LETTERS TO THE EDITOR
Re: A Simple Method for Cranial
Bone Chip Harvesting
In the craniofacial surgery prac-
tice, bone grafts are one of the useful
materials for the reconstructive surgical
procedures. Solid bone grafts are used in
most cases.1 But, in some cases, the
surgeon needs bone chips for filling the
cavities such as the alveolar cleft. Dr.
Paul Tessier used to use the cranial bone
chips for alveolar bony reconstruction.
Mostly, iliac bone chips or
crushed cranial bone is used for bone
chips usage. Crushed cranial bone has
also been used for bony reconstruction
of the craniofacial skeleton. In this paper
an easy, safe, and useful technique has
been described for harvesting of the cra-
nial bone chips. According to the tech-
nique, a rasp is used for the harvesting
of cranial bone chips. The rasp for hump
reduction during a rhinoplasty proce-
dure can be used for harvesting of cra-
nial bone chips (Fig 1).
Personally, I prefer the use of the
cranial bone chips for augmentation of
the nasal dorsum in the case of mild
saddle-nose deformity or bony irregular-
ities of the nasal dorsum with the mild
deficiency of the nasal projection.2
Many techniques have been de-
scribed and used for the harvesting of
the iliac bone chips. Tessier described a
crushing technique for preparation of
the cranial bone chips from a solid cra-
nial bone graft and used a special device
for this purpose.
The cranial bone chips are har-
vested with any kind of hand or electri-
cal rasp. The length of teeth of the rasp
is chosen according to desired volumes
of the bone chips. Usually I prefer a rasp
having teeth 2 mm in length.
The cranial bone chips can be har-
vested from all areas of the skull. In the
case of unesthetic bony fullness, espe-
cially on the frontal area, the graft
should be harvested from that region
correcting the unesthetic fullness.
A very short scalp incision (1 cm
in length) is cut over the preferred area
of the head. A subperiosteal dissection is
done over the planned donor area. Then
434
FIGURE 1. Harvesting cranial bone chips.
the rasp is used for harvesting of the
bone chips. The donor area is planned as
wide as possible, avoiding significant
thinning on the region of the skull.
The areas of reconstruction are as
follows: dorsal nasal augmentation, 46;
periapertural augmentation, 12; alveolar
reconstruction, 8; and others, 7.
The use of the cranial bone chips
has the advantage of working at the same
location. The cranial bone chips show less
resorption rates. The cranial bone also has
similar histological and structural charac-
teristics with the craniofacial bones.3– 6 As
known, the bone chips have the advantage
of early revascularization when compared
with a solid bone graft. According to the
technique that I described, the harvesting
of cranial bone chips is very safe for donor
site complication. However, no overcor-
rection is necessary in nasal augmenta-
tion. In the case of the use of cranial
bone chips for dorsal nasal augmenta-
tion, underlying nasal bones must be
rasped for bony healing effect with nasal
bones and graft material.
According to the experience with
the use of the cranial bone chips in nasal
reconstruction, the augmentation may be
evaluated as overcorrected at the early
postoperative period. It is observed that
Annals of Plastic Surgery • Volume 51, Number 4, October 2003
this overcorrected appearance will be
settled down by the remodeling process
of bony healing.
In conclusion, cranial bone chips
can be harvested with a rasp without
donor site complication and patient dis-
comfort.
Muzaffer Çelik, MD
Cranioplast Clinic and Florence
Nightingale Metropolitan Hospital
Karanfil caddesi no: 26
1. Levent
Istanbul, Turkey
REFERENCES
1. Çelik M, Tuncer S. Nasal reconstruction using
both cranial bone and ear cartilage. Plast Re-
constr Surg. 2000;105:1624.
2. Çelik M, Bayçyn N, Olyai B. An anatomically
adopted graft: bone and cartilage chips to aug-
ment the nose. Presented at the 16th Congress
of ISAPS, Istanbul, Turkey, May 26 –29, 2002.
3. Missori P, Rastelli E, Polli FM, et al.
Reconstruction of suboccipital craniotomy with
autologous bone chips. Acta Neurochir. 2002;
144:917.
4. Widmark G, Ivanoff C. Augmentation of ex-
posed implant threads with autogenous bone
chips: a prospective clinical study. Clin Implant
Dent Relat Res. 2000;2:178.
5. Sclegel KA, Sindet-Pedersen S, Hoepffner H.
Clinical and histological findings in guided
bone regeneration around titanium dental im-
plants with autogenous bone chips using a new
resorbable membrane. J Biomed Mater Res.
Annals of Plastic Surgery • Volume 51, Number 4, October 2003
2000;53:392.
6. Çelik M, Tuncer S, Emekli U, et al. Histologic
analysis of prefabricated, vascularized bone
grafts: an experimental study in rabbits. J Oral
Maxillofac Surg. 2000;58:292.
Extra-Articular Ankylosis of the
Mandible Caused by Possible
Migration of Bone Grafts
Dear Sir,
Limitation of mandibular mobility
secondary to ankylosis may result from
a series of disorders that affect the tem-
poromandibular joint (TMJ) and adja-
cent structures. The lesion is classified
by its location (intra-articular or extra-
articular), by the type of tissue involved
(osseous, fibrous), or by the extension of
the involved segment (complete or in-
complete).1 TMJ ankylosis most fre-
quently occurs after trauma, infection,
and orthognathic or intracranial sur-
gery.2,3 The most common cause of in-
tra-articular TMJ ankylosis is blunt
trauma associated with a condylar pro-
cess fracture in early childhood.4 Extra-
articular ankylosis occurs less fre-
FIGURE 1. Preoperative computed tomography (A) and spiral three-dimensional computed tomography of the patient (B). Arrows
demonstrate a bony bridge between the left mandibular coronoid process and the posteromedial wall of the left maxilla.
