Bone grafting with granular biomaterial in segmental maxillary osteotomy: A case report

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InternationalJournalofSurgeryCaseReports25(2016)238–242

ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

jo u r n al ho me p a g e :w w w . c a s e r e p o r t s . c o m

Bone

grafting

with

granular

biomaterial

in

segmental

maxillary

osteotomy:

A

case

report

Orion

Luiz

Haas

Junior,

Lucas

da

Silva

Meirelles

∗

,

Neimar

Scolari,

Otávio

Emmel

Becker,

Marcelo

Fernandes

Santos

Melo,

Rogério

Belle

de

Oliveira

DepartmentofOralandMaxillofacialSurgery,PontiﬁcialCatholicUniversityofRioGrandedoSul−PUC/RS,Av.Ipiranga,n.6681,Building6,91530-001 PortoAlegre,RioGrandedoSul,Brazil

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Articlehistory: Received22March2016

Receivedinrevisedform22June2016 Accepted22June2016

Availableonline25June2016

Keywords:

Orthognathicsurgery Computer-assistedsurgery Virtualplanning Syntheticbonesubstitute

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INTRODUCTION:Segmentalmaxillaryosteotomyenablescorrectionofanterioropenbites.However,the outcomecanbesomewhatunstable,particularlyifpseudarthrosisoccurs.Bonegraftscanbeusedto preventthiscomplication.Amongthemanybiomaterialsavailableforgrafting,Bio-oss®hasbeenused successfullyinarangeofmodalities,withstudiestosupportseveralindications.Thisreportdescribes acaseofsegmentalmaxillaryosteotomyinwhichBio-oss®_granules_were_used_as_bone_grafts_in_the

surgicalgap.

PRESENTATIONOFCASE:A24-year-oldfemalepresentedwithanterioropenbite,AngleclassIIIposterior occlusion,andAngleclassIIanteriorocclusion.Virtualsurgicalplanningoftheprocedurepredictedagap ofapproximately5mmintheregionoftheosteotomy,whichwasbridgedwithBio-oss®granules. DISCUSSION: Althoughautogenous bone graftingis the gold standard due to itsosteoconductive, osteoinductive,andosteogenicproperties,itinvolvesincreasedmorbidityforthepatient,unpredictable resorptionrates,increasedoperativetime,andriskofinfectionatthedonorsite.UseoftheBio-oss® mate-rialcanprovidegoodbonestability,osteoconduction,andbiocompatibility,whilereducingoperative timeandsurgicalmorbidity.

CONCLUSION:Thisistheﬁrstreportofbonegraftingwithagranularbiomaterialinsegmentalmaxillary osteotomy.Successfulformationofnewbonewithdensitygreaterthanthatofthesurroundingtissue wasachieved,preventingpseudarthrosisandpostoperativeinstability.

1. Introduction

LeFortIsegmentedosteotomyisindicatedformanagementof transverseandverticaljawdiscrepancies,correctionofprojecting upperincisors,andclosureofanterioropenbiteswhenthereisa differencebetweentheocclusalplaneoftheupperincisorsandthe backteeth.Thisishamperedbytheorthodontictechniqueused

[1,2].

Themaincomplicationsassociated withLeFortIsegmented osteotomytechniquesare oronasalcommunication, unfavorable segmentation (unwanted fracture), tooth damage, periodontal complications,andpseudarthrosis(nonunion)[1,2].Thesesurgical complicationscanbepreventedthroughvirtualplanning,which allowspreoperativevisualizationoftheeffectofosteotomieson postoperativeboneanatomy,therebyhelpingthesurgeonprepare andoptimizeoperativetechnique[3,4].

∗ Correspondingauthorat:Av.Ipiranga,n.6681,Building6,PortoAlegre,Rio GrandedoSul91530-001,Brazil.

E-mailaddress:[email protected](L.daSilvaMeirelles).

Whenboneaugmentationisrequired,autogenousgraftingisthe goldstandard,astheonlymaterialthatexhibitsosteoconductive, osteoinductive,andosteogenicproperties.However,high morbid-ityatthedonorsite,unpredictableresorptionrates,andthelimited amountofbonetissueavailablehavepromptedthedevelopment ofseveralsubstitutes[5,6].

