateral crura. This simple suture
is the most effective approach to correct a boxy and/or bifid tip (Figure 8.(
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Figure 8. Interdomal suture
6.1. Common mistakes
The interdomal suture should be done in a way that two domes form a 45 degree angle to each
other. Careless non-anatomic interdomal suturing will provide a pointed tip that has no
definition and is not aesthetically pleasing. [12-15].
7. Basic grafts in tip plasty
7.1. Collumellar strut
The columellar strut is a quadrangular piece of cartilage that is inserted and fixed, in a pocket
between the two medial crura. The columellar strut is aimed to reinforce tip support; the strut
may indirectly have positive effects on tip rotation and increasing tip projection (Figure 9). [16].
7.2. Cap graft
The cap graft is a small ovoid cartilage that is prepared from septal cartilage, remnants of
excised cephalic trimming or choncal cartilage. This graft is placed and fixed over the domes
(Figure10). Cap grafts may have several aesthetic results namely:
1. Slightly increases tip projection

2. Shapes the tip
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3. Covers the irregularities of the tip cartilages
Figure 9. Collumellar strut
Figure 10. Cap graft

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7.3. Shield graft
Shield graft is a quadrangular piece of a cartilage that is formed and trimmed according to the
aesthetic needs of the deformity. A shield graft is generally placed and fixed caudal to the
medial crural cartilages (Figure 11).This graft has nearly the same role as a cap graft though
its heavier and stronger; there are two specific uses for it:
1. To form the bulky tip
2. To increase tip projection [17-21]
Figure 11. Shield graft
8. Crushed cartilage
A small piece of cartilage is placed in a crusher and with few strokes of a mallet, a smooth soft
texture is provided that may be used to cover the irregularities or fill subtle deformities(Figure
12).Tip grafts are best fixed by delicate 6-0 PDS sutures to prevent any future dislodgment or
displacement. The skin may be re-draped several times to seek any spicules. Sharp edges or
shadows of tip grafts are corrected intra-operatively to avoid later revisions. [22]
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Figure 12. Crushed cartilage
9. Hump modification
The dorsal hump is a complex anatomic component of the nose. The nasal hump is formed by
two upper lateral cartilages, the septal cartilage and two nasal bones. Dorsal modification is
usually started with resection of excessive parts and in some cases augmentation of shallow
and defective parts. Hump resection may be done in a way that all excessive parts are resected
in one piece (composite resection) or in a way that each component is trimmed and resected
separately in an incremental manner (component resection).
9.1. Composite hump surgery
When it is planned to remove a maximum of 2 or 3mm of dorsal hump, composite resection

may be done. In this technique, cartilaginous part is cut by surgical knife and a hump osteotome
is inserted beneath the cut cartilage and hump resection is continued with mallet strokes to
cut the excessive bone; then the resected hump is simply removed (Figure 13).
9.2. Salient points
1. Integrity of the underlying mucous is crucial in internal nasal valve function so this
technique is best preserved for minor resections and in case further resection is necessary
component resection should be performed.
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2. The resected hump is a potential graft material that may be used as a strut, tip graft or as
The resected hump is a potential graft material that may be used as a strut, tip
an ideal material for dorsal augmentation. ‐2
.graft or as an ideal material for dorsal augmentation

Figure 13. Composite hump surgery Figure 13: Composite hump surgery
Component hump resection
9.3. Component hump resection
In this technique the upper lateral cartilages are precisely separated from the
In this technique the upper lateral cartilages are precisely separated from the nasal septum
nasal and
septum and underlying
underlying mucosa, thenmucosa, then excessive
excessive septal septal cartilage
cartilage is trimmed is trimmed
until the ideal position is
until achieved.
the ideal To adjust the bony part, a bone rasp or osteotome is used. In final stepsrasp
position is achieved. To adjust the bony part, a bone or
excessive
upper laterals
osteotome may
is used. In befinal
trimmed very
steps conservatively.
excessive upper laterals may be trimmed very
.conservatively
9.4. Important points
Important points
1-In major hump resections (more than 3mm), the dorsal hump may be reconstructed to avoid
breathing problems
In major hump and to provide
resections (more a pleasant aestheticthe
than 3mm), browdorsal
line. A spreader graft isbe
hump may the gold
‐1
standard with which to reconstruct the internal nasal valve; additionally, autospreader
reconstructed to avoid breathing problems and to provide a pleasant aesthetic grafts
and splay grafts are also effective methods in indicated cases [23-24].
brow line. A spreader graft is the gold standard with which to reconstruct the
internal nasal valve; additionally, autospreader grafts and splay grafts are also
.(effective methods in indicated cases (23‐24
10. Basic grafting techniques in dorsal surgery
Basic grafting techniques in dorsal surgery
10.1. Spreader grafts
Spreader grafts
Spreader grafts are two quadrangular pieces of cartilage (3mm in width and 20mm in
Spreader grafts
length) are betwo
that may quadrangular
modified pieces
according to of cartilage
the patients' (3mm These
specific needs. in width and
cartilages are
placed on both sides of nasal septum and fixed with 5-0 PDS sutures. This grafting technique
20mm in length) that may be modified according to the patients' specific needs.
These cartilages are placed on both sides of nasal septum and fixed with 5‐0 PDS

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will change the geometry of internal nasal valve and prevent internal nasal valve incompe‐
tency (Figure 14). [25-27].
Figure 14. Spreader grafts.
10.2. Crushed cartilage
Crushed cartilage is an ideal augmentation material that may be precisely added to defective
dorsal segments and cover irregularities.
10.3. Temporalis fascia
Temporalis fascia is a soft smooth graft material that is frequently reported to be used in
augmentation rhinoplasty. This graft easily blends-in with normal nasal tissues and does not
make shadows or visible borders. To harvest temporalis fascia a 5cm curvilinear incision is
made on the posterior hairline. With upward and anterior subcutaneous dissection, ideal
access to temporalis fascia is obtained then adequate fascia is harvested and placed in the
recipient site in the nose. This approach provides ideal access to the area. A direct incision in
hair-bearing areas of the temporalis area is also frequently used.
10.4. Lateral osteotomy
Lateral osteotomy is generally done to narrow a wide bony vault and/or to close an open roof
deformity. This is beneficial to reshape a malformed bony vault (like traumatic noses).Lateral
osteotomy may be done by two main options; external perforating osteotomy or internal
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continuous osteotomy. Both techniques have their own advantages and disadvantages; the
literature has shown that both work well in the hands of skilled and trained surgeons.
10.5. External perforating osteotomy
The osteotomy line is planned and marked over the skin. A small stab incision is made on the
nasal skin, midway of the bony vault; then a 2mm osteotome is inserted through the incision
line. Using sweeping movements of the osteotome it finds its proper place at the beginning of
marked osteotomy line under the periosteum of the bony vault. Then, with mallet strokes the
osteotomy is started. After performing one osteotomy site, the osteotome is gently pulled out
of the bone in a way that it stays inside the skin incision and is guided in the planned osteotomy
line and the next osteotomy site is done adjacent to first one. In this way several osteotomy
holes are made along the planned line. Then a gentle finger pressure is applied over the bony
vault and the osteotomized bony segment is moved medially. Gauze soaked in cold serum is
pressed over the osteotomy region and held for a few minutes to control bleeding and edema
(Figure 15).
Figure 15. External perforating osteotomy

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10.6. Internal continuous osteotomy
A 3 to 4mm guided osteotomy is usually used in this method of osteotomy. First a nasal
speculum is used to find the best place in pyriform aperture. A small 5 mm incision is done.
Then the osteotome is inserted inside the incision in a way that the guide stays laterally and
blade medially toward the nostrils. With mallet strokes, the osteotomy is started and continues
toward the medial canthus in the planned line. Then gentle finger pressure is applied to
medialize the bony segment. The same procedure is done on the other side and gauze is pressed
over the bony nasal vault and held for few minutes to control the bleeding and edema.
10.7. Salient points
1. Medial movements of the bony pyramid can be done by gentle finger pressure after lateral
osteotomy. Failing to do so means that inadequate osteotomy is performed and osteotomy
should be repeated properly. Aggressive use of force to in-fracture the bony segments by
the surgeon or osteotome handle may dislodge the segments or lead to severe bony
collapse.
2. It is generally suggested to limit the osteotomy line up to the medial canthus; further
extension does not lead to acceptable results and will add the possibility of complications
[28-32].
11. Nasal base surgery
The nasal base is a triangular view of the nose that is formed by two nostrils, nasal columella
that separates these two nostrils and nasal lobule or the area above the nostrils. Nasal base
surgery is usually based on thorough preoperative evaluations. It should be kept in mind that
this stage of rhinoplasty is quite irreversible and any mistake in design or incision line will
result in valve incompetency, nasal base deformity and visible scars (Figure 16).
11.1. Suturing and taping
After finishing the operation the skin flap is turned back to its proper place and all the details
are checked several times. When the surgeon is sure that the desired result is achieved, suturing
is done. As a rule, all the incisions must be closed by sutures to avoid unfavorable scars or
dead spaces. It is suggested to irrigate the wound during suturing to avoid clot formation over
incision lines. The incisions are immediately covered by antibiotic ointment. Taping helps to
control dead spaces and edema; after suturing, a one centimeter tape is applied to re-drape the
skin flap over newly formed cartilaginous and bony structure. This taping is applied imme‐
diately after suturing and is continued for one month or longer after operation.
11.2. Intranasal splint fixation
Internal splints usually have small tubes that help the patient breathe through the nose in the
first post-operative days. It’s believed that internal splints prevent intranasal edema and
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Figure 16. Nasal base surgery Figure 16: Nasal base surgery
synechia. Internal splints may be removed after 24 hours; however, Suturing and taping

it is possible to preserve
it for one week or longer according to septal or turbinate manipulations done during surgery.
After finishing the operation the skin flap is turned back to its proper place and all
the details are checked several times. When the surgeon is sure that the desired
11.3. External splint application
result is achieved, suturing is done. As a rule, all the incisions must be closed by
External splints are usually thermoplastic stents softened in warm water and trimmed to
sutures to avoid unfavorable scars or dead spaces. It is suggested to irrigate the
provide suitable protection. The splint is gently placed over the taped nose. Irrigation with
wound during suturing to avoid clot formation over incision lines. The incisions are
cold water will fix the splint in place. The splint is held for 5 days to one week. It is believed
immediately covered by antibiotic ointment. Taping helps to control dead spaces
that external splints will hold the bony segments in their new position and will help the skin
and edema; after suturing, a one centimeter tape is applied to re‐drape the skin
envelope re-drape over its new structure [33-35].
flap over newly formed cartilaginous and bony structure. This taping is applied
11.4. Post-operative
immediately care and is continued for one month or longer after
after suturing
.operation
Careful post-operative care will help the operated nose achieve its ideal shape in a predictable
period of time. Sutures are usually removed in 5-7 post-operative days. Internal and external
Intranasal splint fixation
splints are usually removed on the same day though in some cases due to some specific
indications such as extensive septoplasty splints may be preserved for a longer period of time.
Internal splints usually have small tubes that help the patient breathe through the
Clot andfirst
nose in the debris are gently cleaned
post‐operative in periodic
days. postoperative
It’s believed visits. Frequent
that internal normal
splints saline
prevent
rinse by the patient and phenylephrine drops (only for three days after operation) may help
intranasal edema and synechia. Internal splints may be removed after 24 hours;
the patient breathe better in the immediate post-op period. Taping is continued for one month.
however, it is possible to preserve it for one week or longer according to septal or
Patients are asked to avoid moderate sport activities for one month though vigorous activities
.turbinate manipulations done during surgery
such as contact sports or professional exercises are best postponed for three months.

External splint application
External
1. splints
Diluted are usually thermoplastic
corticosteroids stents
(triamcinolone) may be softened in control
beneficial to warm the
water
edemaand
and
trimmed to provide suitable protection. The splint is gently placed over the taped
granulation tissues post-operatively.
nose. Irrigation with cold water will fix the splint in place. The splint is held for 5

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2. Selective taping is an effective method to shape subtle deformities. In this method

prominent edematous points such as supratip area may be pressed under tight taping
while other points that are susceptible to slight depression are left without taping or
covered with light taping
3. Any major revision is best postponed for 6 months to one year after the first operation
while smaller revisions such as alar base surgeries may be done sooner according to
specific conditions of patient after the first operation.
Author details
Payam Varedi1,2* and Behnam Bohluli2,3
*Address all correspondence to: payam.varedi@yahoo.com
1 Department of Oral and Maxillofacial Surgery, Qazvin University of Medical Sciences,

Qazvin, Iran
2 Department of Oral and Maxillofacial Surgery, Craniomaxillofacial Research Center, Shar‐

iati Hospital, Tehran University of Medical Sciences, Tehran, Iran
3 Department of Oral and Maxillofacial Surgery, Buali Hospital, Islamic Azad University of
References
[1] Swamy RS, Sykes JM, Most SP. Principles of photography in rhinoplasty for the digi‐
tal photographer Clin Plast Surg. 2010 Apr;37(2):213-21.
[2] Ziglinas P, Menger DJ, Georgalas C. The body dysmorphic disorder patient: to per‐
form rhinoplasty or not? Eur Arch Otorhinolaryngol. 2014 Sep;271(9):2355-8.
[3] Belli H, Belli S, Ural C. Psychopathological evaluation of patients requesting cosmetic

rhinoplasty: a review. West Indian Med J. 2012 Mar;61(2):149-53.
[4] Chauhan N, Warner J, Adamson PA. Aesthetic outcomes Plast Surg. 2010 Aug;34(4):
510-6
[5] Tan S, Rotenberg B. Functional outcomes after lateral crural J-flap repair of external
nasal valve collapse. Ann Otol Rhinol Laryngol. 2012 Jan;121(1):16-20.
[6] Saleh AM, Younes A, Friedman O. Cosmetics and function: quality-of-life changes af‐
ter rhinoplasty surgery. Laryngoscope. 2012 Feb;122(2):254-9.
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[7] Zoumalan RA, Larrabee WF Jr, Murakami CS. Intraoperative suction-assisted evalua‐
tion of the nasal valve in rhinoplasty. Arch Facial Plast Surg. 2012 Jan-Feb;14(1):34-8.
[8] Fung E, Hong P, Moore C, Taylor SM. The effectiveness of modified cottle maneuver
in predicting outcomes in functional rhinoplasty.
[9] Duron JB, Nguyen PS, Jallut Y, Bardot J, Aiach G. Middle third of the nose and inter‐
nal valve. Alar wall and external valve. Ann Chir Plast Esthet. 2014 Jul 30. pii:
S0294-1260(14)00105-8.
[10] Riechelmann H, Karow E, DiDio D, Kral F. External nasal valve collapse - a case-con‐
trol and interventional study employing a novel internal nasal dilator (Nasanita).Rhi‐
nology. 2010 Jun; 48(2):183-8.
[11] Bohluli B, Varedi P, Nazari S, Bagheri SC. Lateral crural suspension flap: a novel
technique to modify and stabilize the nasolabial angle.J Oral Maxillofac Surg. 2013
Sep;71(9):1572-6.
[12] Xavier R.Nasal tip plasty: the delivery approach revisited. Aesthetic Plast Surg. 2013
Feb; 37(1):16-21.
[13] Gruber RP, Chang E, Buchanan E. Suture techniques in rhinoplasty. Clin Plast Surg.
2010 Apr; 37(2):231-43.
[14] Gruber RP, Weintraub J, Pomerantz J. Suture techniques for the nasal tip. Aesthet
Surg J. 2008 Jan-Feb; 28(1):92-100.
[15] Lee KC, Kwon YS, Park JM, Kim SK, Park SH, Kim JH. Nasal tip plasty using various
techniques in rhinoplasty. Aesthetic Plast Surg. 2004 Nov-Dec; 28(6):445-55.
[16] Atighechi S, Sajadinejad BS, Baradaranfar MH, Dadgarnia MH, Shahbazian H. Cau‐
dal extension graft versus columellar strut with plumping graft for acute nasolabial
angle correction in rhinoplasty surgery.Eur Arch Otorhinolaryngol. 2014 Aug 18.
[17] McCollough EG, Mangat D. Systematic approach to correction of the nasal tip in rhi‐
noplasty. Arch Otolaryngol 07:12, 1981.
[18] Daniel RK. Rhinoplasty: creating an aesthetic tip. Plast Reconstr Surg 80:775, 1987.
[19] Xavier R. Nasal tip plasty: the delivery approach revisited. Aesthetic Plast Surg. 2013
Feb;37(1):16-21.
[20] Lee KC, Kwon YS, Park JM, Kim SK, Park SH, Kim JH. Nasal tip plasty using various
techniques in rhinoplasty. Aesthetic Plast Surg. 2004 Nov-Dec;28(6):445-55. Epub
2004 Dec 2.
[21] Hwang K, Hwang JH, Park JH, Kim DJ, Shin YH. J Experimental study of autologous
cartilage, acellular cadaveric dermis, lyophilized bovine pericardium, and irradiated
bovine tendon: applicability to nasal tip plasty. Craniofac Surg. 2007 May;18(3):551-8.
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[22] Antohi N, Isac C, Stan V, Ionescu R.Dorsal nasal augmentation with "open sandwich"
graft consisting of conchal cartilage and retroauricular fascia. AesthetSurg J. 2012
Sep;32(7):833-45.
[23] Temiz G, Yeşiloğlu N, Sarici M, Filinte GT. Congenital isolated aplasia of lower later‐
al cartilage and reconstruction using dorsal hump material. J Craniofac Surg. 2014
Sep;25(5):e411-3.
[24] Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump reduction: the impor‐
tance of maintaining dorsal aesthetic lines in rhinoplasty. PlastReconstr Surg. 2004
Oct;114(5):1298-308; discussion 1309-12.
[25] Varedi P, Bohluli B, Bayat M, Mohammadi F. Spreader graft placement: A simplified

technique for young surgeons. Int J Oral Maxillofac Surg. 2014 Oct;43(10):1216-7.
[26] Kucuker I, Ozmen S. Extended spreader graft placement before lateral nasal osteoto‐
my. Aesthetic Plast Surg. 2013 Aug;37(4):684-91.
[27] Grigoryants V, Baroni A.The use of short spreader grafts in rhinoplasty for patients
with thick nasal skin. Aesthetic Plast Surg. 2013 Jun;37(3):516-20.
[28] Varedi P, Shirani G, Bohluli B, Besharati R, Keyhan SO. A simplified approach to the
external lateral nasal osteotomy: a technical note. J Oral Maxillofac Surg. 2013 Aug;
71(8):1435-8.
[29] Rootman D, DeAngelis D, Tucker N, Wu A, Hurwitz J. Cadaveric anatomical com‐

parison of the lateral nasal wall after external and endonasal dacryocystorhinostomy
Ophthal Plast Reconstr Surg. 2012 Mar-Apr;28(2):149-53.
[30] Bohluli B, Moharamnejad N, Bayat M.Dorsal hump surgery and lateral osteotomy.
Oral Maxillofac Surg Clin North Am. 2012 Feb;24(1):75-86.
[31] Levie P, Horoi M, Claes J, Monnoye JP, Verheyden PJ, Monnoye V, Lefebvre J, Millet
B, Dartevelle D, Lemaire FX, Hatert AS, de Burbure C. External or internal lateral os‐
teotomy: why I choose the external percutaneous approach. B-ENT. 2010;6Suppl
15:49-50.
[32] Helal MZ, El-Tarabishi M, MagdySabry S, Yassin A, Rabie A, Lin SJ. Effects of rhino‐
plasty on the internal nasal valve: a comparison between internal continuous and ex‐
ternal perforating osteotomy. Ann Plast Surg. 2010 May;64(5):649-57.
[33] Yi CR, Kim YJ, Kim H, Nam SH, Choi YW. Comparison study of the use of absorba‐
ble and nonabsorbable materials as internal splints after closed reduction for nasal
bone fracture. Arch Plast Surg. 2014 Jul;41(4):350-4.
[34] Cayonu M, Acar A, Horasanlı E, Altundag A, Salihoglu M. Comparison of totally oc‐

clusive nasal pack, internal nasal splint, and transseptal suture technique after septo‐
plasty in terms of immediate respiratory distress related to anesthesia and surgical
complications. Acta Otolaryngol. 2014 Apr;134(4):390-4.
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[35] Drezner DA. Thermoplastic splint for use after nasal fracture. Otolaryngol Head
Neck Surg. 1994 Jul;111(1):146-7
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Chapter 32
Advanced Techniques in Rhinoplasty
Behnam Bohluli and Payam Varedi
http://dx.doi.org/10.5772/59745
1. Introduction
Basic techniques of rhinoplasty are known to experienced aesthetic surgeons; however, post-
traumatic nasal deformities, secondary cases and ethnic demands require advanced techni‐
ques. These modern techniques are generally aimed to provide a more normal looking nose
while a great attempt is made to preserve or return the normal function of the nose while
improving some existing functional shortcomings during the surgery. This chapter presents a
problem-based approach to some complex nasal deformities. Current solutions to each
deformity are presented and advantages and limitations of each technique are discussed.
2. Nasal tip deformities
2.1. Under-projected tip
Many techniques are known to increase tip projection all of which may be effectively used
according to patient's special needs and indications:
1. Tip sutures: A tip spanning suture is a mattress suture that is used on each dome area to
refine the angle between lateral crura and medial crura cartilages (Figure 1).This suture
has been shown to increase tip projection.
2. Cap graft: Cap graft is a small piece of cartilage that is precisely formed and trimmed and
fixed over the cartilaginous tip (Figure 2). The main indication of this graft is necessity to
form and refine the tip; though this graft slightly increases tip projection in this technique.
3. Shield graft (Sheen graft): The shield graft is the only technique that may arbitrarily add
to tip projection. A usual approach is to prepare and fix a bigger piece of cartilage. This
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oversized graft is incrementally trimmed and tailored until the ideal tip projection and
contour is achieved (Figure 3).[1,8]
Figure 1. Tip spanning suture
Figure 2. Cap graft

