J Oral Mawllofac Surg

43 856-859. 1985

Composite Graft for Mandibular Alveolar

Ridge Augmentation:
A Preliminary Report

RICHARD A. KRAUT, DDS*

Augmentation of atrophic mandibles with a composite graft system con-

sisting of allogeneic freeze-dried rib, autogenous cancellous bone and
marrow, and hydroxylapatite is reported. The six patients subjected to this
procedure tolerated the surgey well and showed marked improvement in
dental function, with maintenance of 78% of the augmenteb height one
year later and 67% of the height at two years.

The plethora of procedures proposed for aug- cm cutaneous incision was made in the labiomental
mentation of the atrophic mandible underscores the fold (Fig. 1). One patient who was 34 years old and
elusiveness of a predictably stable operation to re- did not have suitable facial aging lines to allow for
construct the atrophic alveolar process of the man- an inconspicuous labiomental fold incision was
dible.‘-‘s This lack of predictability motivated the treated via a submandibular incision from mental
development of a three-component composite graft foramen to mental foramen. Dissection was carried
technique for treatment of severely atrophic man- through the subcutaneous tissues to the periosteum,
dibles. and the periosteum was then incised along the labial
surface of the mandible from the right to the left
Materials and Methods canine area. Next, the periosteal incision was ex-
tended posteriorly to the region of the mental fo-
The patients selected for treatment were dissat- ramen, carefully avoiding damage to the neurovas-
isfied with their well-made conventional dentures cular bundle. A periosteal elevator was then used
and had a bone height in the premolar region of 12 to develop a subperiosteal tunnel extending to the
mm or less. An impression of the mandibular ridge ascending ramus of the mandible. The tunnel ex-
was made using modeling compound, and an acrylic posed the occlusal, the lingual, and a portion of the
model of the mandible was fabricated to facilitate buccal surface of the mandible. An allogeneic rib
contouring of the graft at the time of surgery. The that had been reconstituted overnight using peni-
patients were admitted to the hospital and taken to cillin and streptomycin was despined, and vertical
the operating room the day after admission. Once cuts were placed through the cortex on the inner
the patients were under general anesthesia, one sur- surface to aid in contouring. A bone-contouring for-
gical team harvested cancellous bone and marrow ceps was used to conform the rib to the shape of
from the anterior iliac crest, while a second surgical the patient’s mandible, as determined by the ster-
team prepared the mandible to receive the com- ilized acrylic model (Fig. 2). Care was taken to
posite graft. make sure that the posterior extent of the rib en-
In five of the six patients being reported, a 4-5 gaged the vertical portion of the ascending ramus
to provide posterolateral support for the rib. By
* Colonel, Dental Corps, United States Army: Director of preforming the rib on the model, multiple insertions
Oral and Maxillofacial Surgery. Tripler Army Medical Center. of the rib into the wound were avoided. After place-
Honolulu. Hawaii.
ment in the tunnel, the rib was secured on the lin-
The opinions or assertions contained herein are the private
views of the author and are not to be construed as official or as gual surface of the mandible with bilateral no.2
reflectingthe views of the Department of the Army or the De- Vicryl sutures placed anterior to the mental foramen
partment of Defense.
(Fig. 3). The occlusal-buccal portion of the tunnel
Address correspondence and reprint requests to Dr. Kraut:
Chief, Oral and Maxillofacial Surgery, Tripler Army Medical was then filled with a mixture consisting of equal
Center. Honolulu. HI 96859-5000. volumes of the autologous cancellous bone and

856
KRAUT 857

FIGURE 1 (/efi. top). Diagrams of incisions. Lefr. Placement of the submandibular incision. Right. Position of labiomental incision.
FIGURE 2 Clefr. hotfonll. Contoured allogeneic rib resting passively on an acrylic model.
FIGURE 3 (rigl~r. !op). Rib fastened to mandible with no.2 Vicryl suture. Arrow indicates mental nerve posterior to suture.
FIGURE 4 (,t(qht. fxttrom). Diagram depicting allogeneic rib on lingual surface of atrophic mandible and subperiosteal tunnel partially
filled with hydroxylapatite and cancellous bone and marrow.

marrow and hydroxylapatite (Fig. 4). The incision loplasties three months following augmentation. All
was closed in layers. are using newly fabricated dentures and have ex-
perienced marked improvement in denture func-
Results tion.
The sample size precluded statistical analysis.
The six patients tolerated the procedure well. Measurement on panoramic radiographs of preaug-
Four underwent split-thickness skin graft vestibu- mented mandibles indicated a mean height of 10 mm

Table 1. Results of Mandibular Augmentation Using a Composite Grafting Technique*

Initial Postoperative Postoperative

Preoperative Postoperative I?- I4 Months 24-26 Months

Patient R L R L K L K L

1 9 10 27 28 ?I 22 18 IY
2 9 IO 27 30 21 22 19 20
3 9 11 29 29 23 23 20 19
4 I2 11 30 32 22 24 - -
5 8 9 29 28 23 23 - -
6 12 I2 26 27 21 21 -

* Mandibular height is given in millimeters and was measured at the distal side of the mental foramen.
858 COMPOSITE GRAFT-MANDIBULAR ALVEOLAR AUGMENTATION

(Table 1; Figs. 5 and 6). At two years, 67% of the

increased height was maintained. Mandibular width
was also increased following augmentation, but the
increase was not quantified.

Discussion

The technique reported here was developed to

circumvent several problems with previous aug-
mentation procedures. The dehiscence rate of 53%
reported by Kelly and Friedlaender17 and experi-
enced by this author when grafting allogeneic bone
via a crestal approach to the atrophic mandible
prompted the use of an extraoral approach. This
approach avoids both oral contamination of the
graft and the problems of healing that arise in rel-
atively hypovascular tissue.
The choice of materials for the composite graft
was based on the structural and biologic require-
ments of the procedure. Increasing the height of the
atrophic mandible requires initial structural sup-
port, which is provided by the slowly resorbed al-
logeneic rib. The osteogenic component to unite the
graft to the atrophic mandible and to strengthen it
is provided by the autologous bone and marrow.
Hydroxylapatite, being nonresorbable, was se-
lected as the final component to provide longevity
to the augmentation.
The number of patients for whom this technique
has been used is small. All six have maintained a
greater percentage of their augmentation than have
those operated on by the author using previously
reported techniques. The technique described here
continues to be used, and an increased number of
cases with longer follow up will be reported in the
future.

References

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KRAUT
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