© 2003 Lippincott Williams & Wilkins
quently. Radiation therapy to the
maxillomandibular region, infection, fi-
brous ankylosis of the mandible after
zygomatic fracture, and heterotrophic
bone formation between the coronoid
process of the mandible and the zygo-
matic arch or sphenoid or posterior max-
illary bones after orthognathic or intra-
cranial surgery are the most common
causes of the extra-articular anky-
losis.5– 8
Reports of TMJ ankylosis after
orthognathic surgery are rare; most ac-
tually describe patients with joint hypo-
mobility caused by fibrous rather than
true bony ankylosis.9,10 Osseous anky-
losis caused by bone graft, however, is
not reported in the literature.
We report a case of bony fusion
between the left mandibular coronoid
process and the posteromedial wall of
the left maxilla caused by displacement
of an old bone graft.
A 38-year-old woman was re-
ferred to our clinic with the complaint of
Letters to the Editor
considerable limitation in opening her
mouth. Seventeen years previously, she
underwent subcranial Le Fort III osteot-
omy, bilateral sagittal split ramus osteot-
omy, and zygomatic arch reconstruction
with costal bone grafts to correct a facial
deformity. In the early postoperative pe-
riod, the patient noticed difficulty in
opening her mouth. TMJ ankylosis was
diagnosed; two more attempts at opera-
tive correction were unsuccessful.
In our clinic, physical and radio-
logic examinations revealed osseous an-
kylosis of the TMJ secondary to forma-
tion of a bony bridge between the left
mandibular coronoid process and the
posteromedial wall of the left maxilla
(Fig. 1 A and B), with resultant severe
limitation of TMJ movements.
Under general anesthesia, via a
left preauricular incision, the bony seg-
ment between the coronoid process and
maxilla was removed. The presence of
extensive muscle fibrosis required my-
otomies of the temporal and pterygoid
435
Letters to the Editor
muscles. The patient responded well to
the surgery and to postoperative physi-
cal therapy, and 6 months postopera-
tively, she had no limitation in mandib-
ular movement.
Histopathologic examinations of
the mandibular/maxillary bony bridge
showed it to have been a piece of mem-
branous bone, most likely an old costal
bone graft.
In orthognathic surgery, various
alloplastic materials can be used for the
reconstruction of the zygoma or zygo-
matic arch; however, bone grafts usually
are the first choice.11 Postoperative
complications may include infection, ly-
sis, and displacement of the bone graft;
both occurrence and severity of compli-
cations increase because of poor surgi-
cal technique with excessive trauma, he-
matoma, or presence of residual bone
fragments. Stabilization of bone grafts
with plates and screws, if performed
436
Annals of Plastic Surgery • Volume 51, Number 4, October 2003
carefully and rigidly, tends to lower the
probability of complications.
Ufuk Emeklİ, MD,
Alp Arslan, MD,
Defne Önel, MD, and
Sİnan Nur Kesİm, MD
From the Faculty of Medicine,
Department of Plastic and
Reconstructive Surgery, Istanbul
University, Istanbul, Turkey.
REFERENCES
1. Manganello-Souza LC, Mariani PB.
Temporomandibular joint ankylosis: report of
14 cases. Int J Oral Maxillofac Surg. 2003;
32:24 –29.
2. Shabtaie R, Schwartz HC. Extra-articular an-
kylosis of the mandible after failed orthog-
nathic surgery: report of a case. J Oral Max-
illofac Surg. 2000;58:1452–1454.
3. Hollins RR, Moyer DJ, Tu HK.
Pseudoankylosis of the mandible after tempo-
ral bone attached craniotomy. Neurosurgery.
1988;22:137–139.
4. Nitzan DW, Dolwick MF. Temporomandibular
joint fibrous ankylosis following orthognathic
surgery: report of eight cases. Int J Adult Orth-
odon Orthognath Surg. 1989;4:7–11.
5. Wright GW, Heggie A. Bilateral temporo-
mandibular joint ankylosis after bimaxillary
surgery. J Oral Maxillofac Surg. 1998;56:
1437–1441; discussion 1441–1442.
6. Hong Y, Gu X, Feng X, et al. Modified
coronoid process grafts combined with sagit-
tal split osteotomy for treatment of bilateral
temporomandibular joint ankylosis. J Oral
Maxillofac Surg. 2002;60:11–18; discussion
18 –19.
7. Regev E, Koplewitz BZ, Nitzan DW.
Ankylosis of the temporomandibular joint as a
sequela of septic arthritis and neonatal sepsis.
Pediatr Infect Dis J. 2003;22:99 –101.
8. Rikalainen R, Lamberg MA, Tasanen A.
Extra-articular fibrous ankylosis of the man-
dible after zygomatic fracture. J Maxillofac
Surg. 1981;9:132–136.
9. Karakasis D, Triantafyllidou E, Kavadia S.
Extra-articular ankylosis of the coronoid pro-
cesses to the base of the skull: a case report. J
Craniomaxillofac Surg. 1989;17:46 – 49.
10. Tanaka H, Westesson PL, Larheim TA.
Juxta-articular ankylosis of the temporoman-
dibular joint as an unusual cause of limitation
of mouth opening: case report. J Oral Maxil-
lofac Surg. 1998;56:243–246.
11. Habal MB, Reddi AH. Bone grafts and bone
induction substitutes. In: Vander Kolk CA, ed.
Clinical Plastic Surgery. Philadelphia, PA:
WB Saunders Co; 1994:525–541.
© 2003 Lippincott Williams & Wilkins