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Figure 3. Shield graft (Sheen graft)
2.2. Over-projected tip
An over-projected nasal tip is a common finding that must be detected in preoperative

assessments. Two general groups of techniques are applied to decrease the projection for all
over-projected noses. In the first group it is tried to sever normal tip support mechanisms that
will result in small decrease in tip projection. In the second group lower lateral cartilages are
interrupted in some parts. A few millimeters of cartilage are resected and a new tripod with
smaller limbs is formed.
1. Transfixion incision: All the resective techniques that are done on lower lateral cartilages
may decrease the projection; although, the transfixion incision is the only one that is
specifically done to decrease projection of the nose. This incision may decrease projection
up to 3 mm (Figure 4).
2. Dome splitting: In this technique lower lateral cartilages are divided in dome area, then
a few millimeter of excessive cartilage is resected and a new dome is formed by precise
suturing. A small piece of crushed or morselized cartilage may be placed over dome area
to cover the sutures and sharp edges of cartilages [9,13]
2.3. Drooping tip
There are many modalities to correct the drooping tip or acute nasolabial angle.
1. A wedge is sometimes resected from the caudal part of the septum to provide enough
space for tip rotation (Figure 5).
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Figure 4. Transfixion incision
2. Cephalic trimming of lower lateral cartilages and
3. Collumellar strut insertion
These are other modalities that are basically done to increase nasolabial angle. In case basic
techniques fail to provide the ideal result, the following techniques may be effectively applied
[14,16]
4. Tip rotating suture
This is an effective method to increase and hold the nasolabial angle. In this technique a
mattress suture is used to anchor lower lateral cartilages to the nasal septum, by incremental
tightening of the suture, ideal nasolabial angle is achieved, then with several subsequent ties
this nasolabial angle is fixed and stabilized.
Tip rotating suture easily changes the tip position, though it is clear that a single suture
suspension may lose its effect gradually and will not lead to permanent results; to achieve
stable results, tip support mechanisms should be improved (i.e. application of collumellar
strut) and appropriate space be provided for new tip position (i.e. conservative cephalic
trimming and caudal resection of septum) [17,18]
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Figure 5. A wedge is resected from caudal part of the septum to provide enough space for tip rotation.
3. Tongue in groove
In this technique two medial crura cartilages are completely separated from each other. Then
upper lateral cartilages are stripped off the nasal septum. Medial crural cartilages are pushed
back in a way that each medial cru covers the nasal septum on one side. A delicate needle is
used to temporarily fix the medial crura cartilages to the septum. Skin flap is turned back to
its original position for several times. When the ideal nasolabial angle is achieved, medial crura
are fixed to the septum with several PDS sutures. In this method the lower lateral cartilages
(nasal tip) are permanently fixed to the nasal septum. [19]
4. Lateral crural anchorage flap
In this technique, excessive parts of the lateral crural cartilages that are routinely excised
and resected in tip plasty are marked on both sides. Cartilage incisions are made and
excessive cartilage is separated from its underlying skin in a way that its medial attach‐
ments remain intact. Excessive cartilages are easily omitted while two cartilage flaps with
a strong attachment to medial crural cartilage are available. These two flaps are used to
rotate the nasal tip. Cartilage flaps are fixed with a needle to the nasal septum. The
maneuver may be done for several times to find the ideal tip position. Then the flaps are
precisely fixed with sutures to the nasal septum. [17]
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This technique is based on two cartilage flaps that are in fact excessive parts of the lower lateral
cartilages. These cartilages are supposed to be trimmed and resected in normal rhinoplasty. It
is clear that in weak cartilage, or in case a small strip of cartilage is to be trimmed this approach
will not be possible.
4.2. Weak lower lateral cartilages and pinch deformity
Strength and consistency of lower lateral cartilages play an important role in shape and
function of the lower one third of the nose. Many techniques have been proposed to reinforce
and reshape the lower lateral cartilages; all may be used in specific indications:
1. Batten grafts: a batten graft is a thin oval piece of cartilage that is used over deficient or
weak cartilaginous part of the nose to reshape and reinforce the nose. This graft is
frequently fabricated from septal cartilage or chonchal cartilage. It may be used on one
side or bilaterally according to specific needs and indications. [20,22]
2. Lateral crural strut graft: Unlike batten grafts the lateral crural strut graft is placed beneath
the lower lateral cartilages, so after adequate injection of local anesthetic under the lower
lateral cartilages, the lateral crura is precisely stripped off from its underlying skin and a
quadrangular piece of cartilage is fixed under the lateral crura.
This technique:
a. Restores pinch deformities
b. Reinforces external nasal valve
c. Corrects moderate to severe cephalic positioning of lower lateral cartilages [23,24]
d. Alar contouring grafts: Alar contour or alar rim grafts are quite simple and effective
techniques frequently used for several aesthetic and functional indications. These grafts
are narrow strips of cartilage placed in a pocket anterior to the lower lateral cartilages.
This graft is made from septal or chonchal cartilage.
Indications:
a. To reinforce external nasal valve
b. To correct minor cephalic positioning of lower lateral cartilages
c. To provide a pleasant nostril borders [25]
d. Lateral crural transposition flap: In this technique excessive parts of lower lateral
cartilages that are usually trimmed and discarded in rhinoplasty, are folded inside, in this
way, wide lateral crural cartilages are reshaped while excessive cartilage is used to
reinforce the lateral crural cartilage. [26]
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5. Dorsal problems
5.1. Shallow radix
In some patients pre-operative evaluations show that radix augmentation will help gain a
pleasant aesthetic appearance. A complete familiarity with common autografts, their poten‐
tials and limitations will help the surgeon to select a predictable and stable graft with accept‐
able results in each specific indication. [27,28]
5.2. Low dorsum
Augmentation of a low dorsum is an important task in current concepts of rhinoplasty. Many

modalities and techniques are proposed, though all of them have their own advantages and
disadvantages and no one technique seems to cover all the indications for dorsal augmentation.
Proper case selection and familiarity with characteristics of each technique are prerequisites
for a successful dorsal augmentation.
5.3. 1-rib graft
Rib grafts are extensively used in reconstructive nasal surgery. Considerable amounts of
cartilage and bone, acceptable mechanical properties such as strength and load bearing as well
as its resistance to resorption has made it the gold standard for massive cartilaginous aug‐
mentations and reconstructions. Availability of other autografts, potential drawbacks of rib
cartilage and patient compliance has limited its use to severe deformities and the need for
excessive amount of graft material.
Graft distortion (warping) is a common complication in rib cartilage grafting. Many modalities
have been proposed to control this unwanted effect. Some authors drill the core of the graft
with a long delicate orthopedic bur and insert a strong Krishner wire to control any possible
distortion. Sometimes it is thought that core of the graft has the least potential for warping so
it is suggested to trim the periphery of the graft and to use the core of rib cartilage as the graft
material.[29,31]
6. Temporalis fascia
Temporalis fascia is a well-established augmentation material in rhinoplasty. To harvest

temporalis fascia, after proper application of local anesthesia, a 5 cm incision is done in
posterior neck hair line with anterior and upward dissections adequate access is gained to the
superficial layer of the deep temporalis fascia. Adequate amount of fascial tissue is harvested
and the donor site is precisely sutured after complete control of bleeding. Temporalis fascia
provides a soft and smooth layer that may cover dorsal irregularities. It may be used for
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minimal dorsal augmentations and for greater amounts of augmentation it should be com‐
bined with other grafting techniques otherwise alternatives may be selected. [32,33]
6.1. Postauricular fascia
Postauricular and mastoid fascia provide a thick fascial tissue that is easily harvested with a
4cm curvilinear incision exactly behind the ears; incision lines are completely concealed behind
the ears in normal skin creases and the risk of complications comparing to donor sites in the
temporalis fascia is quiet low. This fascial tissue may be used in moderate dorsal augmenta‐
tions (Figure 6). [34]

Figure 6. Post-auricular fascia harvesting

6.2. Turkish delight
Turkish delight is an efficient technique that was originally designed by Erol in 2000. This
Figure 6: Post‐auricular fascia harvesting
technique was aimed to solve essential problems that were frequently encountered in the use
Turkish delight
of cartilage blocks from the nasal septum or ribs. In Erol's original ‐4 cartilage was
report rib
delicately diced into small particles, then soaked in blood and wrapped in Surgicel. Daniel
Turkish delight is an efficient technique that was originally designed by Erol in
wrapped the diced cartilages in temporalis fascia to omit the unpredictable behavior of Surgicel
2000. This technique was aimed to solve essential problems that were
(oxidized cellulose) coverage. Diced cartilage wrapped in fascia is now commonly utilized in
frequently encountered in the use of cartilage blocks from the nasal septum or
augmentation rhinoplasty and is reported to have acceptable results (Figure 7). [35,36]
ribs. In Erol's original report rib cartilage was delicately diced into small
particles, then soaked in blood and wrapped in Surgicel. Daniel wrapped the
diced cartilages in temporalis fascia to omit the unpredictable behavior of
Surgicel (oxidized cellulose) coverage. Diced cartilage wrapped in fascia is now
commonly utilized in augmentation rhinoplasty and is reported to have
( (35, 36
acceptable results (Figure 7).
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Figure 7. Turkish delight Figure 7: Turkish delight
Fascia‐cartilage sandwich technique‐5
6.3. Fascia-cartilage sandwich technique
Fascia‐cartilage sandwich is reasonable alternative to rib grafts. In this
Fascia-cartilage sandwich is reasonable alternative to rib grafts. In this technique temporalis
technique temporalis or mastoid tissue is harvested, cartilage block from nasal
or mastoid tissue is harvested, cartilage block from nasal septum or chonchal tissue is trimmed
septum or chonchal tissue is trimmed and formed in its ideal contour, and then
and formed in its ideal contour, and then it is covered with fascia. In fact cartilage provides
it
the bulk ofis covered with fascia.
augmentation materialIn and
fact fascia
cartilage provides
covers the bulk
the possible of augmentation
irregularities and shadows
material and fascia covers the possible irregularities and shadows of a cartilage
of a cartilage block graft [37]
.(block graft (37
6.4. Internal nasal valve incompetency
Internal nasal valve incompetency
Sometimes pre-operative evaluations show that one or both internal nasal valves are incom‐
Sometimes pre‐operative evaluations show that one or both internal nasal
petent and do not work well. On the other hand in major hump resections (more than 3mm);
valves
nasal valve are incompetent
reconstruction will beand do not For
necessary. work
thiswell. On internal
reason, the other hand
nasal in reinforcement
valve major
is commonly indicated and may be indicated in most cases. The followings are some ofbe
hump resections (more than 3mm); nasal valve reconstruction will effective
valve reinforcement
necessary. For techniques:
this reason, internal nasal valve reinforcement is commonly
1. indicated
Spreader and Spreader
graft: may be grafts
indicated
werein most
first cases. The
introduced followings
in 1981 by Jackare some
Sheen andof
are now
considered the gold standard in internal nasal valve reinforcements. A spreader graft is
: effective valve reinforcement techniques
a piece of quadrangular cartilage that is placed between upper lateral cartilage and
Spreader graft: Spreader grafts were first introduced in 1981 by Jack ‐1
septum. Spreader grafts are usually used on both sides though due to some specific needs
Sheen
such and are now
as asymmetries considered
unilateral the gold
spreaders may bestandard
utilized.in
[ internal nasal valve
39]
2. Autospreader: In this technique, after incremental trimming of the nasal septum, the
upper lateral cartilages are folded inside. It is thought that this technique prevents

unnecessary graft harvesting and will provide the same effects as spreader grafts though
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the main advantage of this technique is its reversibility and when an ideal result is not
obtained intra-operatively, the sutures can be removed. Upper lateral cartilages are
conservatively trimmed and other standard valve reconstruction techniques such as
spreader grafts may be applied (Figure 8).[40-42]
Figure 8. Autospreader
3. Docile splay graft: The docile splay graft is a piece of septal cartilage that is gently crushed
and is placed over the nasal septum in a way that it covers the nasal septum and the two
upper lateral cartilages are located laterally to the graft. It is believed that this simple graft
will prevent upper lateral cartilages from functional movements and collapse [43]
1. Spreader grafts may be indicated to straighten a curved nasal dorsum that is not corrected
in normal septoplasty techniques [39]
2. Internal nasal valve reconstruction prevents and corrects inverted V deformities and plays
a substantial role in providing aesthetic brow lines.
7. Septal deformities
In most cases basic techniques will result in a straight functional nasal airway though in
complicated cases more aggressive approaches may be necessary.
7.1. Complicated septal deformities
Sometimes the nasal septum is deviated in several different planes, and insisting on basic
septoplasty techniques does not solve the problem and may lead to septal perforation and
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many other complications. Extracorporeal septoplasty is a known modality that may be

applied by experienced surgeons. In this technique, after an open approach skeletonization,
the upper lateral cartilages are completely stripped off from nasal septum and then septal
cartilage is precisely detached from all its anatomic connections and is taken out completely.
The deformed nasal septum, which is now on the surgical table, is completely re-evaluated.
Broken and deformed parts are excised and omitted in a way that a heavy strong L strut
remains or is reconstructed. This newly formed septum is placed back inside the nose and
tightly fixed to the bony vault and upper lateral cartilages [44-47]
7.2. Inadequate osteotomy
Sometimes intraoperative evaluations show that in spite of clear lateral osteotomy lines,
medialization of bony segments is not achieved; in these cases medial osteotomy (in internal
continuous osteotomy) and lateral oblique osteotomy (in external perforating osteotomy) may
be indicated.
7.3. Medial osteotomy
In most rhinoplasty cases, lateral osteotomy will fulfill all the aims of osteotomy and there are
limited indications for medial osteotomy; in indicated cases medial osteotomy may resolve
some potential complications and will complete the bony vault surgery such as:
1. Exteremely wide noses: Sometimes in wide noses lateral osteotomy will not appropriately
metalize the bony segments and medial osteotomy will result in passive movements of
bony segments.
2. When hump reduction is not performed or has not resulted in an open roof of the bony
vault; medial osteotomy will allow the osteotomy to be completed; otherwise excessive
pressure if applied may lead to uncontrolled fractures.
3. Deviated bony pyramid: In this case complete reformation of the bony pyramid is
necessary thus, total release of bony segments and repositioning may be necessary. [48-50]
7.4. Rocker deformity
Rocker deformity is a relatively common sequel of lateral osteotomy. In this complication a

large bony spicule is seen and palpated after lateral osteotomy over nasal radix. Like many
other complications the best is to avoid this deformity by limiting osteotomy line maximum
up to lateral canthus and not to extend it in thicker bony compartments. In case rocker
deformity is seen, sharp bony spicules may be gently trimmed and sometime crushed
cartilages or fascia can be used to camouflage the deformity. [51]
7.5. Crooked bony vault
In some post-traumatic nasal deformities a conventional lateral osteotomy does not result in
an ideal symmetric bony vault; a double layer osteotomy may solve the problem in most cases.
In this technique a deep low or low lateral osteotomy is performed in the traditional way; the
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second line of osteotomy is started in a higher plane and then with light finger pressure the
bony vault is molded. In case adequate results are not achieved a third line may be designed
on one side or both sides of the nose. [52]
1. Internal continuous osteotomy may dislodge the fractured bony segments in two layer
osteotomies, thus external perforating osteotomy is usually preferred in these deformities.
As a predictable alternative, first deep osteotomy may be done by the internal method
and the second line which is used to mold the segment may be added via the external
approach.
2. Crushed cartilage may help the surgeon camouflage residual irregularities and asymme‐
tries. In this technique a small part of crushed cartilage is gently placed on deficient parts,
and then is molded until the ideal symmetric result is achieved.
Author details
Behnam Bohluli1 and Payam Varedi2*
*Address all correspondence to: payam.varedi@yahoo.com
1 Department of Oral and Maxillofacial Surgery, Buali Hospital, Islamic Azad University of
Medical Sciences, Tehran, Iran, and Craniomaxillofacial Research Center, Shariati Hospital,
Tehran University of Medical Sciences, Tehran, Iran
2 Department of Oral and Maxillofacial Surgery, Qazvin University of Medical Sciences,

