Orthognathic Surgery

591
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
Pre retreatment ortho
5 weeks after surgery
Pre retreatment surgery
3 years after surgery
E
E, Occlusal views before retreatment, with orthodontics in progress, 5 weeks after redo jaw surgery, and 3
years after jaw reconstruction.
• Figure 17-14, cont’d 
Continued

592 SECTION 2  Planning, Surgical Technique, & Complications
F
Arch expansion
G
F, Articulated dental casts that indicate analytic model planning. G, Lateral
cephalometric views before and after retreatment.
• Figure 17-14, cont’d 
Calvin Case, who was a prominent contemporary and
outspoken critic of Angle, used contouring appliances and
light rubber bands to move the teeth. He argued that,
although the arches could be expanded and the teeth aligned,
in the long term, occlusal stability was not always satisfactory,
and facial aesthetics could be compromised.
By around 1915, Case had worked out most of the
mechanical principles required for the successful manage­
ment of ortho­dontic extraction sites. With the use of full-
banded appliances, he was able to routinely retract the
anterior teeth into the bicuspid extraction sites to correct
the inclination of the anterior teeth and to eliminate crowd­
ing. Interestingly, only about 10% of his patients were
treated with extractions.
Debate in dental circles regarding the issue of extractions
continued between Angle’s disciples and Case’s followers
throughout the 1920s. The Dewey–Case “Great Extraction
Debate” took place in 1911. Angle’s non-extraction/arch
expansion approach continued to predominate with the
everyday practitioner until after World War II. Angle’s
philosophy was widely accepted as a result of his well-
written and popular textbook; his abilities as a teacher and
lecturer; his consistent treatment philosophy; and his success
as a diligent clinician.
By the late 1930s, when non-extraction treatment was
used on all comers, relapse was a frequent observation that
could no longer be ignored. After Angle’s death, his student
Charles Tweed began re-treating a number of Angle’s patients
who had experienced relapse. Tweed’s retreatment approach
included four bicuspid extractions followed by the realignment
of the remaining dentition. He observed greater occlusal
stability with this approach. By the mid-1940s, Tweed’s
well-documented series of cases involving four premolar
extractions with orthodontic retraction caused a revolution
in orthodontic thinking that led to widespread extraction
therapy in everyday orthodontic practice. Interestingly,
Raymond Begg, who was another of Angle’s students and
who was at this time halfway around the world in Australia,
also concluded that non-extraction treatment was frequently
unstable. Like Tweed, Begg modified the Angle-designed
Edgewise appliance into what he called the “Begg appli­
ance” for use with extraction therapy.
The acceptance of extraction therapy in orthodontics to
stably position the teeth into alveolar housing coincided

593
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
An alternative to the extraction of teeth for the relief of
crowding in the maxilla is to expand the volume of the
alveolar ridge. This may be accomplished via one of three
techniques: (1) rapid palatal expansion (RPE) with the use
of a transpalatal appliance if the palatal suture is open (i.e.,
0.5 mm of widening per day); (2) surgically assisted rapid
palatal expansion (SARPE) followed by transpalatal appli­
ance widening (i.e., 0.5 mm of widening per day); (3) seg­
mental maxillary osteotomies (i.e., Le Fort I down-fracture
and full disimpaction) with immediate repositioning to
correct the arch form. These three options are not equally
appropriate for each individual patient. The level of success
of each of these options will be dependent on the clinical
circumstances.
Orthodontic Treatment of Specific Dentofacial
Growth Patterns: Dental Stability and Relapse
Primary Mandibular Deficiency Growth Pattern with or
without Maxillary Arch Constriction (Skeletal Class II)
Findings
For the patient who presents with mandibular deficiency,
dental compensations often include crowding and flaring of
the lower incisors with an accentuated curve of Spee. This
is a natural biologic response to the eruption of a full
complement of teeth within a small mandible. This is exac­
erbated by constant protrusive tongue activity in combina­
tion with limited lip forces within a small oral cavity. These
dental compensations are inevitable when the combined
size of the mandibular teeth is greater than the available
alveolar bone volume within a hypoplastic lower jaw. The
anterior teeth (i.e. dental roots) follow the path of least
resistance and frequently protrude outside of the labial
cortex. In this dysfunctional matrix, the lower incisor
inclination—when viewed on a lateral cephalometric
radiograph—is obtuse, and it often substantially exceeds
the normal range (i.e. 90 to 95 degrees). The extent of
incisor protrusion is indicative of the degree of mandibular
hypoplasia, and the unequal forces of the tongue and lips.
In approximately one third of cases, there is also a degree
of maxillary arch-width deficiency that requires correction;
this is described in more detail later in this chapter.
Orthodontic Approach in Conjunction with
Orthognathic Surgery
In the presence of moderate to severe mandibular defi­
ciency, the ideal positioning of the lower anterior teeth is
best accomplished by first carrying out extractions to create
space. This most often involves the removal of the lower
first bicuspids. When less space is required and the occlu­
sion will accommodate it, the extraction of a single lower
incisor is an option to consider. In borderline cases and
depending on the specific patient’s dental anatomy, inter­
proximal reduction of the anterior teeth may provide suf­
ficient space. The orthodontist’s ability to achieve lower
incisor inclination of approximately 90 to 95 degrees will
be a good indication of the overall relief of dental compen­
sation within the mandibular arch.
with an appreciation that genetic variations—with dispari­
ties between tooth root volume and jaw size—are common
among normal individuals and will differ among races (see
Chapter 3). That a presenting jaw or dental discrepancy
could benefit from extractions was simply an admission of
a patient’s individuality rather than the orthodontist’s
inability to solve all problems in the same way. By the
early 1960s, approximately 50% of American patients who
were undergoing orthodontic treatment would experience the
extraction of at least some teeth, most commonly the first
premolars.
Orthodontists have also used extractions as a means to
achieve a neutralized occlusion in the presence of a skeletal
discrepancy (i.e., a camouflage approach). This involves
achieving an improved occlusion while accepting the jaw
(facial) disharmony. Examples of this approach include
upper bicuspid extractions to orthodontically treat man­
dibular retrognathism or lower bicuspid extractions to
orthodontically manage Class III skeletal patterns. Interest­
ingly, this orthodontic camouflage approach became
common practice during the 20th century, despite the fact
that, by the early 1900s, mandibular surgery had been per­
formed for both Class II and Class III skeletal deformities.
In reality, corrective jaw surgery was rarely considered an option
(except by a handful of orthodontists and surgeons) until the
later decades of the 20th century (see Chapter 2).
By the 1990s, overemphasis on four bicuspid extractions
as part of routine orthodontic treatment began to wane in
favor of a more discriminating approach. The rationale for
selective extractions as part of a comprehensive surgical and
orthodontic approach has now been confirmed to be effec­
tive for the removal of dental compensation. Extraction
orthodontic therapy in combination with jaw osteotomies
to correct the occlusion, for long-term periodontal health,
to improve the upper airway, and to enhance facial aesthet­
ics is now considered routine for many patients. The inter­
proximal reduction of enamel as an alternative to extractions
was popularized by Dr. J. Sheridan during the 1990s. In
borderline cases, it has been found to provide the necessary
space for incisor uprighting (see Chapters 5 and 6).
Research confirms that clinicians and the general public
prefer a face with full midface projection and with promi­
nent teeth and lips.231,257,261 The “flat face” orthodontic stan­
dards of Tweed, which were typical during the 1950s and
the 1960s, retracted rather than expanded (i.e., filled out)
the face. In borderline cases, the patient’s facial appearance
is generally judged as being better without extractions. The
decision to extract should be viewed in the light of attaining
Andrews’ Six Keys to Normal Occlusion and Six Elements
of Orofacial Harmony (see Chapter 2). The primary goals
are to achieve: (1) the placement of teeth solidly in the
alveolar bone (2) ideal dental alignment within and between
the arches and (3) the adequate position and projection
of the maxillomandibular complex (i.e. facial harmony). If
jaw surgery (with or without extractions) is required to
achieve these objectives, it should be incorporated into
the treatment plan from the outset for the benefit of the
patient.