Amongthese,Bio-oss®hasproventobeanexcellentalternative forarangeofindications,givenitsnaturallyporousarchitecture (75–80%),whichenablesbettervascularization,providesa frame-workforosteoconductivity,andimprovesbloodclotstabilization andnaturalbloodabsorptionbetweenmicro-andmacropores[7]. Withinthiscontext,thisreportdescribesacaseofanterioropen bitetreatedwithsegmentalmaxillaryosteotomyandbonegrafting ofthesurgicalgapwithBio-oss®granules.

2. Casereport

Thepatientwasahealthy24-year-oldwomanwithan ante-rioropen bite(3mm overbite, 4mm overjet, 2mm Angleclass II anterior occlusion, and 2mm Angle class III posterior occlu-sion)whohadbeenundergoingorthodontictreatmentfor2years

http://dx.doi.org/10.1016/j.ijscr.2016.06.034

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Fig.1. A,B,C—PreoperativeOcclusion.D,E,F—Occlusionin3Dvirtualplanning.G,H,I—Postoperativeocclusionafter30days.

(Fig.1A–C).ShepresentedtotheOralandMaxillofacialSurgery CenterofPontifíciaUniversidadeCatólicadoRioGrandedoSulfor treatmentofherdentofacialdeformity,withachiefcomplaintof difﬁcultychewingwiththefrontteeth.Writteninformedconsent wasobtainedfromthepatientforpublicationofthiscasereport, includingaccompanyingimages,andthemanuscriptwaswritten inaccordancewiththeCAREcriteria[8].

2.1. Virtualplanning

A cone-beam computed tomography (CBCT) scan was per-formedusingani-CATsystem(ImageSciencesInternational, Hat-ﬁeld,PA,USA).Three-dimensional(3D)imageswereconstructed usingDolphinSoftware(DolphinImagingandManagement Solu-tions,Chatsworth,CA,USA).Surgicalplanningwasbasedonthe patient’s chief complaint,facial analysis,and 3D cephalometric analysis.Basedonthesefactors,monomaxillarysurgerywithLe FortIosteotomywaschosenfor2mmadvancementofthe pos-terior maxilla and a V-shaped segmental maxillary osteotomy betweenteethUR3/4andUL3/4for8◦clockwiserotationand5-mm downrepositioningofthepremaxilla, therebymodifying occlu-siontoAngleclassIandclosingtheanterioropenbite(Fig.1D–F). Reconstructionsofthesegmentedosteotomiesshowedagapof approximately4.1mmintheareabetweenteethUR3/4andUL3/4 andapproximately4.8mmontheﬂoorofthenasalfossa(Fig.2). Assuch,thedecisionwasmadetoplaceabonegraft.

2.2. Surgicalprocedure

Thepatientwasplacedunderhypotensivegeneralanesthesia. Themaxillaryvestibularapproachwasusedforsurgicalaccessand detachmentofthenasalfossamucosa.Next,aLeFortIosteotomy wasperformedand,afterdownfracture, aV-shaped segmental maxillaryosteotomywasmadebetweenteethUR3/4andUL3/4 and behind the incisive foramen to correct the anterior open biteandover-projectionoftheanteriorteeth.Osteotomieswere performedusing NSKVarioSurg piezoelectricinstruments (NSK AmericaLatinaLtda,Joinville,SantaCatarina,Brazil).

Thesplintwasattachedtotheorthodonticappliancewitha steelwire.Oncethemaxillaandmandiblewerestabilizedin occlu-sion, thesurgery wasconsidered tobein accordance with the virtualplan.Then,aspreviouslyestablished,bonegraftingwas per-formedbyplacing2gofsmallBio-oss®granules(GeistlichPharma AG, Wolhusen,Switzerland) intothe surgicalgaps. Theseareas werethencoveredwithaBio-Gide®collagenmembrane(Geistlich PharmaAG,Wolhusen,Switzerland).