Qazvin, Iran, and Researcher, Department of Oral and Maxillofacial Surgery, Craniomaxillo‐
facial Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran,
Iran
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technique to modify and stabilize the nasolabial angle. J Oral Maxillofac Surg. 2013
Sep;71(9):1572-6.
[18] Tasman AJ, Lohuis PJ. Control of tip rotation. Facial Plast Surg. 2012 Apr;28(2):
243-50.
[19] Ponsky DC, Harvey DJ, Khan SW, Guyuron B.Nose elongation: a review and de‐
scription of the septal extension tongue-and-groove technique.
[20] Chua DY, Park SS. Alar batten grafts. JAMA Facial Plast Surg. 2014 Sep 1;16(5):377-8.
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[21] Bewick JC, Buchanan MA, Frosh AC. Internal nasal valve incompetence is effectively
treated using batten graft functional rhinoplasty. Int J Otolaryngol. 2013;2013:734795.
[22] Sufyan AS, Hrisomalos E, Kokoska MS, Shipchandler TZ. The effects of alar batten
grafts on nasal airway obstruction and nasal steroid use in patients with nasal valve
collapse and nasal allergic symptoms: a prospective study. JAMA Facial Plast Surg.
2013 May;15(3):182-6.
[23] Kuran I, Oreroğlu AR. The sandwiched lateral crural reinforcement graft: a novel
technique for lateral crus reinforcement in rhinoplasty.AesthetSurg J. 2014 Mar;34(3):
383-93.
[24] Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applica‐
tions in rhinoplasty. PlastReconstr Surg. 1997 Apr;99(4):943-52; discussion 953-5.
[25] Toriumi DM, Checcone MA. New concepts in nasal tip contouring. Facial PlastSurg‐
Clin North Am. 2009 Feb;17(1):55-90, vi. doi: 10.1016/j.fsc.2008.10.001. Review.
[26] Ashtiani AK, Bohluli B, Bateni H, Fatemi MJ, Sadr-Eshkevari P, Rashad A. Lateral
crural transposition flap in tip correction: Tehran retrospective rhinoplasty experi‐
ence.Ann Plast Surg. 2013 Jul;71(1):50-3. doi: 10.1097/SAP.0b013e318248b7f1. Erratum
in: Ann Plast Surg. 2013 Aug;71(2):246
[27] Cohen JC, Pearlman SJ. Radix grafts in cosmetic rhinoplasty: lessons from an 8-year
review. Arch Facial Plast Surg. 2012 Nov;14(6):456-61
[28] Besharatizadeh R, Ozkan BT, Tabrizi R. Complete or a partial sheet of deep temporal
fascial graft as a radix graft for radix augmentation. Eur Arch Otorhinolaryngol. 2011
Oct;268(10):1449-53
[29] Baser B, Kothari S, Thakur M.Diced cartilage: an effective graft for post-traumatic
and revision rhinoplasty. Indian J Otolaryngol Head Neck Surg. 2013 Aug;65(Suppl
2):356-9. doi: 10.1007/s12070-012-0525-6. Epub 2012 Feb 25.
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Jun;33(3):190-5.
[31] Christophel JJ, Hilger PA. Osseocartilaginous rib graft rhinoplasty: a stable, predicta‐
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Ital. 2013 Jun; 33(3):183-9.
[33] Baker TM, Courtiss EH. Temporalis fascia grafts in open secondary rhinoplasty. Plas‐
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[34] Cho JM, Jeong JH, Woo KV, Lee YH. Versatility of retroauricular mastoid donor site:
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structive surgery. J Craniofac Surg. 2013; 24(5):e486-90.
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cision for simultaneous harvesting of temporal and mastoid fasciae: a technical
note..J Oral Maxillofac Surg. 2013 Sep;71(9):1598-600.
[36] Erol OO. The Turkish delight: a pliable graft for rhinoplasty. PlastReconstr Surg.
2000 May;105(6):2229-41; discussion 2242-3.
[37] Gerbault O, Aiach G. Diced cartilage wrapped in deep temporal aponeurosis (DC-F):
A new technique in augmentation rhinoplasty. Ann ChirPlastEsthet. 2009 Oct; 54(5):
477-85.
[38] Antohi N, Isac C, Stan V, Ionescu R.Dorsal nasal augmentation with "open sandwich"
graft consisting of conchal cartilage and retroauricular fascia. AesthetSurg J. 2012
Sep;32(7):833-45.
[39] Varedi P, Bohluli B, Bayat M, Mohammadi F. Spreader graft placement: A simplified

technique for young surgeons. Int J Oral Maxillofac Surg. 2014 Oct;43(10):1216-7.
[40] Hussein WK, Elwany S, Montaser M. Modified autospreader flap for nasal valve
support: utilizing the spring effect of the upper lateral cartilage. Eur Arch Otorhino‐
laryngol. 2014 Sep 30
[41] Pepper JP, Baker SR. The autospreader flap in reduction rhinoplasty.Arch Facial
Plast Surg. 2011 May-Jun;13(3):172.
[42] Moharamnejad N, Bohluli B. Docile splay graft for middle vault reconstruction. Br J
Oral Maxillofac Surg. 2013 Dec;51(8):e307-9.
[43] Aaronson NL, Vining EM. Correction of the deviated septum: from ancient Egypt to
the endoscopic era. Int Forum Allergy Rhinol. 2014 Aug 18
[44] Bohluli B, Motamedi MH, Varedi P, Malekzadeh M, Ghassemi A, Bagheri SC. Man‐
agement of perforations of the nasal septum: can extracorporeal septoplasty be an ef‐
fective option?J Oral Maxillofac Surg. 2014 Feb;72(2):391-5.
[45] Nazari S, Bohluli B, Varedi P, Besharatizade R. Carpentering in septorhinoplasty: a

novel technique to straighten the deviated nasal septum.J Oral Maxillofac Surg. 2014
Jan;72(1):157-63.
[46] Karameşe M, Akdağ O, Akatekin A, Koplay TG, Koplay M, Tosun Z. Extracorporeal

Septoplasty Combined With Valve Surgery in Rhinoplasty Patients.Ann Plast Surg.
2014 Oct 2.
[47] Ghassemi A, Ayoub A, Modabber A, Bohluli B, Prescher A. Lateral nasal osteotomy:

a comparative study between the use of osteotome and a diamond surgical burr - a
cadaver study. Head Face Med. 2013 Dec 19;9:41.
[48] Varedi P, Shirani G, Bohluli B, Besharati R, Keyhan SO. A simplified approach to the
external lateral nasal osteotomy: a technical note.J Oral Maxillofac Surg. 2013 Aug;
71(8):1435-8.
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[49] Bohluli B, Moharamnejad N, Bayat M. Dorsal hump surgery and lateral osteoto‐
my.Oral MaxillofacSurgClin North Am. 2012 Feb;24(1):75-86.
[50] Harshbarger RJ, Sullivan PK. The optimal medial osteotomy: a study of nasal bone
thickness and fracture patterns. PlastReconstr Surg. 2001 Dec;108(7):2114-9; discus‐
sion 2120-1.
[51] Cerkes N. The crooked nose: principles of treatment. AesthetSurg J. 2011Feb;31(2):
241-57.
[52] Levie P, Horoi M, Claes J, Monnoye JP, Verheyden PJ, Monnoye V, Lefebvre J, Millet
B, Dartevelle D, Lemaire FX, Hatert AS, de Burbure C. External or internal lateral os‐
teotomy: why I choose the external percutaneous approach.B-ENT. 2010;6Suppl
15:49-50.
[53] Helal MZ, El-Tarabishi M, MagdySabry S, Yassin A, Rabie A, Lin SJ. Effects of rhino‐
plasty on the internal nasal valve: a comparison between internal continuous and ex‐
ternal perforating osteotomy. Ann Plast Surg. 2010 May;64(5):649-57.
[54] Sinha V, Gupta D, More Y, Prajapati B, Kedia BK, Singh SN. External vs. internal os‐
teotomy in rhinoplasty. Indian J Otolaryngol Head Neck Surg. 2007 Mar;59(1):9-12.
[55] Rohrich RJ, Janis JE, Adams WP, Krueger JK.An update on the lateral nasal osteoto‐
my in rhinoplasty: an anatomic endoscopic comparison of the external versus the in‐
ternal approach. Plast Reconstr Surg. 2003 Jun; 111(7):2461-2; discussion 2463.
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Chapter 33
Rhinoplasty in Adult Patients with Cleft — Lip Nasal

Deformities
Fereydoun Pourdanesh and Behnam Bohluli
http://dx.doi.org/10.5772/59237
1. Introduction
Among facial esthetic surgeons, secondary rhinoplasty in adult cleft –nose deformities is
considered to be one of the most challenging surgical interventions due to the congenital
distortion of the cartilaginous and bony nasal pyramid, which compromises both nasal
esthetics and function. It is generally accepted that the cleft-lip nasal deformity (CLND) is
challenging; It is attempted to do this either at the time of primary rhinoplasty in the early of
age with repair of lip or by secondary rhinoplasty later on in life. CLND may vary from minor
to severe deformity. Several techniques have been suggested and plenty of articles have
discussed this issue but still there is no consensus on an optimal technique to manage all of
the problems. The common techniques that we use in routine rhinoplasty may not yield good
results in patients with CLND, and the reasons for that are:
1. The complexity of anatomical pathology which involves all layers, including skin,
cartilage, vestibular lining and skeletal base platform.
2. Numerous former surgical interventions leading to significant scar tissue in the operating
site
3. The inevitable effect of growth over time.
The clinical presentation of cleft nose deformities varies widely, requiring a full knowledge of
surgical techniques; if deformity is severely asymmetric surgical correction is much more
difficult. The clinical features of deformity in a unilateral cleft nose differ from that usually
seen in bilateral CLND. The scenario of rhinoplasty in surgical techniques in bilateral CLND
is entirely different from unilateral CLND. It seems complete correction of all deficiencies of
some noses remain an intangible goal for many, and this is the reason why revision rhinoplasty
is commonly needed in these patients. Furthermore, it should be noted that each patient with
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CLND presents a unique challenge due to complexity and combination of aspects and certain
techniques that may be more suitable than others in individual cases [1, 2].
2. Primary or secondary rhinoplasty
Primary rhinoplasty means performing rhinoplasty simultaneously with repair of cleft lip and
secondary rhinoplasty means performing rhinoplasty at an early age i.e. during school going
age(5-6 years), early adolescence (10-12 years) or later on in life (above 16 yrs. in women and
age 18 yrs. in men). But as a working diagnosis, primary rhinoplasty in adults with CLND
means the first attempt of surgical intervention on the nose and secondary rhinoplasty means
revision rhinoplasty or second operation on the nose.
The best time to attempt correction of CLND is still controversial. With improvement in cleft
lip surgery, there is an increasing interest for correction of the nose at the time of lip repair.
Some authors strongly recommend a primary rhinoplasty and believe if the procedure is
performed correctly it does not adversely affect the growth of the paranasal region. Primary
rhinoplasty improves nasal symmetry in patients with unilateral cleft lip deformity. This does
not exclude the possibility of later revisional surgery although there is tendency to doing an
appropriate primary repair of cleft lip deformity but the fact is, small defects that are left after
primary repair are amplified with the growth process and affect adjacent structures. It is
become clear that primary and secondary rhinoplasty at the same time of lip repair or at age
7-8 can lead to some kind of deformities in adulthood. The adult deformity is related not only
to the original embryological mesodermal deficiency and diminished growth potential, but
also to the pattern of primary surgery, the degree of interceptive surgery during growth and
the level of orthodontic skill practiced within a particular treatment. In our center most cases
are referred for primary rhinoplasty in adulthood [3-9].
3. Clinical signs and symptoms
A variety of clinical signs may be seen in an operated cleft lip and palate patient as well as in
unoperated cases. We are usually faced with a wide variety of signs and symptoms in a
repaired cleft lip case with or without primary rhinoplasty. In this section the clinical signs of
cleft nose deformity will be discussed.
3.1. Unilateral cleft lip nose deformity
Clinical features of cleft nose deformity from a cosmetic point of view have varied from minor
to severe (Figure 1).
It is not easy to accurately describe the anatomic pathology of secondary CLND. Components
of the nasal deformity include defects of all layers of skin, cartilages, septum, entire nasal
pyramid as well as hypoplasia and mal positioning of the maxillary segments and the anatomic
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Rhinoplasty in Adult Patients with Cleft — Lip Nasal Deformities 787

http://dx.doi.org/10.5772/59237
MEDICAL‐EDITED CHAPTER FOR AOMFS VOL 2

Figure 1. Basal view of minor and two difficult cases of unilateral cleft nose.
and functional
Figure.1: Basal deformity of the
view of orbicularis
minor and muscle. It is accepted
two difficult thatof
cases patients who undergo
unilateral cleft
appropriate primary repair for cleft lip will have secondary deformities [8]. Recently many
three dimensional studies have been performed on cleft lip nose deformity patients; thanks to
nose.
advances in technology we can define the details of the anatomic and functional deformity of
each component [10]. The cleft deformity is not restricted to the skin and cartilage. Hogan
It represented
is not easy to accurately describe the anatomic pathology of secondary
the unilateral cleft nasal deformity as a tilted tripod (Figure 2).
CLND. Components of the nasal deformity include defects of all layers of
skin, cartilages, septum, entire nasal pyramid as well as hypoplasia and mal
positioning of the maxillary segments and the anatomic and functional
deformity of the orbicularis muscle. It is accepted that patients who
undergo appropriate primary repair for cleft lip will have secondary
deformities[8] . Recently many three dimensional studies have been
performed on cleft lip nose deformity patients; thanks to advances in
Figure 2. Tilted nasal tripod in CLND
technology we can define the details of the anatomic and functional
Because of the lack of skeletal support, the alar base on the cleft side can, in some cases, become
deformity of each component [10]. The cleft deformity is not restricted to
retro positioned with growth, even following an appropriate primary correction [9]. In most
cases however good the primary correction, the patient is left with asymmetry of the nasal
the skin and cartilage. Hogan represented the unilateral cleft nasal
base and nares [11].
deformity as a tilted tripod [Figure 2]. and lies below the alae on the non- cleft side.
The ala on the cleft side is lengthened vertically
The lower lateral cartilage is depressed and spread across the cleft. The nasal tip is deviated
toward the left side. The columella on the left side is shortened significantly, as compared with
the non-cleft side. The columella is obliquely oriented. With its base deviated to and located
in the non-cleft side away from the midline. Bilateral alar bases are asymmetric, with the cleft
side alar base inferiorly and posteriorly displaced. [12]
The deformities such as a deficient tubercle, vermilion deficiency, irregularities, the short
upper lip, long upper lip, tight upper lip, and unfavorable scars may be common seen in the
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repaired lip [9]. Also the severity of septal deformity is variable. Typically, the septum is
dislocated from the maxillary crest towards the non-cleft side resulting in a septal deflection
towards the cleft side commonly causing nasal obstruction on that side. In addition, the inferior
turbinate on the cleft side is also frequently hypertrophic, further adding to nasal obstruction

on that side. [13] Lee [8] described seven cardinal deformities in unilateral cleft lip nose
 Discontinuity of the orbicularis oris muscle
deformity include:
 the
• Caudal deflection of Long or short lip deformity
nasal septum to the non-cleft side
• Deviation of the nasal dorsum
 Absence of the philtral column
• Low setting of the medial crus

• Tethering deformity of the lateral crus
Although Huffman and Lierle in 1949 published the most detailed
• Discontinuity of the orbicularis oris muscle
descriptions of the cleft lip nasal deformity, over time it has changed; the
• Long or short lip deformity
typical clinical features of the unilateral cleft nasal deformity [Figure 3] is
• Absence of the philtral column
characterized as follow:
Although Huffman and Lierle in 1949 published the most detailed descriptions of the cleft lip
nasal deformity, over time it has changed; the typical clinical features of the unilateral cleft
nasal deformity (Figure 3) is characterized as follow:

Figure 3. Typical deformityFigure 3. Typical deformity in unilateral cleft nose deformity

in unilateral cleft nose deformity
1. The tip of the nose and caudal septum are deviated towards the non-cleft side.
1. The tip of the nose and caudal septum are deviated towards the non‐
2. The base of the columella also deviates towards the non-cleft side.
cleft side.
3. The convexity of the2.septum on the side of the cleft impinges on the airway.
The base of the columella also deviates towards the non‐cleft side.
4. The angle between the medial and lateral crura on the cleft side is excessively obtuse.
5. The dome of the alar cartilage on the cleft side is depressed.
6. The interior of the cleft-side nostril, from its apex down the cephalic margin of the alar

cartilage to the pyriform aperture, is bowed by a linear contracture—the vestibular web.
7. The lateral crus is caudally displaced on the cleft side.
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8. The cleft side ala buckles inwardly (M configuration)

9. The cartilage on the cleft side smaller than the normal side
10. Absent alar-facial groove on the cleft side
11. Hypoplastic maxilla on cleft side
12. Ill-proportioned nares
13. Widened nostril floor on cleft side
14. Retrodisplaced medial crus on the cleft-side
15. Oblique slant of the columella [8-14]
3.2. Bilateral cleft nose deformities

Adult patients with bilateral cleft lip nose deformity (BLCND) show some asymmetry. Typical
characteristics of BLCND include: a short columella, a short, depressed, thick nasal tip, flat–
appearing nasal tip, sometimes notched in the midline, large diverging nostrils, wide nostril
floors, an obtuse columella-labial angle, wide alae, a short nasal bridge, and a wide nasal root,
lateral displacement of both alar domes with bilateral dislocation of the lateral crura from the
septum, hooding of the alar rims and flaring alar bases.The short columella is the most common

problem in bilateral cleft nose deformity. Although the residual deformity in bilateral cleft is
symmetrical correction of nasal tip widening, the retro- positioning of the alar cartilage and
and difficult to treat. The secondary deformity involves the nose and th
shortening of the columella are all encountered and difficult to treat. The secondary deformity
involves the nose and the lip as well as the facial profile (Figure 4) [12, 15, and 16].
as well as the facial profile (Figure 4) [12, 15, and 16].

Figure 4. Preoperative views A: Frontal view B: lateral view

4. Diagnosis
In order to treat CLND, clinical diagnosis and complete knowledge of anatomy, pathology
Figure 4: Preoperative views A: Frontal view B: lateral view
and physiology of the nasal pyramid, maxilla, and lip is imperative. Clinical examination
4‐ Diagnosis
In order to treat CLND, clinical diagnosis and complete knowledg
anatomy, pathology and physiology of the nasal pyramid, maxilla, and l
imperative. Clinical examination consists of a careful examination of
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grown adult we need to evaluate:
1‐The nose and lip
consists2‐ Midface deficiency
of a careful examination of the bony and cartilaginous skeleton, anterior rhinoscopy
evaluating the appearance of the nasal mucosa and the position of the anterior part of the
septum3‐ Oro‐ nasal fistula
is necessary. The problems present in a patient with a cleft lip nasal deformity must
be recognized just as any other rhinoplasty patient and clearly defined in order to formulate
4‐Occlusion and
a successful treatment plan. In fully grown adult we need to evaluate:
1. The nose and lip
5‐ Speech.
2. Midface deficiency
3. Significant
Oro- nasal fistula improvement in growth , function and esthetics has
4. Occlusion and
achieved by almost normal reconstruction of alveolar clefts .To est
5. Speech.
the nasal skeletal base , three dimensional reconstruction of alv
Significant improvement in growth, function and esthetics has been achieved by almost normal
reconstruction of alveolar clefts.To establish the nasal skeletal base, three dimensional
defects with bone grafting has been advocated by clinicians;
reconstruction of alveolar defects with bone grafting has been advocated by clinicians;
diff
different approaches at the different stages of life have been suggested (Figure 4).
approaches at the different stages of life have been suggested [Figure

Figure
Intraope
Figure 5. Intraoperative view of 3D reconstruction of alveolar cleft

Proper jaw relationship plays an important role in the skeletal base of the nose; obviously, final
rhinoplasty must be postponed until completion of orthognathic surgeries. Although some
authors suggested performing orthognathic surgery on growing cleft patients when mandated
by psychological and / or functional concerns; but, because of postsurgical outcome the
consensus of most clinicians is to delay orthognathic surgery until growth is completed.
Different kinds of distraction procedures such as intraoral and extraoral devices may be used
as an alternative to the orthognathic approaches in cleft patients; a proper position of the
maxilla is mandatory before performing rhinoplasty in adults with cleft lip and nose deformity.
Supposedly, the skeletal support enhances the projection of the lip and nose on the cleft side.
CT scan of paranasal sinuses in axial and coronal views may be helpful to define the defor‐
mation of the septum as well as other intranasal structures. It is important to identify both
aesthetic and functional problems associated with the cleft nose deformity. Each component
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of the deformity must be addressed in an orderly manner including the skeletal base, nasal
dorsal bone and cartilage, nasal tip cartilage, and, finally, the skin envelope [1, 8, 11, 17-21].
5. Non-surgical treatment
Before correction of the soft tissues, it is important to make sure if there are any dental problems
that needs to be corrected first. Soft tissue correction before dental treatment can result in very
embarrassing situation that may not be correctable later [22].
6. Surgical treatment
No single procedure has given sufficiently satisfactory results to provide a surgical standard
for CLND correction. Despite considerable progress in the treatment of patients with cleft lip
and palate, there is still no agreement about the optimal treatment method. Secondary
deformity after the primary operation is a significant problem encountered in cleft-lip repair
[23]. The knowledge and experience of the surgeon in rhinoplasty is the keystone for correcting
deformity. Use of four basic techniques in rhinoplasty such as onlay grafting, suturing
methods, cartilage transection, reorientation and cartilage repositioning can help the cosmetic
surgeon to overcome many of the problems inherent to these patients. Familiarity with the
numerous techniques in this regard and selection of the proper one to treat the existing
deformity is essential. No matter which technique is used it is important to address all parts
of the deformity and set all parts in anatomic position. Nostril asymmetry is one of the main
complaints of adult patient with unilateral cleft nose deformities. In 1977, Tajima and Mar‐
uyama introduced an operation in which the deformed alar cartilage was fixed to the upper
lateral cartilage through a reverse-U incision, and the insufficient area within the nostril was
filled with the overhanging alar web tissues. We use this method for the correction of severe
asymmetric nostrils. To obtain ideal treatment outcomes in unilateral cleft nose deformity the
below list of procedures are used.
1. Using open rhinoplasty approach

2. Doing septoplasty and harvesting graft from the septum via open approach incision.
3. Release septum to upper lateral cartilage on the non-cleft side.
4. Release upper lateral cartilage from the skin and nasal pyriform
5. Correcting deformed caudal and dorsal part of the septum which is fixed to the non-cleft
side.
6. Release and splitting of lower lateral cartilage on the cleft side.
7. Medial and lateral crus elevation
8. Using reverse U incision for correcting web.
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9. Using Z- plasty incision in vestibular pica for vertical lengthening.

10. Reshaping and repositioning of lower lateral cartilage is essential for correcting nostril
deformity.
11. Using multiple sutures to stabilize the final shape of lower and upper lateral cartilages.
12. Using autogenous graft for augmentation
13. Augmentation approach is better than reduction
14. Strut, tip, sheen and batten grafts are help to restore the nasal tip.
15. Unequal alar base resection
MEDICAL‐EDITED CHAPTER FOR AOMFS VOL 2
16. Release depressor septi muscles
Internal or external osteotomy can be used (Figure 5) [8, 24].
Internal or external osteotomy can be used (Figure 5) [8, 24].

A B

C D

Figure 5: A, Before surgery: B, Intraoperative: C, Immediately

Figure 6. A, Before surgery: B, Intraoperative: C, Immediately after surgery: D, one week post surgery
after surgery: D, one week post surgery
In bilateral cleft nose deformity although confronted with almost symmetric deformities the
lengthening of the columella, correction of the depressed nasal tip, bilateral dislocation of alar

cartilage and eversion of the alar bases are on the top of the clinician’s concern. There are many
ways to elongate the shortness of the columella such as forked flap, v-y advancement,
prolabium advancement
flap combined with an Abbe flap, composite graft and skin rim
rotation flap [26]. Using strong and proper struts, repositioning and reshaping lower lateral
cartilages, supraperiosteal dissection of the pyriform area to allow the reposition of nasal
In bilateral cleft nose deformity although confronted with almost symmetric
deformities the lengthening of the columella , correction of the depressed
nasal tip, bilateral dislocation of alar cartilage and eversion of the alar bases
are on the top of the clinician’s concern. There are many ways to elongate
the shortness of the columella such as forked flap, v‐y advancement,
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correcting alar component, use of different suturing methods and augmentation with autog‐
enous grafts can help to achieve almost ideal results (Figure 6).
Figure 7. A and B, before surgery basal and lateral view, C: intraoperative D and E: 6 months after surgery
7. Outcomes
Normalized esthetics of the lip and nose is on the top of the specific goals of surgical care for
children born with cleft lip and palate followed by nasal airway patency and normal speech
[25]. The focus of secondary correction of unilateral cleft-lip nose deformity has been nasal
symmetry. Importance has been placed on correction of the cleft-lip nasal deformity by
translocation of the alar cartilage with its attached vestibular lining into a normal position,
thereby establishing the normal vault and shape of the cartilage.[23] There is no doubt that
definitive rhinoplasty should logically only be undertaken after reconstruction of skeletal base
and correction of the jaws relationship. The key point is overcorrecting the cleft-side nostril
and its alar cartilage is believed to produce better symmetry compensating for possible relapse
during the postoperative period [12]
8. Complications
There is no difference between the complications associated with cleft lip rhinoplasty and
traditional open rhinoplasty in non-cleft patients. Theoretically the risk of infection is more
likely particularly when cartilage grafts are used. The risk of bleeding is similar to that of
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traditional rhinoplasty. Patients should be warned of possible need for secondary rhinoplasty,
need for minor or even major revision, existence of nostril asymmetry, visible scars, skin
necrosis, dysfunction of nasal system and anomalies associated with the donor site. Clinical
failures using different kinds of grafts consisting of autograft, allograft and alloplastic
materials may be seen in the future. Failure to achieve the desired nasal contour and normal
looking appearance is a common finding in cleft lip nasal rhinoplasty.
Author details
Fereydoun Pourdanesh1* and Behnam Bohluli2
*Address all correspondence to: drpourdanesh@gmail.com
1 Associate Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry,

Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Associate Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry,

Azad University, Tehran, Iran
References
[1] Hellings P et al, Unique approach to secondary cleft lip rhinoplasty in facial plastic
surgery, B-ENT, 2010,6:97-101
[2] Monasterio, O,F Ruas J,E, Cleft Lip Rhinoplasty: The Role of Bone and Cartilage
grafts clinics in Plastic Surgery-Vol. 16, No. 1, January 1989,177-187
[3] Anastassov E.G,Joos U., Comprehensive management of cleft lip and palate deformi‐
ties, Joms, Volume 59, Issue 9, 2001, Pages 1062–1075
[4] Thomas C, Primary Rhinoplasty for the Cleft Nasal Deformity. J Def Manag 2013 S3:
005. Doi:10.4172/2167-0374.S3-005
[5] Penfold C,Douminguez – gonzalez S Bilateral cleft lip and nose repair,bjomfs. Vol‐
ume 49, Issue 3, 2011, Pages 165–17
[6] Nakajima T, Ogata H, Sakuma H, Long-term outcome of simultaneous repair of bi‐

lateral cleft lip and nose (a 15 year experience),brithis journal of plastic surgry,2003,
(56),205-217
[7] El bestar M, Mansour O: Cleft lip nasal deformity : primary repair,Egypt.J,plast. Re‐
constr.surg.vol 28 No, 1 2004, pages 15-21
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[8] Lee DW, Choi B-K, Park Be-Y.Y, Seven Fundamental Procedures for Definitive Cor‐
rection of Unilateral Secondary Cleft Lip Nasal Deformity in Soft Tissue Aspects, J
Oral Maxillofac Surg,2011 :69:e420-e430,
[9] BANKS P, the surgical anatomy of secondary cleft lip and palate deformity and its
significance in reconstruction, british journal of oral surgery (1983) 21, 78-93
[10] Nakamura N, Okawachi, T, Nozoe E,, Nishihara K, and Matsunaga K, Three-Dimen‐

sional Analyses of Nasal Forms After Secondary Treatment of Bilateral cleftlip–Nose
Deformity in Comparison to Those of Healthy Young Adults, J Oral Maxillofac Surg
69:e469-e481, 2011
[11] Hopper A.R, Cutting C, Grason B, chapter 23, cleft lip and palate,Grabb and smith’s
plastic surgery,6th edition by Charles H Thorne,2007,pages 201-225
[12] Banks p, the surgical anatomy of secondary cleft lip and palate deformity and its sig‐
nificance in reconstruction, British Journal of Oral Surgery (1983) 21, 78-93
[13] Lun-Jou Lo, Primary Correction of the Unilateral Cleft Lip Nasal Deformity: Achiev‐
ing the Excellence, Chang Gung Med J 2006;29:262-7)
[14] Huffman WC,Leirle DM,studies on the pathologic anatomy of the unilateral harelip
nose,plast reconstr surg,1949,4:225
[15] Yonehara, Y, Mori Y, Chikazu D, Saijo H, Tsuyoshi Takato T, Secondary Correction

of Bilateral Cleft Lip and Nasal Deformity by Simultaneous Placement of an Abbe
Flap, Septal Cartilage Graft, and Cantilevered Iliac Bone Graft, J Oral Maxillofac Surg
66:581-588, 2008
[16] Ahmed SA, Ramadan M.M, Correction of Secondary Deformities of the Cleft Lip
Nose,Suez Canal Univ Med J Vol. 11, No. 1, March, 2008 1 -7
[17] Precious S.D, A New Reliable Method for Alveolar Bone Grafting at About 6 Years of
Age, J Oral Maxillofac Surg 67:2045-2053, 2009
[18] Epker N.B, Correction of the Skeletal Nasal Base in Rhinoplasty, J Oral Maxillofac
Surg 49:939-946, 1991
[19] Pourdanesh f.Behnia H, Using l-shaped bone graft to restore alar base region in pa‐
tients with alveolar cleft, International Journal of Oral & Maxillofacial Surgery Vol‐
ume 42, Issue 10, Page 1202, October 2013
[20] Wolford M.L, Cassano S.D, Cottrell A.D, El Deeb M, Karras, Goncalves R.J, Orthog‐
nathic Surgery in the Young Cleft Patient: Preliminary Study on Subsequent Facial
Growth, J Oral Maxillofac Surg 66:2524-2536, 2008
[21] Showkatbakhsh R, Pourdanesh F, Jamilian A, Ghorbani A, Behnaz M. Hyrax applica‐

tion as a tooth-borne distractor for maxillary advancement., J Craniofac Surg. 2011
Jul;22(4):1361-6.
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[22] Tung K.M, Management of Post Cleft Deformities of the Lip & Nose,medical bulle‐
tin,vol.12,no 11,November 2007
[23] Fujimoto T, Imai K, Hatano T, Makoto Takahashi, Tamai M, Follow-up of unilateral

cleft-lip nose deformity after secondary repair with a modified reverse-U method,
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 747e753
[24] Tajima S, Maruyama M: Reverse-U incision for secondary repair of cleft lip nose.
Plast Reconstr Surg 60:256, 1977
[25] Taheri Talesh K, Kalantar Motamedi MH, cleft lip and palate surgery, A text book of
advanced oral and maxillofacial surgery p 560- 569
[26] Nakamura N, Sasaguri M, Okawachi T, Nishihara K, Nozoe E, Secondary correction

of bilateral cleft lip nose deformity e Clinical and three-dimensional observations on
pre- and postoperative outcome, Journal of Cranio-Maxillo-Facial Surgery 39 (2011)
305e312
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Chapter 34
Advanced Applications of the Er:YAG Laser in Oral and

Maxillofacial Surgery
Dragana Gabrić, Anja Baraba, Goran Batinjan, Marko Blašković,

Vanja Vučićević Boras, Irina Filipović Zore, Ivana Miletić and
Elizabeta Gjorgievska
http://dx.doi.org/10.5772/59273
1. Introduction
Lasers are becoming widely used in medicine and dentistry due to their beneficial effects such
as: coagulation properties (less postoperative bleeding), less pain and edema. Lasers also allow
good and rapid healing, a very low level of discomfort both during and after intervention and
a rapid disappearance of symptoms.
Four responses within tissues are described when the laser beam hits the target tissue namely
reflection, absorption, transmission and scattering. The main mechanisms of interaction
between the lasers and biological tissues are: photothermic, photoacoustic and photochemical.
The effect of lasers on the soft tissues is based on the transformation of light energy into heat.
Operator-dependent factors affecting the effect of lasers are: power density, energy density,
pulse repetition rate, pulse duration and the mode of energy transferred. Operator non-
dependent factors which affect laser treated areas are specific laser wavelengths and optical
properties of the target tissues [1].
Effects on the tissues when lasers are applied include the increase in the temperature,
coagulation, hemostasis, tissue sterilization, tissue welding, incision, excision, ablation and
vaporization [1]. When laser energy is absorbed in the water of the hard tissues, a rapid volume
expansion of the evaporating water occurs as a result of a substantial temperature elevation
at the interaction site. Micro-explosions are produced causing hard tissue disintegration. If
pulp temperatures are raised beyond 5 degrees, pulp damage is irreversible. If heat is intensive
and lasts for an extended period of time the consistency of the intracellular ground substance
may not be preserved [1].
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Erbium-yttrium-aluminum-garnet (Er: YAG) lasers produce invisible infrared light at a

wavelength of 2.940 nm which is ideal for absorption by hydroxylapatite and water [2].
Therefore, they can be used for treatment of both soft and hard tissues (unlike for example
diode lasers). As the Er: YAG wavelength corresponds to the absorption coefficient of water,
Er: YAG laser irradiation transforms water within tissue into steam leading to the development
of micro-explosions [3].
2. Advantages of Er: YAG laser treatment
Laser technology has certain advantages such as accuracy of the incision, absence of vibration
and manual pressure during use; this is also true for Er: YAG laser application. Due to laser
positive coagulation effects during surgical procedure, better sight of the work field is
obtained. Komori [4] and Gouw-Soares [5] have reported that Er: YAG lasers are appropriate
for the treatment of hard dental tissues without inducing discomfort, vibration or noise.
Furthermore, risk of surgical field contamination and damage to the surrounding tissues is
decreased when compared to the other similar techniques. Additionally Er: YAG lasers are
characterized by low intraoperative and postoperative pain levels. Decreased pain levels by
use of Er:YAG as well as other lasers may be explained by the fact that laser application leads
to the formation of protein coagulum on the surface of the wound which acts as a dressing [6].
Furthermore, lasers have the ability to seal sensory nerve endings which results in decreased
pain perception. Last but not least, Er: YAG lasers produce rapid wound healing [7].
3. Possible hazards of laser use
It is very important to acknowledge possible thermal damage induced by Er: YAG lasers in
the clinical setting. Kreisler [8] suggested that temperature elevation did not exceed 47°C after
120 seconds of Er:YAG laser irradiation with pulse energy between 60 and 120 mJ and
frequency of 10 Hz. Geminiani [9] reported that application of Er:YAG lasers in continuous
mode for 10 seconds generated a high temperature which was above critical threshold.
Monzavi [10] reported that use of Er: YAG was safe without cooling and that, an increase of
4.30°C was observed. Use of air and air water cooling eliminated the risk of possible thermal
damage. Mitsunaga [11] retrieved literature data from the year 2001 to 2012 with regard to
complications after laser irradiation such as cervicofacial subcutaneous emphysema. They [11]
reported 13 such cases, of which eight had undergone CO2 laser treatment and two had
undergone Er: YAG laser treatment. Nine patients had emphysema following laser irradiation
for soft tissue incision [11].
4. Application of ER: YAG laser in soft tissue surgery
Lasers have played an integral part in the evolution of oral and maxillofacial surgery (OMS);
and rapidly became the standard of care for many procedures performed by oral surgeons.
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Advanced Applications of the Er:YAG Laser in Oral and Maxillofacial Surgery 801
http://dx.doi.org/10.5772/59273
The reason for this transition is simple: many procedures can be executed more efficiently and
with less morbidity using lasers when compared with scalpel, electrocautery or high frequency
devices. Onisor [12] performed an in vitro study using Er: YAG and CO2 laser for crown
lengthening, gingivoplasty and maxillary labial frenectomy. The same authors [12] concluded
that Er: YAG is able to provide good cutting and coagulation effects on soft tissues. Specific
parameters have to be defined for each laser in order to obtain the desired effect. Reduced or
absent water spray, defocused light beam, local anesthesia and use of long pulses are important
in order to obtain optimal coagulation and bleeding control. Kaya [13] described a case of
pyogenic granuloma around an implant seven years after its insertion which they treated by
use of Er: YAG laser. Türer [14] compared Er: YAG laser to the scalpel in the preparation of
the recipient site for free gingival grafts. The same authors [14] stated that Er: YAG laser may
be used with similar effectiveness as the scalpel for this purpose.
Laser surgery has emerged as an established method in advanced medicine. Laser-induced

remote tissue treatment provides a number of advantages: controllable coagulation and cutting
of surgical tissues with wavelength tissue-specific cutting efficiency [15]. At the Department
of Oral Surgery, School of Dental Medicine, University of Zagreb, two clinical studies of Er:
YAG laser use for soft tissue surgery was performed.
4.1. Er: YAG laser-assisted surgery of benign oral tumors
The aim of first study was to evaluate the efficacy of a high power diode laser, Er:YAG and
Nd:YAG laser in surgical therapy of benign oral lesions in comparison to the conventional
methods on the basis of following temperature difference in surrounding tissue during the
laser operation procedure.
Infrared thermography is a diagnostic method with ability to record infrared radiation emitted
by the skin and convert it into electronic video signals. Infrared thermography is unique in its
capability to show physiological and/or pathological temperature changes [16]. One hundred
and twenty patients who had indication for surgical removal of benign oral lesions were
randomly divided into four groups dependent on the type of therapy. First group (Diode
group) received diode laser therapy with Laser (Hager & Werken GmbH & Co., Germany).
Depending on the indications settings specified by the manufacturer for removal of fibroma
a “Fibroma removal mode” was used (wavelength of 975 nm, power of 5W, CW). Second (Er:
YAG) and third (Nd: YAG) groups received Er: YAG and Nd: YAG therapy modules. All
settings of the Er: YAG and Nd: YAG laser were according to manufacturer specifications.
Light Walker AT (Fotona, Slovenia) was used for Er: YAG and Nd: YAG treatments. The laser
settings were 150 mJ for fibroma removal in pulse mode QSP and 15 Hz frequency. Non-contact
X-Runner digitally controlled handpiece was used for treatments. The shape with the X-
Runner handpiece was selected according to the required treatment area. The handpiece was
held at the distance 15 mm from the treatment tissue, without water spray (Figures 1-3). In the
fourth group (scalpel group) procedure was performed using the conventional methods using
the cold knife for fibroma removal and afterwards the wounds were sutured.
YAG and Nd: YAG therapy modules. All settings of the Er: YAG and Nd: YAG laser were according to
YAG and Nd: YAG therapy modules. All settings of the Er: YAG and Nd: YAG laser were according to
manufacturer
manufacturer specifications.
specifications. Light
Light Walker
Walker AT (Fotona,
AT (Fotona, Slovenia)
www.dentalbooks.co Slovenia) was
was used for for
used Er: Er:
YAG YAG
and and
Nd: YAG
Nd: YAG
treatments.
treatments. The The laser
laser settings
settings were 150
were 150 mJ
mJ for
for fibroma
fibroma removal
removal in in
pulse mode
pulse QSP QSP
mode and and
15 Hz
15 Hz
frequency. Non‐contact X‐Runner digitally controlled handpiece was used for treatments. The shape
frequency. Non‐contact X‐Runner digitally controlled handpiece was used for treatments. The shape
802 A with the X‐Runner handpiece was selected according to the required treatment area. The handpiece
Textbook of Advanced Oral and Maxillofacial Surgery Volume 2
with the X‐Runner handpiece was selected according to the required treatment area. The handpiece
was held at the distance 15 mm from the treatment tissue, without water spray (Figures 1‐3). In the
was held at the distance 15 mm from the treatment tissue, without water spray (Figures 1‐3). In the
fourth group (scalpel group) procedure was performed using the conventional methods using the
fourth group (scalpel group) procedure was performed using the conventional methods using the
cold knife for fibroma removal and afterwards the wounds were sutured.
cold knife for fibroma removal and afterwards the wounds were sutured.