Themaxillawaspositionedforrigidinternalﬁxationwith bilat-eralL-shapedminiplatesinthezygomaticbuttressandbilateral L-shapedmicroplatesaroundthepiriformaperture,toensure sta-bilityofthecollagenmembranesforbonegraftprotection(Fig.3). 2.3. Postoperativeperiod

Thesurgicalsplintremainedinplacefor30dayswith maxillo-mandibularﬁxation,afterwhichtimethepatientwasinstructed tofollowa liquid/semisolid dietand avoidschewing.The over-biteimprovedfrom−3mmto2mm andoverjet from4mm to 2mm,ensuringclosureoftheanterioropenbiteandmaintaining coordinationbetweentheposteriorandanteriorsegmentsof den-talocclusionatAngleclassI(Fig.1G–I)RepeatCBCT performed 6 months after surgery revealed bone formation with density greaterthanthatofthetissuesurroundingthesegmentalmaxillary osteotomy,providingstableocclusion(Fig.4).

3. Discussion

Closinganterior openbitesisone ofthe greatestchallenges in orthognathicsurgery, particularlywhen segmental maxillary osteotomyisused.Assuch,aseriesofprecautionsmustbetakenat diagnosistomitigatetheeffectsofinstabilityandpreventrelapse. Thisallowsadjuvanttherapiessuchasglossectomy[9]andbone grafting[2,10]tobeplannedbeforehandwhennecessary.Inthe casereportedherein,thepatientdidnotexhibittruemacroglossia ortongueinterpositionbetweentheanteriorteeth;accordingly, oneofthemaincausesofopenbiterelapsewasnotaconcern. How-ever,3Dsurgicalplanningofthesegmentalmaxillaryprocedure showedagapofapproximately4–5mmbetweenbonesegments.

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Fig.2. Virtualplanning.A—Axialview−V-shapedsegmentalmaxillaryosteotomyshowinga4.1mmsurgicalgapbetweenUR3/4andUL3/4,anda4.8mmsurgicalgapon theﬂoorofthenasalfossa(redarrows).B,C,D—Lateralandfrontalview.

Fig.3.SurgicalprocedureA—Gapbetweenthesectionsofthemaxilla.B—FrameworkﬁlledwithBio-oss®_granules._C—Collagen_membrane_placed_over_the_grafted_area.

D—RigidinternalﬁxationwithL-shapedmicroplatesstabilizingthecollagenmembranes.

Moreover,consideringlossofbonestructureduringosteotomy,a gapofatleast5–6mmwouldbeexpected,whichcouldresultin nonunionofthebonesegmentsandincreasepostoperative insta-bility.Inordertoprovideabettersurgicalprognosisandprevent

pseudarthrosis,thedecisionwasmadetoplacebonegraftsinthe gapsbetweenthesectionedareasofthemaxilla.

Bonegraftingisnecessaryinaround25%ofcasesandboth auto-genousbone[2,10]andbonesubstitutes[2,5]havebeenreported

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Fig.4. Cone-beamCTImages6monthsafterorthognathicsurgeryshowingnewlyformedboneinthesurgicalgapwithdensitygreaterthanthatofthesurroundingtissues (redarrows).A—Axialview−Areaontheﬂoorofthenasalfossa.B—Coronalview−AreabetweenUR3/4andUL3/4.C—Saggitalview−AreabetweenUL3/4upto4.98mm longwithnewlyformedbonetissue(redline).C—Saggitalview−Areaontheﬂoorofthenasalfossaofupto5.17mmlongwithnewlyformedbonetissue(redline).

asoptionsintheliterature.Althoughautogenousboneisthegold standardduetoitsosteoconductive,osteoinductive,andosteogenic properties,italsoinvolveshighermorbidityforthepatient, unpre-dictableresorptionrates, increasedoperativetimes, andrisk of infectionatthedonor site.Considering theseaspects,the deci-sionwasmadetousea biomaterial,Bio-oss® granules,thathas beentested inlongitudinal studiesand shownto providegood bonestability,osteoconduction,andbiocompatibilitywhile reduc-ingoperativetimeandsurgicalmorbidity.Inaddition,theporous structureandinterconnectedmacroporesofthismaterialfacilitate angiogenesis[11].Bonesubstitutessuchascalciumtriphosphate weredisregarded becauseof theirtendency for lossof volume andunpredictableresorptionratesascomparedtoBio-oss®[12]. Although theuse of Bio-oss® granules in orthognathic surgery formaxillarysegmentalosteotomyhadnotbeendescribed previ-ously,thereisscientiﬁcevidencetosupportthestabilityofBio-oss Collagen® inLeFortIosteotomy[13] andbilateralsagittalsplit osteotomyofthemandibularramus[14].However,themainreason forusingthisbiomaterialweretheresultsobtainedforgraftingin maxillarysinusliftprocedures,wherelong-termfollow-upshowed closecontactbetweenthebonegraftandnewbonemarrow, angio-genesis,andlowsubstitutionrates[7],allofwhicharenecessary topreventpseudarthrosisandmaintainmaxillaryosteotomy sta-bility.CBCT imagesobtained6 monthsafter surgeryconﬁrmed thebiomaterialcharacteristicscitedabove,showingclosecontact betweenthegraftedareawithgreaterbonedensityandthe sur-roundingbone,providingthedesiredocclusalstability.