Figure 1. Fibroma of the right cheek (left) and removal of the lesion using Er: YAG laser with X‐
FigureRunner handpiece (right)
1. Fibroma of the right cheek (left) and removal of the lesion using Er: YAG laser with X-Runner handpiece

(right)
Figure 1. Fibroma of the right cheek (left) and removal of the lesion using Er: YAG laser with X‐
Runner handpiece (right)
Figure 2. Fibroma of the hard palate (left) and removal of the lesion using Er: YAG laser with X-Runner handpiece
(right)
Figure 3. Follow-up (case from Figure 2), 3 weeks after surgery
4.2. Thermographic measurement and thermogram processing
Prior to the start of the procedure each patient spent 15 minutes in operating anteroom in which
the temperature and humidity are the same as the operating room since both areas have
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http://dx.doi.org/10.5772/59273
controlled environment (air conditioned). Camera was set on a tripod at fixed, predetermined
distance (30 cm from the head of the patient), thus camera settings were always the same.
Infrared (IR) camera in general records temperature distribution in a given area. In this case
it recorded temperature distribution in the oral cavity prior to, during and after laser treatment
and during postoperative check-up. Taking thermographic images (thermograms) allowed us
to monitor the effects of laser treatment on tissues, i.e. the changes in temperature of tissue
treated with the laser (and surrounding tissue in close proximity) caused by the effects of laser
on the tissues, i.e. the effects during the procedure. Thermographic images taken using FLIR
T335 camera (Flir systems, USA) during laser procedure were stored on the computer for later
processing. Images had to be spatially calibrated firstly during image interpretation in order
to obtain data regarding spatial temperature distribution in the image. Spatial market, metal
equilateral triangle of known dimensions, was used for that purpose. Metal triangle was easily
visible on thermographic images since its temperature was a few degrees lower. Since the
triangle dimensions were known and well defined, triangle outlines on the image were used
for spatial measurement. In this procedure metal triangle was used as spatial marker in the
same way as a ruler (as a “standard” spatial marker) is used (Figure 4, in the middle).
Figure 4. Thermographic image processing
In all the surgical procedures performed, thermal increase was evaluated until the end of the
procedure; thermal decrease was evaluated in the few seconds after surgery. Matlab program
(MathWorks, USA) was used for processing thermograms in the RGB format. The oral health
related quality of life (OHRQoL) was assessed in all four groups after the surgical procedure.
All participants filled-out the Oral Health Impact (OHIP) 14-CRO Questionnaire. The ques‐
tions were related to the period during and after the surgical procedure. Patients answered
each question using the 0-4 Likert scale (0=absence of problems; 4=the most severe problems).
The OHIP Summary Score was calculated for statistical analysis. Results of this study showed
no significant temperature differences between diode and Nd: YAG group during the surgical
procedure. They had almost the same temperature in the region (p=0.76). Er: YAG group had
significantly lower temperature increase in the operative areas when compared to the other
two laser groups (p<0.001). The highest superficial thermal increase was recorded for diode
laser, the lowest one for Er: YAG laser (Table 1). Participants in all three laser groups had
significantly lower OHIP14-CRO summary scores (p<0.001, Table 2).
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LASER THERMAL EFFECT

Mean (μm) ± SD
Er:YAG 38,92 ± 19,92
Nd:YAG 81,23 ± 3,53
Diode laser 82,76 ± 5,38
Table 1. Thermal effect of the operated area during the surgical procedure, mean value and standard deviation (SD)
Group mean SD t P
(OHIP score)
OHIP Summary score Laser groups 12.65 3.84 -6.776 <0.001 *
Scalpel group 26.50 8.29
Degree of freedom = 38, * significant at 99% probability, p<0.01
Table 2. Difference in the OHIP 14 scores as well as in the OHIP 14 Summary Scores between the laser groups and the
scalpel group together with significance of the differences
Most laser excisional or incisional procedures are accomplished at 100°C, where vaporization
of intracellular and extracellular water causes ablation or removes biological tissues. Clinicians
must be aware of the heat generated within tissues during a procedure. If the tissue temper‐
ature exceeds 200°C during a laser procedure, carbonization and irreversible tissue necrosis
will occur. This adverse consequence can be avoided completely by using the lowest power
setting necessary to achieve the desired treatment goal [17].
Er: YAG lasers operate at a higher wavelength on the principle of ablation in non-contact mode
at a 2940 nm wavelength, while the diode and Nd: YAG laser work at smaller wavelength on
the principle of excision in contact mode which denotes a more aggressive approach. That is
probably the reason why the diode and Nd:YAG lasers cause higher heating of the surrounding
tissues and a higher dispersion of energy which damages more surrounding structures within
targeted therapeutic areas and result in slower healing. However, they result in better
hemostasis and less swelling due to the effects of diode laser on tissue targets (melanin and
hemoglobin). When considering use of diode laser for soft tissue surgery, the clinician must
consider several factors. Diode lasers are attracted to pigment, and frena are typically thicker
fibrous tissue and have very little pigment. The lack of pigment and more fibrous nature of
the tissue mean that higher energies and patience are required to ablate this tissue. Other lasers,
such as Er: YAG lasers may ablate frena faster, and can be used in non-contact mode, but the
drawback compared to diode lasers is an increased risk of bleeding. Er: YAG lasers are not
well absorbed in hemoglobin as the soft tissue diode lasers are, so hemostasis can be an issue
with these wavelengths. Some studies [18-23] compared the efficacy of diode and Er: YAG
lasers in soft tissue oral surgery. Some studies showed that the Er:YAG laser induced deeper
gingival tissue injury than diode laser, as judged by bleeding at surgery, delayed healing and
deformed specimen for histopathological analysis [23]. In some studies the use of diode laser
showed additional advantages over Er: YAG in terms of less postoperative discomfort and
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pain, but some studies show no difference between these two lasers [3]. Some studies indicate
that only the Er: YAG laser can be used for lingual frenectomy without local anesthesia, and
there was no difference between the two groups regarding the degree of the postsurgical
discomfort except in the first 3 hours [19]. Results indicate that the Er: YAG laser is more
advantageous than the diode laser in minor soft-tissue surgery because it can be performed
without local anesthesia and with only topical anesthesia.
Since the introduction of the lasers in clinical practice, different wavelengths have been used
for oral surgery on the basis of the different characteristics and affinities of each. One study
compared different laser wavelengths in relation to both thermal increase and "histological
quality" in a model of soft tissue surgery procedures. Thermal evaluation was noticed, during
laser-assisted surgery excision performed on a bovine tongue, by a thermal camera device to
evaluate thermal increase on the surface of the sample and with four thermocouples to evaluate
thermal increase on the depth of the specimen. Temperature was recorded before start of the
surgical procedure and at the peak of every excision. The results of this study are similar to
ours because the highest in depth thermal increase was recorded for the 5 W diode lasers, the
lowest one for Er: YAG laser [21].
4.3. Evaluation of Er:YAG laser for surgical treatment of precancerous lesion (leukoplakia)
Leukoplakia is a white precancerous lesion of the oral cavity with a recognizable risk of
malignant transformation. According to the World Health Organization, the name leukoplakia
can be used to describe the clinical finding of white patches on the oral mucosa that cannot be
removed or classified as other oral diseases. Histologically, leukoplakia consists of epithelial
hyperplasia, with or without hyperkeratosis, minimal inflammation, and different degrees of
dysplasia. Oral leukoplakia is the most common potentially malignant lesion of the oral cavity,
and the incidence of malignant transformation increases during the years. Treatment options
are: scalpel excision, electrocoagulation, cryotherapy and CO2 laser therapy. Extremely
extensive lesions are the biggest challenge. Pharmacological treatments include vitamin A and
retinoids, topical antioxidants and bleomycin [24-26]. Out of all available ablative lasers in the
treatment of leukoplakia Er: YAG laser is emphasized due to the highest degree of absorption
in water. The latest laser technology allows extremely precise ablation or excision of these
lesions using computerizing, automatic guided laser beams with precise and individually
determined limits by use of QSP mode (X-Runner, LightWalker, Fotona, Slovenia, 2013).
Besides complete visibility during ablation due to its coagulation effect, speed, precision of the
procedure and rapid healing without postoperative complications or healing without scar are
its main advantages [27].
We evaluated the effectiveness of ablative Er: YAG laser in the treatment of leukoplakia and
frequency of recurrence after ablative laser therapy. By regular monitoring of postoperative
pain via visual analogue scale of pain scores (VAS), the impact of leukoplakia at the quality of
life (QoL) using OHIP-14 questionnaire was also assessed. The study was conducted at the
School of Dentistry, University of Zagreb, Croatia. Ablative Er: YAG laser was used on 28
lesions with histologically confirmed diagnosis of oral leukoplakia. Lesions were measured
(in millimeters), which was necessary for monitoring results and the potential recurrence, as
www.dentalbooks.co
well as for the choice of laser parameters. During surgery, after applying a local anesthetic
(Ubistesin 2%, 3M ESPE), depending on the size of the lesion, the size of the working field of
the laser was selected. All hyperkeratotic lesions were removed by ablation. Their degree was
recorded as was the number of sessions required for ablation. Patients were seen at follow-up
a week, two weeks, four weeks and eight weeks after the irradiation. At the follow-up, lesions
were re-measured for each patient when applicable and the results were compared with the
initial data. Postoperative pain was assessed by VAS where the patient rated the degree of pain
after the procedure on the scale from 1-10. Also, each patient filled-out the OHIP - 14 ques‐
tionnaire of the impactAt of
irradiation. the lesions
follow‐up, on thewere
lesions quality of their
re‐measured life
for each (Figures
patient 5-15). and
when applicable Allthe
data were used
for statistical analysis.
results were compared with the initial data. Postoperative pain was assessed by VAS where the
patient rated the degree of pain after the procedure on the scale from 1‐10. Also, each patient filled‐
irradiation. At the follow‐up, lesions were re‐measured for each patient when applicable and the
out the OHIP ‐ 14 questionnaire of the impact of lesions on the quality of their life (Figures 5‐15). All
data were used for statistical analysis.
irradiation. At the follow‐up, lesions were re‐measured for each patient when applicable and the

Figure 5. Leukoplakia of the right cheek (left) and removal using Er: YAG laser with X‐Runner
Figure 5. Leukoplakia of the right cheek (left) and removal using Er: YAG laser with X-Runner handpiece
handpiece (right)
(right)
handpiece (right)

handpiece (right)

Figure 6. Immediate postoperative view (left) and follow‐up 3 weeks after surgery (right)

Figure 6. Immediate postoperative view (left) and follow-up 3 weeks after surgery (right)


Figure 7. Leukoplakia of the right lateral tongue (left) and removal using Er: YAG laser with X‐


Figure 7. Leukoplakia of the right lateral tongue (left) and removal using Er: YAG laser with X-Runner handpiece
(right)
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8
Book Title
8
Book8 Title
Book Title
8
Book Title





Figure 9. Leukoplakia of the left lateral tongue (left) and removal using Er: YAG laser with X‐Runner
handpiece (right)

handpiece (right)
Figure 9. Leukoplakia of the left lateral tongue (left) and removal using Er: YAG laser with X-Runner handpiece (right)
handpiece (right)

handpiece (right)




Figure 11. Sublingual leukoplakia (left) and immediate postsurgical view after removal using Er: YAG laser with X-
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Figure 11. Sublingual leukoplakia (left) and immediate postsurgical view after removal using Er:
Figure 11. Sublingual leukoplakia (left) and immediate postsurgical view after removal using Er:
YAG laser with X‐Runner handpiece (right)
YAG laser with X‐Runner handpiece (right)

Figure 12. Follow-up 3 weeks after surgery
Figure 12. Follow‐up 3 weeks after surgery

Figure 13. Leukoplakia of the upper lip (left) and removal using Er: YAG laser with X‐Runner
Figure 13.
Figure 13. Leukoplakia Leukoplakia of the upper lip (left) and removal using Er: YAG laser with X‐Runner
of the upper lip (left) and removal using Er: YAG laser with X-Runner handpiece (right)
handpiece (right)
handpiece (right)

Figure 14. Leukoplakia of the alveolar ridge (left) and removal using Er: YAG laser with X‐Runner
Figure 14. Leukoplakia of the alveolar ridge (left) and removal using Er: YAG laser with X‐Runner
handpiece (right)
Figure 14. Leukoplakia of the alveolar ridge (left) and removal using Er: YAG laser with X-Runner handpiece (right)
handpiece (right)

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http://dx.doi.org/10.5772/59273
The results of our study confirmed that treatment of leukoplakia by Er: YAG laser had less
edema, post-operative bleeding and pain, in comparison to the conventional surgical methods
of treatment such as scalpel. The procedure was easily tolerated and postoperative pain was
low or absent. Significant differences between men and women regarding the location of the
lesions, number of laser sessions and VAS were found (Tables 3 and 4).
Gender N (%) Differences in gender Differences compared to the recurrence

Male 10 (37) 0.148
Female 17 (63)
Age (mean ± SD) 53.3. ± 13.3 0.459 0.643
Smoking Yes 9 (33.3) 0.260 0.121
Smoking No 18 (66.7)
Cigarettes per day (mean ± 18.3 ± 10 0.809 0.471
SD)
Lesion in mm2 74.8 ± 90.4 0.166 0.381
(mean ± SD)
Buccal mucosa 11 (40.7) <0.001* 0.004*
Tongue 6 (22.2)
Sublingual mucosa 3 (11.1)
Other 7 (26)
Table 3. Demographic data regarding participants and location of the leukoplakia lesions.
Laser parameters – shape N Differences in gender Differences compared to the

(%) recurrence
Circle 10 (37) 0.456 0.926
Rectangle 8 (29.6)
Combination 9 (33.3)
Number of ablations 7 (25.9) 0.05 0.694

≤10
11-20 16 (59.3)
>20 4 (14.8)
Number of laser sessions 2.1 ± 0.8 0.036* <0.001*

(mean ± SD)
Recurrence Yes 20 (74.1) 0.148
Recurrence No 7 (25.9)
VAS (mean ± SD) 2.68 ± 3.28 0.008* 0.200
OHIP 9.6 ± 9.8 0.493 0.283
Table 4. Data regarding laser parameters, number of ablations, recurrence rate as well as VAS scores and OHIP results.
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The results indicate that sublingual leukoplakia lesions tend to recur less frequently in
comparison to the ones situated on the buccal mucosa, tongue and on other parts of the oral
mucosa. All leukoplakia lesions found sublingually were seen in women. Women tended to
have higher VAS scores in comparison to the men. Men had less laser sessions compared to
the women due to the fact that lesions in men were mostly located on the buccal mucosa.
In the published literature there are few papers on treatment of leukoplakia which is refractory
to conventional therapy. In the recent years, lasers are having shown to be highly effective in
the soft tissue surgery due to the properties of coagulation during surgery and post-operative
swelling and pain reduction [28-31]. It was found that laser-assisted removal of the precan‐
cerous lesion with the non-contact, digitally controlled X-Runner handpiece was very safe and
9 (33.3)
pleasant for the patient and very effective and comfortable for the operator. The operational
Combination
Number of ablations
7 (25.9)
field is very clear, especially because there
≤10
is no bleeding during the operation with the QSP
11‐20 16 (59.3) 0.05 0.694
mode. The interventions
>20
were performed
4 (14.8)
very quickly because of the automatic coverage of
the area with the X-Runner handpiece
Number of laser sessions
2.1 ± 0.8 [27].
0.036* <0.001*
(mean ± SD)
Recurrence Yes 20 (74.1)
0.148
4.4. Gingival melanin
Recurrence No depigmentation
7 (25.9)
VAS (mean ± SD) 2.68 ± 3.28 0.008* 0.200
So far, there are not many published studies regarding the use of Er: YAG lasers in the
OHIP 9.6 ± 9.8 0.493 0.283
treatment of gingival melanin pigmentations (Figures 16

In the published literature there are few papers on treatment and 17).which
of leukoplakia Theis results of the study of
refractory to
conventional therapy. In the recent years, lasers are having shown to be highly effective in the soft
Simsek Kaya.tissue surgery due to the properties of coagulation during surgery and post‐operative swelling and
[3] have showed that both diode and Er:YAG laser applied at 1 W can perform
gingival depigmentation. However, it seems that treatment duration is longer when Er: YAG
pain reduction [28‐31]. It was found that laser‐assisted removal of the precancerous lesion with the
non‐contact, digitally controlled X‐Runner handpiece was very safe and pleasant for the patient and
lasers are applied compared to the diode lasers. This difference may be explained by the fact
very effective and comfortable for the operator. The operational field is very clear, especially because
that diode lasers penetrate
there is deeper
no bleeding during in comparison
the operation tomode.
with the QSP the The Er:interventions
YAG lasers. were Furthermore,
performed wave‐
very quickly because of the automatic coverage of the area with the X‐Runner handpiece [27].
length of diode lasers lies within the spectrum absorbed by melatonin. Overall, it seems that
Gingival melanin depigmentation
Er: YAG lasers limit the thermal damage of the surrounding tissues due to the lower penetra‐
So far, there are not many published studies regarding the use of Er: YAG lasers in the treatment of
tion force [3].gingival melanin pigmentations (Figures 16 and 17). The results of the study of Simsek Kaya. [3] have
Ergun [32] reported a case of refractory pigmentations on the lips and oral mucosa
in a female patient
showed with Laugier-Hunziker
that both diode and Er:YAG laser syndrome,
applied at 1 W successfully treated
can perform gingival with Er: YAG laser.
depigmentation.
However, it seems that treatment duration is longer when Er: YAG lasers are applied compared to the
Similar skin lesions (hyperkeratosis,
diode lasers. This difference may be nevus,
explained spots and
by the patches)
fact that canpenetrate
diode lasers also bedeeper
removed
in using Er:
YAG laser with X-Runner handpiece (Figures 18 and 19).
comparison to the Er: YAG lasers. Furthermore, wavelength of diode lasers lies within the spectrum
absorbed by melatonin. Overall, it seems that Er: YAG lasers limit the thermal damage of the
surrounding tissues due to the lower penetration force [3]. Ergun [32] reported a case of refractory
pigmentations on the lips and oral mucosa in a female patient with Laugier‐Hunziker syndrome,
successfully treated with Er: YAG laser. Similar skin lesions (hyperkeratosis, nevus, spots and patches)
can also be removed using Er: YAG laser with X‐Runner handpiece (Figures 18 and 19).

Figure 16. Gingival melanin pigmentation (left) and removal using Er: YAG laser with X‐Runner
handpiece (right); QSP mode, 120 mJ, 20 Hz, 10 ml/min
Figure 16. Gingival melanin pigmentation (left) and removal using Er: YAG laser with X-Runner handpiece (right);
QSP mode, 120 mJ, 20 Hz, 10 ml/min
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12
Book Title


Figure 18. Isolated keratosis of the left elbow (left) and removal using Er: YAG laser with X‐Runner
Figure 18. Isolated keratosis of the left elbow (left) and removal using Er: YAG laser with X-Runner handpiece (right);
handpiece (right); QSP mode, 120 mJ, 20 Hz, 10 ml/min
QSP mode, 120 mJ, 20 Hz, 10 ml/min

Figure 19. Immediate postoperative view
APPLICATION OF ER: YAG LASER IN ENDODONTIC SURGERY
The main goal of endodontic treatment is to remove necrotic tissue and microorganisms from root
canals by means of mechanical preparation and disinfection in order to seal the root canal space and
to prevent subsequent recontamination. According to the literature, the success of primary
endodontic treatment reaches values from 47‐97% [33]. Failures of orthograde root canal fillings
Figure 19. Immediate postoperative view
occur in cases with pre‐operative presence of periapical radiolucency, root canal filling with voids or
root canal fillings more than 2 mm short of the radiographic apex and inadequate coronal restoration
[34]. If microorganisms remain present in the root canal system or invade the periradicular tissues or
periradicular tissues become contaminated with root canal filling materials, inflammatory and
immune response or foreign body reaction may occur, causing local bone destruction and
5. Application
impairment of ER:healing.
of tissue YAGFailures
laser in endodontic
in endodontic treatment can surgery
be managed by retreatment or
endodontic surgery although certain clinical situations can only be resolved by means of surgical
The main goal of endodontic treatment is to remove necrotic tissue and microorganisms from
root canals by means of mechanical preparation and disinfection in order to seal the root canal
space and to prevent subsequent recontamination. According to the literature, the success of
primary endodontic treatment reaches values from 47-97% [33]. Failures of orthograde root
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canal fillings occur in cases with pre-operative presence of periapical radiolucency, root canal
filling with voids or root canal fillings more than 2 mm short of the radiographic apex and
inadequate coronal restoration [34]. If microorganisms remain present in the root canal system
or invade the periradicular tissues or periradicular tissues become contaminated with root
canal filling materials, inflammatory and immune response or foreign body reaction may
occur, causing local bone destruction and impairment of tissue healing. Failures in endodontic
treatment can be managed by retreatment or endodontic surgery although certain clinical
situations can only be resolved by means of surgical endodontics. Endodontic surgery has been
reported to have a success rate from 44-95% [35] while modern techniques and materials used
in endodontic surgery nowadays yield even more consistent success rates, from 88-96% [36-8].
5.1. Endodontic surgery indications
• periradicular disease due to iatrogenic or developmental anomalies which prevent orthog‐

rade root canal treatment;
• periradicular disease in root canal of filled teeth in which conventional retreatment cannot
be performed or has failed or if the orthograde access to root canal may be detrimental to
the retention of the tooth;
• when biopsy of periradicular tissue is required;
• when visualization of the periradicular tissues and tooth root is required, i.e. when perfo‐
ration or root fracture is suspected [39].
Although there are only few absolute contraindications for endodontic surgery, some factors
should be considered. Regarding patients, it is important to assess medical history and the
presence of any systemic diseases as well as psychological conditions (uncooperative patient)
[40]. Factors which may also preclude surgical approach are local anatomical factors (e.g.,
inaccessible root end), unusual bony or root configurations, possible involvement of neuro‐
vascular structures, tooth with inadequate periodontal support and nonrestorable tooth or
tooth without function [40]. Skills, training and experience of the operator as well as available
facilities should also be considered.
Endodontic surgical treatment or apicectomy is a procedure performed through a trans-

osseous approach with resection of the root apex, removal of inflammatory periapical tissue
and retrograde obturation of root apex in order to prevent microbes or their byproducts from
reaching the periapical tissues.
Conventional techniques for apicectomy may include the use of scalpels, curettes, burs and
ultrasound tips. This surgical procedure starts with soft tissue flap design depending on a
number of factors such as: access to and size of the periradicular lesion, periodontal status,
state of coronal tooth structure, the nature and extent of coronal restorations, aesthetics and
adjacent anatomical structures. After flap reflection, hard tissue management or osteotomy is
performed and the bone should be removed accurately in order to have an access to the root.
Bone can be removed using diamond, steel or tungsten carbide burs with continuous cooling
with saline sterile water. In cases of missing or very thin cortical bone plate even curettes may
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be used for osteotomy. Although osteotomy should provide clear visibility and adequate
access to root apex, microsurgical approach is recommended [41]. Soft tissue in the periradic‐
ular inflammatory region should be removed, usually using curettes, ensuring good visuali‐
zation of the operating field. When resecting the root, the angle of the resection should be 90
degrees to the long axis of the tooth in order to reduce the number of exposed dentinal tubules
[42]. Regarding the length of the resected part of the root, at least 3 mm of root end should be
resected to eliminate the majority of anomalies in the apical third. Traditionally, root end
resection is done using rotating burs. It is important to examine the resected root surface for
presence of any cracks or canal irregularities [43, 44]. The traditional way for root-end
preparation is using small round or inverted cone steel burs. The goal of root-end preparation
is to surgically remove root canal ramifications, enhance access to the apex, create a working
surface for retrograde preparation, facilitate debridement of periapical tissues and to remove
irritants from root canal space [45]. Root end preparation should ensure space for root end
obturation providing adequate seal apically and optimizing conditions for pariapical tissue
healing [45]. This preparation should be 3 mm deep, following the long axis of the tooth. This
became easier to achieve in the early 1990s, when sonically or ultrasonically driven microsur‐
gical retrotips were commercially available. When compared to burs, the advantages of
ultrasonic tips are: easier access to root ends, smaller osteotomy needed due to angulation and
small size of the retrotips, preparation of deeper cavities following more closely the original
path of the root canal which also lessens the risk of lateral perforations [45, 46]. The use of
retrotips does not require a beveled root end resection decreasing the possible leakage through
dentinal tubules. Furthermore, ultrasonic preparations demonstrated less smear layer when
compared to the bur preparation, however, bur preparations showed less superficial debris
and better canal debridement of gutta-percha [45]. More cracks and microfractures were found
after sonic or ultrasonic root-end preparation but it is still unknown if these influence the
healing success [45]. Apical leakage studies did not show any difference between the bur and
retrotip cavity preparation, although when coronal leakage was investigated using polymi‐
crobial marker, a better seal was established with ultrasonically prepared cavities [45].
Lasers can also be used in periapical surgery for apex resection or for improving the apical
sealing following apicectomy and retrograde filling. Different authors have evaluated ruby,
CO2, Nd: YAG, Er: YAG, excimer and argon laser or combinations of different lasers and their
effects upon soft and hard tissues, as well as on dental materials and instruments [47-50]. The
main advantages of laser use in endodontic surgery in comparison to the conventional
techniques are reduction in tissue trauma and lower risk of contamination [47].
Among all other lasers, Er: YAG laser has shown the greatest potential in periapical surgery
application. This laser can be used in almost all steps of periradicular surgery: incision for flap
lifting, bone removal, removal of granulation tissues, apex resection and retrograde cavity
preparation because of its efficacy in soft tissue, bone and hard dental tissues removal.
Er: YAG laser was approved by the FDA (Food and Drug Administration) in 1997 and has
been since used in dentistry. This laser has a wavelength of 2.940 nm which coincides with the
peak of water absorption. The main principle of Er: YAG laser operation is that during laser
irradiation, the energy delivered causes vaporization of water within a mineral substrate
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giving volume expansion and disruption of dental tissues by micro-explosions, with ejection
of both organic and inorganic particles [51, 52]. There is also a small absorption at around 2.800
nm by the hydroxyl group of the hydroxyapatite, although water is the main absorber of laser
energy. Regarding mineralized tissues, water is present among the crystals in enamel, dentin,
bone and cementum in ascending quantity [53, 54].
Oral soft tissues also contain water and when healthy or minimally pigmented, wavelengths
which are highly absorbed in water, like the wavelength of Er: YAG laser, will provide efficient
ablation [55]. Er: YAG laser affects 10 to 50 microns thick layers in soft tissues which are
important to avoid thermal damage to underlying periosteum and hard dental tissues which
are vulnerable to excessive heat, especially in sites with thin oral mucosa [56, 57]. Er: YAG laser
use for management of soft oral tissues is advantageous in comparison to scalpel as it provides
better hemostasis [58, 59]. Hemostasis occurs due to tissue absorption of laser energy and
controlled heating of the tissues, resulting in blood proteins coagulation and sealing of small
blood vessels [60-62]. After surgical treatment, bacteria can cause infection and subsequent
reduction of bacteria by using Er: YAG laser is also important. Several different mechanisms
are responsible for bactericidal effect of the Er: YAG laser. High temperatures during laser
irradiation cause changes in the cell wall and membrane of bacteria, denaturization of proteins
and damage of nucleic acid which result in bacterial death via photothermal effects [63].
Photothermal effect after absorption of a laser beam in water also causes microexplosions and
breakup of bacteria [64]. Yamaguchi [65] found that lipopolysaccharides in the cell membrane
of Gram negative bacteria have peak value of absorption of 2.92 µm, which is close to the
wavelength of the Er:YAG laser. Furthermore, it was also found that amines and amine groups
which are present in bacteria also absorb the wavelength of the Er: YAG laser leading to
bacterial death due to photochemical effects [66]. One study performed on the animals
compared nociceptive response during Er: YAG laser oral tissue incision and scalpel incision
and found less pain when the laser was used [67], which is promising. All these beneficial
effects make Er: YAG laser a desirable tool for incision of soft oral tissues for endodontic
surgery procedures. Besides the incision, Er: YAG laser may also be used for vaporization of
granulation tissue.
Removal of bone by conventional drills in order to perform apicectomy increases the chance
of thermal bone damage, causes bacterial decontamination and produces vibrations which are
uncomfortable for the patient. Er: YAG laser enables bone ablation to be carried out with
minimal thermal damage and the whole procedure is more convenient for the patient due to
reduced vibration. In a study by Gabric Panduric [68] Er:YAG laser showed shorter prepara‐
tion time, a lower heat generation, sharp edges of the preparation sites without bone fragments
and minimal thermal alterations of the bone tissues in comparison to the surgical drill. Studies
investigating healing of laser-ablated bone showed that the reduction of physical trauma,
tissue heating and bacterial contamination may lead to uncomplicated healing processes when
compared to conventional surgical methods [69-71]. When compared to the mechanical bur
and CO2 laser groups, Er:YAG irradiated bone tissue showed a more pronounced inflamma‐
tory cell infiltration, fibroblastic reaction and a faster revascularization adjacent to the
irradiated bone surface with a significantly greater and more rapid bone neo-formation [70],
all being desirable after surgical treatments.
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Er: YAG laser is also efficient in hard dental tissue removal, namely enamel, dentin and cement.
However, the lower ablation rates of the early Er: YAG lasers in comparison to the mechanical
bur presented a limitation of their use in dental practice [72-74]. With development of new
technology incorporated into Er: YAG laser system with high energies and low pulse dura‐
tions, the speed of ablation is faster than the diffusion of heat into the tissue, enabling a cold
and efficient ablation. Therefore, ablation rates even higher than those obtained with a
mechanical handpiece can be achieved [75, 76]. After using different pulses of Er: YAG laser,
dentin surface is irregular and clean, with open dentin tubules and no smear layer [76] which
may enhance apical seal with modern retrograde filling materials. This makes Er: YAG laser
suitable for both root-end resection and preparation.
Different studies have investigated the performance of Er: YAG laser in endodontic surgery.
In comparison to Ho: YAG laser, Er: YAG laser produced smoother and cleaner surfaces in the
resection area without any thermal damages [77]. Er: YAG laser was also superior in reduction
of postoperative complaints and showed better wound healing in comparison to the ultra‐
sound and diamond drills [78]. Another study also confirmed better postoperative healing
with Er: YAG laser when compared to the traditional surgical techniques [79]. Cavities
prepared with Er: YAG laser had significantly lower microleakage of different retrograde
filling materials in comparison to the cavities prepared with ultrasonic [80]. In a study by
Grgurevic [81], optimal settings for apicectomy with Er: YAG laser were 380 mJ/100 at
microseconds/20 Hz and there was no difference in time needed for root resection in compar‐
ison to mechanical handpiece.
Beneficial effects of Er: YAG laser in periradicular surgery are attributed to biostimulatory effect
and disinfection of the operating field which promote early healing [82], as well as stimula‐
tion of platelet-derived growth factor which enhances the healing of osteotomy sites [83].
Furthermore, Er:YAG laser enhances osteoblast proliferation through activation of the mitogen-
activated protein kinase which helps promote healing in periodontal or implant sites [84].
Therefore, Er: YAG laser can be considered as a suitable method for periapical surgery (Figures
20 and 21) as it is an efficient and safe surgical method which ensures good post-operative
healing.
16
Book Title

Figure 20. Use of Er: YAG laser for bone removal prior to apicectomy (X‐Runner, QSP mode, 750 mJ,
10 Hz, 10 ml/min)
Figure 20. Use of Er: YAG laser for bone removal prior to apicectomy (X-Runner, QSP mode, 750 mJ, 10 Hz, 10 ml/min)

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Figure 20. Use of Er: YAG laser for bone removal prior to apicectomy (X‐Runner, QSP mode, 750 mJ,
10 Hz, 10 ml/min)

Figure 21. Laser‐assisted apicectomy of the upper left central and lateral incisors (X‐Runner, QSP
Figure 21. Laser-assisted apicectomy of the upper left central and lateral incisors (X-Runner, QSP mode, 750 mJ, 10 Hz,
mode, 750 mJ, 10 Hz, 10 ml/min)
10 ml/min)
APPLICATION OF ER: YAG LASER IN BONE SURGERY
Common instruments used for osteotomies in oral surgery are diamond or steel burrs, oscillating
saws, chisels or mills [85, 86]. Despite the fact that they are considered a gold standard for bone
6. Application of ER: YAG laser in bone surgery
osteotomies, these instruments have some disadvantages; they are used in contact with the bone
tissue with some extent of grinding pressure causing increase of focal temperature, deposition of
metal shavings, biomechanical stress, microfractures and dispersal of bony particles and debris into
Common surrounding tissue and osteotomy walls. Bone fragments and fibrin like debris can be found which
instruments used for osteotomies in oral surgery are diamond or steel burrs,
cover the osteotomy walls after drill instrumentation and can be contributing factor in the infection.
oscillatingThe saws,
debris chisels or mills
can interfere with the [85, 86].healing
wound Despite thethus
process factimpairing
that they are considered
the adhesion of blood a gold
standard for bone osteotomies, these instruments have some disadvantages; they are used in
elements to the osteotomy walls [68, 86‐89]. Hence, alternative methods have been developed for
hard tissue surgery [90]. Continuous wave (CW) carbon dioxide (CO2) laser was the first laser in oral
contact with thefor
surgery bone tissuetreatment
soft tissue with some which extent of grinding
was introduced pressure
in the year causing
1964 [91]. increase
Shortly after, the of focal
temperature, deposition
development of metal
and research shavings,
of hard biomechanical
tissue laser assisted ablation stress, microfractures
began [92, and
93]. Different types of dispersal
high energy laser have been investigated, among which the Erbium: Yttrium‐Aluminum‐garnet (Er:
of bony particles and debris into surrounding tissue
YAG) laser demonstrated the most promising results and osteotomy walls. Bone fragments and
[94‐99]. Er: YAG emits at a wavelength 2.94 µm
fibrin like which
debris can
has be found
a high absorption which cover
in water the osteotomy
and hydroxyl walls after[100‐
ions of hydroxyapatite drill102].
instrumentation
The water and
absorption coefficient of Er: YAG laser is 10 higher than the CO2 lasers, and 15,000‐ 20,000 times
can be contributing factor in the infection. The debris can interfere with the
higher than Nd: YAG lasers [103]. This high absorption rate enables bone ablation with minimal
wound healing
process thus impairing
adjacent the adhesion
thermal damage, making Er: of
YAG blood elements
lasers safe for use in to the
oral osteotomy
surgical procedures walls [68, 86-89].
[68, 104,
Hence, alternative methods have been developed for hard tissue surgery [90]. Continuous
105, 106]. Erbium laser was the first dental laser cleared by the US Food and Drug Administration for
use in cutting human teeth in vivo [107].
wave (CW) carbon dioxide (CO2) laser was the first laser in oral surgery for soft tissue treatment
Removal of partially erupted third molars
which was introduced in the year 1964 [91]. Shortly after, the development and research of
hard tissue laser assisted ablation began [92, 93]. Different types of high energy laser have been
investigated, among which the Erbium: Yttrium-Aluminum-garnet (Er: YAG) laser demon‐
strated the most promising results [94-99]. Er: YAG emits at a wavelength 2.94 µm which has
a high absorption in water and hydroxyl ions of hydroxyapatite [100- 102]. The water absorp‐
tion coefficient of Er: YAG laser is 10 higher than the CO2 lasers, and 15,000- 20,000 times higher
than Nd: YAG lasers [103]. This high absorption rate enables bone ablation with minimal
adjacent thermal damage, making Er: YAG lasers safe for use in oral surgical procedures [68,
104, 105, 106]. Erbium laser was the first dental laser cleared by the US Food and Drug
Administration for use in cutting human teeth in vivo [107].
6.1. Removal of partially erupted third molars
The Er: YAG laser can be used successfully for third molar removal. Histological analyses
found no signs of carbonization or charred surfaces which might lead to undisturbed bone
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healing. Another advantage of laser ablation was no bone particle or other kind of debris
deposits found within the surgery site, absence of mechanical pressure and accurate cut
geometry [68, 98, 105-121]. Higher percentage of patients found that the laser assisted surgery
was more acceptable compared to the standard drill osteotomy which was explained by the
absence of friction sound and vibration. On the other side, the laser osteotomy is more time
consuming. Inadequate suction of operative field may lead to prolonged ablation time because
increase in volume of irrigation fluid and blood slow down the laser ablation [121]. When a
contact free handpiece was used, the ablation process was faster but the intraoral maneuver‐
ability of the articulated arm was more difficult, requiring additional care to ensure only
ablation of the target tissues [121]. Prolonged treatment may be responsible for an elevated
incidence of trismus and swelling in the patients treated with laser in comparison to the
surgical bur [122]. Er: YAG lasers lack the feedback of depth control. Hence, in cases of tooth
apex proximity to the inferior alveolar nerve, it is recommendable to finish the osteotomy using
the surgical bur in order to prevent nerve damage [121].
6.2. Bone graft harvesting
The osteotomy for harvesting bone blocks plays an important role in the success of the bone
grafting technique. Incorrect harvesting technique may cause mechanical and thermal damage
with reduced or loss of bone vitality. When performed with classical surgical bur or oscillating
saw, clinicians are faced with some limitations during bone block grafting due to the mechan‐
ical pressure and vibrations, accumulation of debris within the osteotomy lines and in the
adjacent soft tissue as well as possible injury of adjacent vital structures. When Er:YAG contact
free handpiece with variable squared pulse (VPS) was employed for bone block harvesting
excellent results were obtained resulting in reasonable time necessary to finish the osteotomies
(2 minutes for the chin bone block harvesting) [105, 114, 123]. The histological results obtained
from the bone blocks specimens, showed sharp cutting edges (Figures 22 and 23) and vital
bone containing osteocyte lacunae occupied with cells thus presenting normal osteocyte
structural characteristics [124]. The anatomical situation in the distal part of the lower jaw
limited the access of the laser handpiece preventing the maintenance of predetermined
distance between bone surface and the handpiece. Furthermore, deficient aspiration led to
water and blood accumulation which inhibited laser ablation because the accumulated fluid
formed a protective layer against the laser beam. Afore mentioned reasons make the Er: YAG
block osteotomy difficult or impossible in the ramus region [123]. On the other hand, the
osteotomy in the symphysis area is straightforward, allowing control of the direction of laser
beam and maintenance of predetermined distance. The procedure was much more comfortable
for the patients owing to the absence of mechanical stress or vibrations. Lasers are less
traumatic when ablating bone compared to surgical burs, hence less bleeding tendency can be
observed (Figures 25-27). One major disadvantage of lasers is the lack of depth control which
is time consuming and difficult in the ramus region. Periodontal probes can be used for
controlling the osteotomy depth [123].
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18
Book Title
18
Book Title
Figure 22. Macroscopic comparison of laser (left) and surgical drill (right) osteotomy (106)



Figure 23. Light microscopy comparison of laser (left) and surgical drill (right) osteotomy (106)
Figure 23. Light microscopy comparison of laser (left) and surgical
drill (right) osteotomy (106)
Figure 23. Light microscopy comparison of laser (left) and surgical drill (right) osteotomy (106)

Figure 24. SEM (scanning electron microscopy) comparison of laser (left) and surgical drill (right)
Figure 24. SEM (scanning electron microscopy) comparison of laser (left) and surgical drill (right)
osteotomy (106)
Figure 24. SEM (scanning electron microscopy) comparison of laser (left) and surgical drill (right) osteotomy (106)
osteotomy (106)

Figure 25. OPG and CBCT of the patient with dislocated dental implant in the right maxillary sinus,
after transcrestal sinus floor elevation procedure
Figure 25. OPG and CBCT of the patient with dislocated dental implant in the right maxillary sinus, after transcrestal
sinus floor elevation procedure

Figure 26. Removal of the cortical plate of the maxilla using Er: YAG laser (X‐Runner, QSP mode,
750 mJ, 10 Hz, 10 ml/min) to show the implant within the sinus and to allow implant removal
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Figure 26. Removal of the cortical plate of the maxilla using Er: YAG laser (X-Runner, QSP mode, 750 mJ, 10 Hz, 10 ml/
min) to show the implant within the sinus and to allow implant removal


Figure 27. Removal of the implant after laser‐assisted sinus surgery (left) and follow‐up OPG 3
months after surgery (right)
Figure 27. Removal of the implant after laser‐assisted sinus surgery (left) and follow‐up OPG 3
Use of Er: YAG laser in the treatment of bisphosphonate‐related osteonecrosis of the jaws
Figure 27. Removal months after surgery (right)
of the implant after laser-assisted sinus surgery (left) and follow-up OPG 3 months after surgery
In the last decade, there has been an exponentially increasing number of bisphosphonate‐related
(right) Use of Er: YAG laser in the treatment of bisphosphonate‐related osteonecrosis of the jaws
osteonecrosis of the jaws (BRONJ) reports; however its treatment still remains a dilemma. Promising
In the last decade, there has been an exponentially increasing number of bisphosphonate‐related
results were accomplished using lasers in the therapy for BRONJ. Er: YAG laser therapy was used for

osteonecrosis of the jaws (BRONJ) reports; however its treatment still remains a dilemma. Promising
ablation of necrotic bone [105, 83, 125, 126]. When the laser ablation was used in combination with
6.3. Use of Er:
low YAG laser in the treatment of bisphosphonate-related osteonecrosis
results were accomplished using lasers in the therapy for BRONJ. Er: YAG laser therapy was used for
level laser therapy (LLLT) additional benefits were observed in terms of mucosal healing [83, of the
ablation of necrotic bone [105, 83, 125, 126]. When the laser ablation was used in combination with
jaws 125]. Surgical sites treated with Er: YAG showed superior results when compared with traditional
low level laser therapy (LLLT) additional benefits were observed in terms of mucosal
healing [83,
surgical treatment and remained stable for a mean follow‐up period of 13 months [83]. Atalay [127]
125]. Surgical sites treated with Er: YAG showed superior results when compared with traditional
evaluated the use of Er:YAG laser (200 mJ, 20 Hz) using a fiber tip 1.3 mm in diameter and 12 mm in