However, the question emergesas to how a granular bone graftcouldbeusedinsegmentalmaxillaryosteotomy.By trans-ferringscientiﬁcknowledgefoundintheliteratureregardinguse ofthisbiomaterialinmaxillarysinuslifts[7,15,16]andanalyzing 3Dvirtualplanning,thatindicateda4–5mmthree-dimensional frameworkbetweentheosteotomies,easyplacementandstability ofgranularbonegraftswereexpected.Additionalprecautionswere alsotaken,includingkeepingthemucosaofthenasalfossaintact, placingcollagenmembranesoverthegraftedareaasamechanical barrier,andstabilizingthemembraneundertheﬁxationplates.

InadditiontotheuseofBio-oss®granules,twoothertoolsplayed amajorroleinthesuccessfuloutcomeofthiscase.

Theﬁrstwasvirtualplanning,whichenabledmobilizationofthe osteotomizedbone,combiningrotationandtranslation,inthree dimensions.Thiscloselymimicstherealityofsurgery, minimiz-ingpotentialrisksandcomplications[3,4],and,assuch,wasvital indetectingtheneedforbonegrafting.Thesecondessentialtool waspiezoelectricinstrumentation,whichdoesnotinjuresofttissue duringosteotomy[16].

This is the ﬁrst case reported in the literature to use Bio-oss® granulesas bonegraftsin segmental maxillary osteotomy for orthognathic purposes. The granularnature of thematerial facilitated its application between the bone segments, and we subsequentlyobservedstabilizationofthebiomaterialandnewly formedbone,preventingpseudoarthrosisandocclusalinstability. Inaddition,thepropertiesexhibitedmakeBio-oss®avalid alter-nativetoautogenousgrafting,preventingtheaddedmorbidityofa donorsurgicalsite.

Conﬂictsofinterest

Noconﬂictsinterest.

Funding

Nofunding.

Ethicalapproval

CEP05/02890-PontiﬁcialCatholicUniversityofRioGrandedo Sul–PUC/RS.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereport,includingaccompanyingimages.

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Authorcontributions

OrionLuizHaasJunior:Conceptionanddesignofcasereport, Acquisitionofdata:laboratoryandclinical/literaturesearch, Anal-ysisand interpretationof postoperativeCT cone-beam,Drafting ofarticleand/orcriticalrevision,Finalapprovalandguarantorof manuscript.

LucasdaSilvaMeirelles:Conceptionanddesignofcasereport, Acquisitionofdata:laboratoryandclinical/literaturesearch, Anal-ysisand interpretationof postoperativeCT cone-beam,Drafting ofarticleand/orcriticalrevision,Finalapprovalandguarantorof manuscript.

NeimarScolar:Conceptionanddesignofcasereport,Drafting ofarticleand/orcriticalrevision,Finalapprovalandguarantorof manuscript.

MarceloF.SantosMelo:Conceptionanddesignofcasereport, Draftingofarticleand/orcriticalrevision,Finalapprovaland guar-antorofmanuscript.

OtávioEmmel Becker:Conceptionand designof casereport, Acquisitionofdata:laboratoryandclinical/literaturesearch, Anal-ysisand interpretationof postoperativeCT cone-beam,Drafting ofarticleand/orcriticalrevision,Finalapprovalandguarantorof manuscript.

RogérioBelledeOliveira:Conceptionanddesignofcasereport, Acquisitionofdata:laboratoryandclinical/literaturesearch, Anal-ysisand interpretationof postoperativeCT cone-beam,Drafting ofarticleand/orcriticalrevision,Finalapprovalandguarantorof manuscript.

Guarantor Yes. References

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