In the last decade, there has been an exponentially increasing number of bisphosphonate-
surgical treatment and remained stable for a mean follow‐up period of 13 months [83]. Atalay [127]
evaluated the use of Er:YAG laser (200 mJ, 20 Hz) using a fiber tip 1.3 mm in diameter and 12 mm in
related osteonecrosis of the jaws (BRONJ) reports; however its treatment still remains a
dilemma. Promising results were accomplished using lasers in the therapy for BRONJ. Er: YAG
laser therapy was used for ablation of necrotic bone [105, 83, 125, 126]. When the laser ablation
was used in combination with low level laser therapy (LLLT) additional benefits were observed
in terms of mucosal healing [83, 125]. Surgical sites treated with Er: YAG showed superior
results when compared with traditional surgical treatment and remained stable for a mean
follow-up period of 13 months [83]. Atalay [127] evaluated the use of Er:YAG laser (200 mJ, 20
Hz) using a fiber tip 1.3 mm in diameter and 12 mm in length in order to remove necrotic and
granulation tissue from the area of avascular necrosis in 10 patients with BRONJ. Their findings
[127] suggest that Er: YAG laser surgery is a beneficial alternative in the treatment of patients
with BRONJ.
Laser ablation of oral hard tissues has progressively improved. Initial drawbacks, extensive
thermal damage of the adjacent tissue, impaired haling and prolonged time necessary for laser
osteotomy, were gradually resolved by development of Er: YAG laser with the pulse mode
and water spray cooling. Numerous advantages associated with laser bone ablation lead to
the fast and safe procedure resulting in the less trauma to the surrounding tissues. Some of
these advantages are: minimal thermal damage to the bone, rapid osseous healing, precise cut
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geometry with regular shaped borders, absence of organic debris or metal shavings, reduced
hard tissue bleeding, the possibility of operating with non contact handpiece, elimination of
pressure and vibration from the procedure and decreased risk of injury to the adjacent tissues.
20
Despite these advantages, routine use of Er: a YAG laser has not been established Book Title in clinical
practice. Somelength in order to remove necrotic and granulation tissue from the area of avascular necrosis in 10
factors which limit the everyday clinical application of lasers in bone ablation
are: difficult access in the distal part of the lower jaw, inhibited laser ablation because the fluid
patients with BRONJ. Their findings [127] suggest that Er: YAG laser surgery is a beneficial alternative
in the treatment of patients with BRONJ.
accumulation in the deep parts of the surgical field and the lack of depth control. These issues
Laser ablation of oral hard tissues has progressively improved. Initial drawbacks, extensive thermal
are to be improved inthe adjacent
damage of the future. The
tissue, main
impaired disadvantage
haling and prolonged time ofnecessary
laser for
osteotomies
laser osteotomy, is the inability
to control the were
depth of the
gradually cut which
resolved my complicate
by development of Er: YAG laser the
with procedure.
the pulse mode and water spray
cooling. Numerous advantages associated with laser bone ablation lead to the fast and safe
procedure resulting in the less trauma to the surrounding tissues. Some of these advantages are:
minimal thermal damage to the bone, rapid osseous healing, precise cut geometry with regular
shaped borders, absence of organic debris or metal shavings, reduced hard tissue bleeding, the
possibility of operating with non contact handpiece, elimination of pressure and vibration from the
7. Application of ER: YAG laser in dental implantology
procedure and decreased risk of injury to the adjacent tissues. Despite these advantages, routine use
of Er: a YAG laser has not been established in clinical practice. Some factors which limit the everyday
clinical application of lasers in bone ablation are: difficult access in the distal part of the lower jaw,
7.1. Implant site preparation and second stage surgery
inhibited laser ablation because the fluid accumulation in the deep parts of the surgical field and the
lack of depth control. These issues are to be improved in the future. The main disadvantage of laser
osteotomies is the inability to control the depth of the cut which my complicate the procedure.
The bone preparation for implant site determines the beginning and the progression of bone
APPLICATION OF ER: YAG LASER IN DENTAL IMPLANTOLOGY
healing and the subsequent success of osseointegration of the implant. Direct bone to implant
Implant site preparation and second stage surgery
contact (BIC) The bone preparation for implant site determines the beginning and the progression of bone healing
established without the interposition of non-bone or connective tissue is
mandatory for successful osseointegration. Atraumatic bone ostetomy leads to less bone
and the subsequent success of osseointegration of the implant. Direct bone to implant contact (BIC)
established without the interposition of non‐bone or connective tissue is mandatory for successful
injury, less bone remodeling, better implant to bone contact and hence better implant stability
osseointegration. Atraumatic bone ostetomy leads to less bone injury, less bone remodeling, better
in the early stage ofto healing
implant [105,
bone contact 115, better
and hence 116] implant
(Figures 28in and
stability 29).stage of healing [105, 115,
the early
116] (Figures 28 and 29).

Figure 28. Er:YAG laser (LightWalker, Fotona, Slovenia) usage for preparation of the dental implant
Figure 28. Er:YAGsite in the lateral part of the right mandible; cortical bone – H02, SP mode, 1000 mJ, 20 Hz, 20 W,
laser (LightWalker, Fotona, Slovenia) usage for preparation of the dental implant site in the lateral
water 6, air 4; spongious bone – H14, SP mode, 600 mJ, 20 Hz, 12 W, water 6, air 2 (Courtesy of Dr.
part of the right mandible; cortical bone – H02, SP mode, 1000 mJ, 20 Hz, 20 W, water 6, air 4; spongious bone – H14,
Jean Jacques Paverani)
SP mode, 600 mJ, 20 Hz, 12 W, water 6, air 2 (Courtesy of Dr. Jean Jacques Paverani)

Figure 29. Implant site prepared using laser‐assisted surgery (left) and dental implant inserted
Figure 29. Implant site prepared using laser-assisted surgery (left) and dental implant inserted after laser preparation
after laser preparation (right) (Courtesy of Dr. Jean Jacques Paverani)
(right) (Courtesy of Dr.the
Since Jean Jacques
late Paverani)
1990 different Er: YAG lasers were tested for implant bed preparation in numerous
animal studies. The primary concern was how the thermally changed layer of bone tissue would
affect the bone healing and osseointegration. All the authors demonstrated that osseointegration
could be successfully achieved after Er: YAG implant bad bone preparation [117‐120]. The carbonized
amorphous tissue layer produced no irreversible damage and was progressively substituted with new
bone in the first 2‐12 weeks [118]. Significantly better bone‐to‐implant contact (BIC) was seen in the
surgical drill group compared to the Er: YAG group within first two weeks. Afterwards the differences
gradually disappeared and after 12 weeks they were not evident [119]. Some authors found even
better results for Er: YAG group compared to the surgical drill group. Histological evaluation revealed
higher BIC percentages in the laser prepared bone compared to the drill prepared bone after 3 weeks
and 3 months of healing [120].
It can be concluded that Er:YAG laser ablation presents a promising tool for implant bed preparation
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http://dx.doi.org/10.5772/59273
Since the late 1990 different Er: YAG lasers were tested for implant bed preparation in
numerous animal studies. The primary concern was how the thermally changed layer of bone
tissue would affect the bone healing and osseointegration. All the authors demonstrated that
osseointegration could be successfully achieved after Er: YAG implant bad bone preparation
[117-120]. The carbonized amorphous tissue layer produced no irreversible damage and was
progressively substituted with new bone in the first 2-12 weeks [118]. Significantly better bone-
to-implant contact (BIC) was seen in the surgical drill group compared to the Er: YAG group
within first two weeks. Afterwards the differences gradually disappeared and after 12 weeks
they were not evident [119]. Some authors found even better results for Er:
YAG group
Figure 29. Implant site prepared using laser‐assisted surgery (left) and dental implant inserted
compared to after laser preparation (right) (Courtesy of Dr. Jean Jacques Paverani)
the surgical drill group. Histological evaluation revealed higher BIC percentages
in the laser prepared bone
Since the late 1990 compared tolasers
different Er: YAG the were
drilltested
prepared bone
for implant after 3 weeks
bed preparation and 3 months of
in numerous
healing [120].animal studies. The primary concern was how the thermally changed layer of bone tissue would
affect the bone healing and osseointegration. All the authors demonstrated that osseointegration
could be successfully achieved after Er: YAG implant bad bone preparation [117‐120]. The carbonized
It can be concluded that Er:YAG laser ablation presents a promising tool for implant bed
amorphous tissue layer produced no irreversible damage and was progressively substituted with new
preparation bone in the first 2‐12 weeks [118]. Significantly better bone‐to‐implant contact (BIC) was seen in the
and second stage surgery for dental implants exposure (Figures 30-32), but
surgical drill group compared to the Er: YAG group within first two weeks. Afterwards the differences
some major gradually
disadvantages limit
disappeared and after the everyday
12 weeks clinical
they were not application:
evident [119]. manual
Some authors found even guided laser
osteotomy resulted in a more imprecise osteotomy with a wide gap around implant.
better results for Er: YAG group compared to the surgical drill group. Histological evaluation revealed
higher BIC percentages in the laser prepared bone compared to the drill prepared bone after 3 weeks
Prolonged time required for Er: YAG ablation compared to the surgical drill preparation
and 3 months of healing [120].
caused by bleeding at the bottom of the osteotomy cavity can be a potential risk of accidental
It can be concluded that Er:YAG laser ablation presents a promising tool for implant bed preparation
tissue damage [105]. stage surgery for dental implants exposure (Figures 30‐32), but some major
and second
disadvantages limit the everyday clinical application: manual guided laser osteotomy resulted in a
more imprecise osteotomy with a wide gap around implant. Prolonged time required for Er: YAG
ablation compared to the surgical drill preparation caused by bleeding at the bottom of the
osteotomy cavity can be a potential risk of accidental tissue damage [105].

Figure 30. Second stage surgery using Er: YAG laser (X‐Runner, QSP mode, 120 mJ, 20 Hz, 10
ml/min)
Figure 30. Second stage surgery using Er: YAG laser (X-Runner, QSP mode, 120 mJ, 20 Hz, 10 ml/min)
22
Book Title

Figure 31. Comparison between Er: YAG laser (lateral implants) and scalpel for second stage
Figure 31. Comparison between Er: YAG laser (lateral implants) and scalpel for second stage surgery (first/mesial im‐
surgery (first/mesial implant)
plant)

Figure 32. Follow‐up healing evaluation 3 days after surgery, same patient.
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Figure 32. Follow-up healing evaluation 3 days after surgery, same patient.
7.2. Implant surface temperature changes during Er: YAG laser irradiation
It is known that Er: YAG lasers do not induce damage to the titanium implant surfaces when
used within appropriate energies. The results of studies have showed that Er: YAG irradiation
at 100 mJ/pulse and 10 pps for 60 seconds was safe for use on hydroxylapatite implant surfaces
without any microscopic changes noticed. Furthermore, bacterial load on implant surfaces
decreased up to 98%. It has been reported that energies exceeding 140-180 mJ/pulse result in
implant surface alterations. Monzavi [10] used Er:YAG laser with a wavelength of 2.94 on the
sheep model, energy output of 100 mJ/pulse, repetition rates of 10 pps and pulse duration of
230 µs delivered with a non-contact handpiece (4 mm above surface) for 60 seconds. However,
Leja [128] reported that irradiation of Er: YAG laser on dental implants for 18 seconds increased
the temperature up to 10°C. Fornaini [129] studied in an animal model thermal elevation
induced by four different laser wavelengths (diode, Nd: YAG, Er: YAG, KTP) during implant
uncovering. The same authors [129] reported that thermocouples recorded a lower increase in
temperature for Er: YAG and KTP laser; Nd: YAG and diode lasers produced similar increase
in temperature characterized by higher values. The thermo-camera pointed out lower increase
for Er: YAG and higher for diode laser. KTP laser resulted in faster uncovering of the implants
and diode laser was the one with which more time was needed for the same procedure. This
in vitro study showed that laser utilization with the recommended parameters is without risk
of dangerous thermal elevation to the tissues and implants [129]. Geminiani [9] concluded that
irradiation of implant surfaces with CO2 and Er: YAG lasers may produce a temperature
increase above the critical threshold 10⁰C after ten seconds of continuous irradiation. Galli
[130] reported that Er:YAG laser at energy levels at 150 and 200 mJ/pulse at 10 Hz can alter the
surface profile of titanium implants and that these changes may negatively affect the viability
and the activity of osteoblastic cells. Therefore, the same authors [130] concluded that Er: YAG
lasers should be used with caution on titanium surfaces. Shin [131] evaluated surface rough‐
ness and microscopic changes of irradiated dental implant surfaces in vitro after use of Er: YAG
laser. Irradiation with Er: YAG laser led to the decrease in implant surface roughness that was
not significant. The melting and fusion phenomenon of implant surfaces were observed with
at all application times (1, 1.5 or 2 minutes) with 180 mJ/pulse irradiation. The sand-blasted,
large-grit and acid-etched (SLA) surface implants are stable with laser intensities of less than
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http://dx.doi.org/10.5772/59273
140 mJ/pulse and irradiation times less than 2 minutes. With SLA surfaces no significant change
in surface texture could be found on any implant surface in the 100 and 140 mJ/pulse sub‐
groups. The anodic oxidized surfaces were not stable with laser intensities of 100 mJ/pulse
when Er: YAG laser was used to detoxify implant surfaces [131].
7.3. Implant surface microbial changes during Er: YAG laser irradiation
Tosun [132] examined CO2, diode and Er:YAG laser irradiation on Staphylococcus aureus
contaminated, sandblasted, large-grit, acid-etched surface titanium discs and concluded that
complete or near complete elimination of surface bacteria on titanium surfaces can be accom‐
plished in vitro by use of CO2, diode and Er:YAG laser as long as appropriate parameters are
used [132].
7.4. Treatment of peri-implantitis
In the published literature, there are several reports upon use of Er: YAG lasers for debride‐
ment which results in decontamination of implant surface in patients suffering from peri-
implantitis [133-137]. As lasers use unidirectional light beams they gain better access to all
implant surfaces in comparison to the manual curettes and ultrasonic tips. Furthermore, Er:
YAG does not cause alterations of the implant surface. Also Er: YAG lasers are suitable for
calculus elimination. Badran [138] used Er: YAG laser (energy 120 mJ; frequency 10 Hz) and
sterile water irrigation for the treatment of severe peri-implantitis. Each site was irradiated with
Er: YAG laser for 60 seconds, with a 10-15 degree working angulation during six weeks. The
results of their study [138] showed that severe cases of peri-implantitis may be cured by use of
Er: YAG laser. Fast healing, ease of use, bactericidal effect, effective ablation, hemostasis and
adaptation with irregular implant surface are the main advantages of laser beam for treat‐
ment of peri-implantitis. Major side effects of laser application on metal objects inserted in the
vital bone is thermal increase. Eriksson [139] demonstrated that increase of 10°C during 60
seconds leads to the permanent damage of bone tissues. Renvert [140] compared treatment of
severe peri-implantitis either by use of air-abrasive or Er: YAG monotherapy. The same authors
concluded that there were no differences between the bleeding on probing (BOP), periodon‐
tal pocket depth (PPD) and bone gain regarding the type of the aforementioned treatments
[140]. Schwarz [141] reported that 4-year clinical outcomes obtained following combined
surgical resective-regenerative therapy of advanced peri-implantitis were not influenced by the
method of surface decontamination, i.e. Er: YAG laser or with plastic curettes/cotton pellets/
sterile saline. Taniguchi [137] concluded that optimized irradiation parameters effectively
removed calcified deposits from contaminated titanium microstructures without causing
substantial thermal damage. It seems that Er:YAG laser irradiation at pulse energies below 30
mJ/pulse (10.6 J/cm2/pulse) and 30 Hz with water spray in near contact mode did not cause
damage and resulted in effective debriding of the microstructure surfaces (except for ano‐
dized microstructures). Nevins [142] investigated use of Er:YAG laser in order to decontami‐
nate complex rough surface of the implant by stripping the contaminated oxide laser for
induction of hard and soft tissue adaptation to a compromised or failing implant. The results
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have shown that new bone-implant contact was established along the whole defect area without
any evidence of inflammation.
8. Conclusion
Laser technology has made rapid progress over the past decades, and lasers have found a niche
in many surgical specialties. Because of their many advantages, lasers have become indispen‐
sable in OMS as a additional modality for soft and hard tissue surgery. There are many uses
for lasers in OMS, and the advent of new wavelengths will undoubtedly lead to new proce‐
dures that can be performed with laser technology. Practitioners should seek novel clinical
approaches with a sound scientific basis. Despite the enthusiastic acceptance of this technology
by professionals and the public, further research, including controlled clinical studies, to
investigate the higher efficacy, as well as side effects of laser therapy, are still needed.
“The medical application of the laser is fascinating for two reasons. It is an optimistic
mission, on the one hand, while on the other it counteracts the original impression of the
laser being a death ray.“
Dr. Theodore Maiman, the inventor of the first laser
Acknowledgements
The authors are grateful to Fotona D.D. for technical support. We would like to thank our
clinical photographers Mirjana Krajačić and Darije Petolas, and especially all employees of the
Department of Oral Surgery and Department of Oral Medicine, School of Dental Medicine,
University of Zagreb.
Author details
Dragana Gabrić1*, Anja Baraba2, Goran Batinjan1, Marko Blašković1, Vanja Vučićević Boras3,
Irina Filipović Zore1, Ivana Miletić2 and Elizabeta Gjorgievska4
*Address all correspondence to: dgabric@sfzg.hr
1 Department of Oral Surgery, School of Dental Medicine, University of Zagreb; University

Dental Clinic, Clinical Hospital Center Zagreb, Zagreb, Croatia
2 Department of Endodontics and Restorative Dentistry, School of Dental Medicine,

University of Zagreb; University Dental Clinic, Clinical Hospital Center Zagreb, Zagreb,
Croatia
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http://dx.doi.org/10.5772/59273
3 Department of Oral Medicine, School of Dental Medicine, University of Zagreb; University
Dental Clinic, Clinical Hospital Center Zagreb, Zagreb, Croatia
4 Department of Pediatric and Preventive Dentistry, Faculty of Dentistry, University of
Skopje, Macedonia
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Chapter 35
Basics of
Craniofacial Surgery
Hamid Mahmood Hashemi, Farnoush Mohammadi,

Iman Tavakoli and Amirsalar Sayedyahossein
http://dx.doi.org/10.5772/59966
1. Introduction
1.1. History
Craniofacial surgery includes a wide range of procedures in the face and cranium from
congenital malformations such as orofacial clefts to traumatic deformities. Many scientists
contributed to develop this field of surgery. Rene Le Fort was a French surgeon who
discovered the lines of weakness in the facial skeleton. He classified the pattern of fractures
through these lines into three categories known as LeFort 1, 2 and 3.[1] Gillies was the first
surgeon who performed Le Fort 3 osteotomy for a patient with Crouzon or Pfeiffer
syndrome, but the result was not satisfactory.[2] Tessier accomplished LeFort 3 osteoto‐
my in a different and of course a more accurate way for a child with Crouzon's syndrome.
[3] The presentation of this surgery had a great influence on this remarkable field and
become a turning point in craniofacial surgery. Tessier introduced different approaches to
the craniofacial skeleton such as transcranial approach to the orbital hypertelorism,
transconjunctival approach to the orbital floor or development of subperiosteal facelift
technique.[1]-[3] He is named the father of craniofacial surgery. During the years much
progress has been made in this field. Refined surgical techniques and instruments, new
imaging techniques like 3D computed tomography(CT) scan has had a great impact on
craniofacial surgery, not only in diagnosis of craniofacial anomalies but also in treatment
planning of surgery. Stereolithic models are 3D printing models which can replicate the
actual shape of the defect. These models facilitate reconstruction of prosthesis; they can
help in determining the site of insertion of prosthesis or the correct position of the plates
or devices like distraction osteogenesis.
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2. Craniofacial anomalies
Craniofacial anomalies (CFA) include different dysmorphogenic conditions in this region of

the body. People with these anomalies generally have problems not only in function but also
with their ordinary life in the society. These people, especially children with CFA have less
social competence and lack of self-esteem. The aim of craniofacial surgery is to give a normal
appearance to the patients. Specialized centers would be a great help in treating patients with
CFA. Accurate data of epidemiology of CFA is of utmost importance for managing and
treatment of patients.
Cleft lip and palate are the most common congenital anomalies which affect the orofacial
region. The incidence of oral clefts in United States is 1 in 700 births.[4] Orofacial clefts are
more common in boys but cleft palate without cleft lip have a slight tendency to involve girls.
One fourth of oral clefts are bilateral and the rest are unilateral. In unilateral cases the left side
is affected more frequently.
Craniosynostosis means premature fusion of cranial vault sutures. There are six major cranial
vault sutures. Any of these sutures can be affected in craniosynostosis, alone or in combination
with other sutures. In this section we discuss the prevalence of nonsyndromic single suture
synostosis.
Sagittal suture synostosis or scaphocephaly is the most common single suture synostosis with
the prevalence of 1 in 5000 live births. [5] Boys are affected three times more frequently than
girls.
Coronal suture synostosis or anterior plagiocephaly is the second most common single suture
synostosis. The prevalence is approximately 1 in 10000 births. [6]
Metopic suture craniosynostosis or trigoncephaly is an unusual type of synostosis with an

approximate prevalence of 1 in 15000. [7]
Lambdoid suture synostosis or posterior plagiocephaly is a rare entity with a prevalence of 1

in 150000 live births. [8]
Bilateral coronal suture craniosynostosis or brachycephaly is also rare.
3. Craniofacial pathology
Pathology includes any deviations from normal function and structure. The pathologic
conditions show themselves as aplastic, hypoplastic, hyperplastic, neoplastic, traumatic or
developmental entities. In craniofacial pathology a good access to the lesion and preservation
of vital structures are important factors in a successful operation. Most operations in this field
should be carried out in a team work manner engaging both the maxillofacial surgeon and the
neurosurgeon.
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Basics of Craniofacial Surgery 841

http://dx.doi.org/10.5772/59966
3.1. Fibrous dysplasia
Fibrous dysplasia is a benign fibro-osseous lesion. Fibro-osseous lesions are a category of

entities in which normal bone tissue is replaced with fibrous and mineralized tissue. In fibrous
dysplasia normal bone is substituted with cellular fibrous tissue and immature bone.[9]
In most of cases it is monostotic involving a single bone.[10] The rate of growth is very slow.
The maxilla and frontal bone are the most affected sites.[11] The most common feature is
painless swelling. Radiographic feature of ground glass is of significant importance for
diagnosis. This pattern is due to superimposition of disorganized poorly calcified bone
trabecular.
Polyostotic Fibrous dysplasia is uncommon. In syndromic conditions like Jaffe-Lichtenstein,

McCune-Albright and Mazabraud syndromes, polyostotic fibrous dysplasia forms an impor‐
tant part of these syndromes.
Treatment of fibrous dysplasia depends on the degree of functional or cosmetic impairment

from shaving of involved area to resection. The aim is not to remove the entire lesion but to
have an acceptable appearance. Regrowth after surgical reduction is unpredictable.
3.2. Sarcoma
One of the most important issues in morbidity and mortality of children is malignant neo‐
plasms.[12] One third of malignant solid tissue tumors during infancy and childhood are
caused by sarcomas.[13] The most common sarcoma in children is rhabdomyosarcoma and
after that fibrosarcoma.[14] For management of rhabdomyosarcoma, radiotherapy and
chemotherapy in combination with surgery are recommended in accessible tumors by many
authors.
3.3. Lymphoma
Malignant lymphoid tissue tumors are common in head and neck region. There are different
types of classification for lymphoma but separation to Hodgkin and non- Hodgkin types is the
most common. Both have manifestations in the head and neck area. In Africa, another type of
this condition known as Burkitt's lymphoma is common in children. Surgery is usually not
indicated and chemotherapy should be done by an oncologist.
3.4. Melanoma
Approximately 20% of melanomas occur in head and neck regions.[15] An important etiologic
factor is excessive exposure to ultraviolet light but many risk factors have been proposed in
development of this lethal entity. Most of them arise from pigmented lesions. Melanoma can
be categorized to superficial spreading, nodular, lentigo maligna, acral lentigenous and
desmoplastic type according to clinical and histological evaluations. Excision of the lesion is
the treatment of choice. Elective lymph node dissection is a controversial matter.
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4. Nonsyndromic craniosynostosis
The pathophysiology of malformed skulls was described in the 18th century. It was reported
that “bony expansion ceases in a direction perpendicular to the synostosed suture with
compensatory expansion in the opposite direction.” This is called the Virchow’s law. Early
closure of cranial sutures is termed as craniosynostosis which can be categorized to syndromic
and non-syndromic synostosis. The latter is the main point of concern of this chapter.
4.1. Anterior plagiocephaly
Plagiocephaly is simply the Greek synonym for slanted head. It is reported in 5% to 25 %

of deliveries. It can be associated with external forces or synostosis. Those associated with
external forces are deformational and are commonly the result of compressive forces applied
by the maternal pelvis to the head of the fetus which is more common on the left side.
Anterior plagiocephaly can be due to unilateral coronal synostosis (UCS). This is almost
nonsyndromic but can be seen in a familial feature relating to a mutation in fibroblast
growth factor receptor gene. A surgical approach to treat this condition is basically to
decompress the intracranial pressure which can itself cause brain damage and ophthal‐
mic consequences due to optic atrophy. The superior forehead and superior orbital region
is the main affected site. The ipsilateral superior orbital rim is displaced superiorly and
nasal root is displaced to the problematic side. Presurgical radiological evaluation of the
patient is best carried out by 3D CT scans which are available now and a multidisciplina‐
ry approach involving pediatric craniofacial surgeon, pediatric neurosurgeon, ophthalmol‐
ogist and radiologist is necessary.
The surgical technique presented by Posnick is based on removing, reshaping and reassem‐
bling the cranial vault and bilateral three-quarter orbital osteotomies. The procedure is started
by a postauricular coronal incision with wide subperiosteal dissection anteriorly to bilateral
infraorbital rim regions and superior of the zygomatic bone and maxilla and posteriorly half
way from the coronal to lambdoid suture. Bilateral lateral canthotomy is carried out. Frontal
bone is removed from the preferred marked lines then the osteotomy is carried out including
orbital roof, superior aspect of orbital medial wall, lateral orbital wall and lateral side of inferior
orbital floor to the inferior orbital fissure.
4.2. Trigonocephaly
The prevalence of this type of craniosynostosis is 1 in every 15000 newborns. This results from
early closure of the metopic suture which makes a triangular shape deformity of anterior
cranial vault and anterior cranial base and orbits presents with orbital dystopia. Correction of
the position of the superior and lateral orbital rims is the main concern in trigonocephalic
patients. Beside the esthetic considerations, preventing the increase in intracranial pressure in
growth is an important indication for surgical intervention.
If there is no sign of deficits due to increased intracranial pressure then it is recommended to
postpone the surgical intervention 9 to 11 months of infant age. This supports the fact that at
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that age most of the brain growth is done and the outcome is less dependent on brain growth.
Also better bony reshaping can be performed and hemodynamic concerns at the time of
surgery are more controllable.
It is obvious that every surgical treatment plan should be programmed based on the individual
characteristics of the deformity but a general surgical approach involves releasing of the
metopic suture and also osteotomies of the anterior cranial vault, temporal and three-quarter
orbital osteotomies. A postauricular coronal incision with subperiosteal dissection is carried
out. Bilateral lateral canthotomy is performed. Frontal craniotomies are performed by the
neurosurgeon considering the retraction of frontal and temporal lobes and remaining anterior
to the olfactory bulbs. Orbital osteotomies are done including orbital roof and lateral aspect of
orbital floor to the inferior orbital fissure. For better correction of the orbital segment a vertical
split osteotomy can be done in the midline to separate sides from each other. Temporal
osteotomy can then be performed and reshaping, repositioning and reassembling of frontal
bone in strip figures are done.
Bony gaps can be filled with autogenous grafts and segments are fixed by means of screws
and microplates.
4.3. Scaphocephaly
Early closure of the sagittal suture which makes the calvarium grow more in the anteropos‐
terior direction is called scaphocephalia. This leads to a more prominent frontal and occipital
region. This condition is seen in 1 in every 5000 births. Like other synostotic conditions
increased intracranial pressure and hydrocephalus are points of concern. It is accepted that
craniotomies can at least release the external pressure on the brain. Papilledema and optic
atrophy are other possible situations related to synostotic conditions that can lead to blindness.
There can be 3 types of scaphocephalia depending on the location of synostosis along the
sagittal suture. If the anterior portion is involved in synostosis then posterior projection and
prominence of the skull occurs. If posterior parts of the suture gets involve then anterior skull
projection is seen and there is a condition when the whole suture is synostotic that leads to a
more significant growth of the skull in the anteroposterior direction. Again it is recommended
that surgical intervention occurs at 9 to 11 months of age supporting the concept that it is the
age that most of brain tissue growth has occurred and bony tissue can be reshaped easier and
estimated blood loss during the operation is a lesser challenge.
The general concept in the surgical approach which is done again by a post auricular coronal
approach is to remove the sagittal suture and portions of temporal bone then reshaping the
segments in a manner to decrease the anteroposterior projection while increasing the biparietal
length. Dissections are carried out anteriorly to the periorbital regions and posteriorly to the
occipital prominence of the skull. Craniotomies are done and brain tissue is retracted gently
to allow the surgeon to have access for orbital osteotomies. Strip portions of bone are reshaped
in an individualized manner to correct the deformity.
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4.4. Brachycephaly
Brachycephaly is the Greek synonym for short headedness, occurs in bilateral coronal
synostosis. This condition can be seen in some syndromes like Crouzon, Apert and Pfeiffer. In
syndromic conditions other synostoses can be seen like in cranial base and upper face that
leads to concave facial profile, proptosis and midface deficiency. In non-syndromic conditions
no midface deficiency is present. Forehead height is apparently increased and the orbits are
retruded and widened. The general concept in surgical approach is to increase the cranial
capacity and therefore decrease the intracranial pressure preventing brain damage and
conditions like hydrocephalus. Beside the esthetic concerns these conditions if left untreated
may lead to ophthalmic deterioration and even blindness.
Again like other synostotic conditions the forehead and upper parts of the orbit are the center
of concern for reconstruction. In these patients the forehead has a retruded position. In a normal
condition the eyebrows are slightly more projected anteriorly comparing to the globes in
contrast to brachiocephalic patients whose forehead and upper orbital rims have a retruded
position. Here an anterior coronal flap is preferred because the malformed bony parts are
located in the anterior skull region. Subperiosteal dissection anteriorly to periorbital region
and posteriorly halfway between coronal and lambdoid sutures is carried out. As was said
before the aim is to remove the synostotic and bad shaped bony parts and reshaping and
reassembling them in a new position to correct the deformity. Osteotomies of the frontal and
temporal bone are done as well as osteotomies of the orbital roofs. A vertical osteotomy should
be carried out in the midline to help reduce the width of the superior orbital parts. In all the
dissections in any form of cranial synostosis where lateral canthotomy is performed, at the end
of operation lateral canthopexies are done using wire sutures.
5. Distraction osteogenesis
This method increases the length of bone by means of gradual distraction. Distraction techni‐
ques provide circumstances to achieve large advancements in craniofacial anomalies. Not only
lengthening of the skeleton but also distracting the overlying soft tissue occurs with this
technique. Because of this fact, some prefer to use the term "distraction histogenesis" than
distraction osteogenesis. Ilizarov a Russian orthopedic surgeon published the first case series
of DO for limb lengthening.[16] The first reports of mandibular lengthening by DO were
reported by Molina and McCarthy.[17],[18] Since that time DO has been used for patients with
various craniofacial deformities. Advantages of DO include achieving large advancements,
obviating bone grafting and lesser risk of relapse than conventional osteotomies. We may
however, encounter some problems. Higher rates of postoperation infection than conventional
osteotomy, difficulty in control of vector direction, nonunion or malunion of the surgical site
are disadvantages of this method.
The procedure of DO entails a corticotomy at the site where the device would be placed. During
the procedure special consideration should be given to protection of periosteum. Minimal
disturbance of the periosteum is an important matter in success of DO.[4] The aim of this step
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is to provide an environment for remodeling and growth of the bone without significant tissue
damage or vascular supply insufficiency. Corticotomy and device placement cause tissue
damage like other surgical procedures. A latency period is needed for inflammatory mediators
and subsequent inflammation to subside. This period ranges from 0 to 10 days depending on
the age of the patient and conditions of the surgical site. After this period, distraction phase
begins. Distraction rate is approximately 1mm per day. Soft tissue matrix covering the bone is
distracted with this rate of traction. The term distraction histogenesis can describe this
phenomenon better than distraction osteogenesis. Distraction at a higher rate may result in
malunion or nonunion of involved bone and distraction at a lower rate will cause bone healing
without any changes in length of the bone. After distraction, consolidation begins. Time lapse
for this phase ranges from 3 months to 6 months depending on the amount of advancement,
age of the patient and the type of deformity. Consolidation phase can be confirmed with
radiography.[19]
5.1. Mandibular distraction osteogenesis
In severe mandibular retrognathia DO is indicated. This condition can be acquired or congen‐

ital. Congenital mandibular retrognathia includes craniofacial anomalies such as Treacher-
Collin's syndrome, Pierre Robin sequence and hemifacial microsomia. Acquired anomalies
include traumatic events to the mandible such as condylar fractures in young children in which
ankylosis of the temporomandibular joint and subsequently, retardation of mandibular
growth occur.[19], [20]
5.2. Maxillary distraction osteogenesis
Midface deficiency can occur in a variety of syndromic and nonsyndromic patients. In cleft
patients, post-surgical scar tissue causes retardation in maxillary growth. Because of scar tissue
formation, Le Fort advancement with conventional osteotomy and rigid fixation are not
appropriate for these patients. Difficulty in mobilization of the maxilla and a tendency to
relapse are the major concerns in these cases with conventional osteotomy.[21], [22] Cranio‐
facial syndromes like Apert, Crouzon or Pfeiffer's syndromes show different degrees of
paranasal hypoplasia. Midface advancement at the Le Fort 1 or 3 levels with DO technique is
a good method for large advancements. Lower rate of relapse is another advantage of this
technique.
5.3. Cranial vault distraction osteogenesis
Conventional treatment for patients with craniosynostosis is an aggressive dismantling of the

cranial vault. A high rate of morbidity and even mortality in some cases is of major concern in
these patients. Recently, corticotomy of the cranial vault and slow distraction with DO has
shown new horizons in correction of calvarial deformities. Although some advantages like
decreasing morbidity or reducing scar formation are mentioned for distraction techniques, its
disadvantages cannot be ignored.[23], [24] A 3D deformity cannot be corrected with a
unidirectional force. However, accurate selection of position of the appliance and prebending
it as much as possible may be helpful.
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Author details
Hamid Mahmood Hashemi*, Farnoush Mohammadi, Iman Tavakoli and

Amirsalar Sayedyahossein
*Address all correspondence to: hamid5212@yahoo.com
Tehran University of medical sciences Tehran, Iran
References
[1] Le Fort R. Etude expérimentalsur les fractures de la machoiresupérieure 1901
[2] Gillies HD, Millard DR. The principles and art of plastic surgery. Boston, little,
brown, 1995.
[3] Tessier P. The definitive plastic surgical treatment of the severe facial deformities of
craniofacial dysostosis. Crozoun's and Apert's diseases. PlastReconst Surg. 1971;48:
419-442
[4] Jones C: The genetics of cleft lip and palate: information for families, Chapel Hill,
NC, 2000, Cleft Palate Foundation.
[5] Lajeunie E, Le Merrer M, Bonaïti-Pellie C, Marchac D, Renier D. Genetic study of sca‐

phocephaly.Am J Med Genet. 1996;62(3):282-5
[6] Cohen MM Jr.An etiologic and nosologic overview of craniosynostosis syn‐

dromes.Birth Defects Orig Artic Ser. 1975;11(2):137-89.
[7] Lajeunie E, Le Merrer M, Marchac D, Renier D.Syndromal and nonsyndromal pri‐

mary trigonocephaly: analysis of a series of 237 patients. Am J Med Genet. 1998;75(2):
211-5.
[8] Cohen MM Jr.Craniosynostosis update 1987.Am J Med Genet Suppl. 1988;4:99-148.
[9] Daves MI, Yurdley JH. Fibrous dysplasia of bone. Am J Med Sci. 1957 Nov;234(5):
590-606.
[10] Fries JW. The roentgen features of fibrous dysplasia of the skull and facial bones; a
critical analysis of thirty-nine pathologically proved cases. Am J Roentgenol Radium
TherNucl Med. 1957; 77(1):71-88.
[11] Firat D, Stutzman L. Fibrous dysplasia of the bone. Review of twenty-four cases. Am
J Med. 1968 Mar;44(3):421-9.
[12] Anderson GJ, Tom LW, Womer RB, et al. Rhabdomyosarcoma of the head and neck
in children. Arch Otolaryngol Head Neck Surg. 1990;116:428-31
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[13] Enneking WF: Reticuloendothelial lesions. In musculoskeletal tumor surgery. New

York, Churchill-Livingstone, 1983, p1345.
[14] Schuller DE, Lawrence TL, Newton WA Jr. Childhood rhabdomyosarcomas of the
head and neck. Arch Otolaryngol.1979 ;105:689-94.
[15] Rigel DS. Epidemiology and prognostic factors in malignant melanoma. Ann Plast
Surg. 1992 ;28:7-8.
[16] Ilizarov GA.The principles of the Ilizarov method. 1988. Bull HospJt Dis. 1997;56(1):
49-53
[17] McCarthy JG, Schreiber J, Karp N, et al. Lengthening the human mandible by gradu‐
al distraction.PlastReconstr Surg. 1992;89(1):1-8
[18] Molina F, Ortiz Monasterio F. Mandibular elongation and remodeling by distraction:

a farewell to major osteotomies.PlastReconstr Surg. 1995;96(4):825-40
[19] Choi IH, Shim JS, Seong SC, et al. Effect of the distraction rate on the activity of the
osteoblast lineage in distraction osteogenesis of rat's tibia. Immunostaining study of
the proliferating cell nuclear antigen, osteocalcin, and transglutaminase C. Bull
HospJt Dis. 1997;56(1):34-40
[20] Walker D. Management of severe mandibular retrognathia in the adult patient using
distraction osteogenesis. J Oral Maxillofac Surg. 2002;60(11):1341-6
[21] Yadav R, Bhutia O, Shukla G, et al. Distraction osteogenesis for management of ob‐
structive sleep apnoea in temporomandibular joint ankylosis patients before the re‐
lease of joint. J Craniomaxillofac Surg. 2014 Jul;42(5):588-94.
[22] Gateno J, Engel ER, Teichgraeber JF, et al. A new Le Fort I internal distraction device
in the treatment of severe maxillary hypoplasia. J Oral Maxillofac Surg. 2005;63(1):
148-54.
[23] Houston WJ1, James DR, Jones E, et al. Le Fort I maxillary osteotomies in cleft palate
cases. Surgical changes and stability. J Craniomaxillofac Surg. 1989;17(1):9-15.
[24] Yonehara Y, Hirabayashi S, Sugawara Y, et al. Complications associated with gradu‐

al cranial vault distraction osteogenesis for the treatment of craniofacial synostosis. J
Craniofac Surg. 2003;14(4):526-8.
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A Textbook of Advanced Oral

Edited by Mohammad Hosein Kalantar Motamedi

A Textbook of Advanced Oral and Maxillofacial Surgery. Volume 2

Publishing Process Manager

Published: 22 April, 2015

Chapter 10 Advanced Adjunct Orthosurgical Esthetic Prodedures

Chapter 21 Current Management of Frontal Sinus Injuries

Chapter 32 Advanced Rhinoplasty: Problems and Solutions

The scope of OMF surgery has expanded; encompassing treatment of

Overview of Local Anesthesia Techniques

Mohammad Ali Ghavimi, Yosef Kananizadeh,

Additional information is available at the end of the chapter

4 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

Overview of Local Anesthesia Techniques 5

The mandibular branch (V3) is considered a motor-sensory nerve innervating masticatory

6 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

Figure 1. The superficial branches of the trigeminal nerve

Figure 2. Branches of the trigeminal nerve

Overview of Local Anesthesia Techniques 7

3.1. Inferior alveolar nerve block

Two problems occur very commonly with this technique [7]:

8 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

Figure 3. The Inferior Alveolar Nerve Block

Overview of Local Anesthesia Techniques 9

3.2. Vazirani-Akinosi (closed mouth) mandibular block

3.3. Gow-Gates mandibular nerve block

In 1973, George Albert Edwards Gow-Gates described a new approach to mandibular

10 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

Figure 4. The Gow-Gates technique

Overview of Local Anesthesia Techniques 11

3.4. Buccal nerve block

3.5. Mental and incisive nerve block

4. Maxillary anesthesia techniques

4.1. Supraperiosteal injection (infiltration)

12 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

Figure 5. The infiltration technique

4.2. Maxillary nerve block

4.3. High-Tuberosity approach

Overview of Local Anesthesia Techniques 13

4.4. Greater foramen approach

4.5. Posterior superior alveolar nerve block

Figure 6. The PSA nerve block

14 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

4.6. Middle superior alveolar nerve block

4.7. Anterior superior alveolar nerve block

4.8. Greater palatine nerve block

Overview of Local Anesthesia Techniques 15

4.9. Nasopalatine nerve block

4.10. Anterior middle superior alveolar nerve block

4.11. Palatal anterior superior alveolar nerve block

5. Supplemental anesthesia techniques

These techniques include intraosseous, intrapulpal, intraseptal and intraligamentary methods.

16 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

2. Intraligamentary technique: Advantages include minimal anesthetic drug requirements,

Overview of Local Anesthesia Techniques 17

Figure 7. Intraligamentary (PDL) technique

Figure 8. Intraseptal technique

18 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2