594 SECTION 2  Planning, Surgical Technique, & Complications
the Frankfort plane or 102 to 104 degrees to the sella–nasion
plane) should be considered. With only borderline crowding
and limited incisor flaring the decision for maxillary extrac­
tions becomes more difficult. Also, a degree of maxillary
incisor flaring may be aesthetically tolerated when planning
bi-maxillary osteotomies, which incorporate clockwise rota­
tion of the maxillo-mandibular complex to correct any
A-point–B-point facial disharmony (see Chapter 12).
If interarch width discrepancies (posterior crossbites)
require correction, then simultaneous segmentation of the
down fractured maxilla (2 or 3 segments) is carried out (see
“Management of Transverse Maxillary Deficiency” later in
this chapter).
In the mandibular arch, the incisors are generally retro­
clined, and a reverse curve of Spee is often excessive. Man­
dibular extractions are only indicated if there is significant
crowding in the lower arch with inadequate alveolar bone.
In the patient with a skeletal Class III growth pattern,
the failure to orthodontically remove these specific dental
compensations as part of the comprehensive orthodontic
and surgical approach is likely to negatively affect long-term
occlusal stability, periodontal health, and the achievement
of preferred Euclidian facial proportions.
Long Face Growth Pattern: Maxillary Vertical Excess with
Mandibular Deformity
Findings
A long face growth pattern classically includes maxillary
deformity (vertical excess, transverse deficiency, and a lack
of horizontal projection), mandibular deformity (high-angle
retrognathia), and deformity of the chin (vertical excess and
sagittal deficiency). Of note is that the mandibular defor­
mity may also present as a Class III rather than the more
common Class II growth pattern (see Chapters 4 and 21).
The biologic dental compensations in the maxillary arch
are reflective of the skeletal transverse deficiency and the
differential degrees of maxillary vertical alveolar excess (i.e.,
the anterior and posterior aspects of the maxilla). If there
is marked dental crowding in the maxilla, then bicuspid
extractions will be indicated. In the lower arch, depending
on the extent of mandibular micrognathia and flaring of the
incisors, limited space for the orthodontic retraction of the
teeth may be present. If so, mandibular first bicuspid extrac­
tions will generally be indicated followed by orthodontic
retraction and alignment.
Orthodontic Approach in Conjunction with
Orthognathic Surgery
The preoperative orthodontic leveling of a moderate to
severe curve of Spee in the maxilla is ideally performed with
segmental arch mechanics. This is necessary to match the
dental alignment with the extent of dysmorphic anterior
and posterior alveolar bone. This is done in preparation for
segmental maxillary osteotomies, which will then level the
curve of Spee and adjust the arch width. This segmental
orthodontic preparation places the teeth solidly in the avail­
able alveolar bone within each component (segment) of the
The failure to remove these compensations limits the
surgeon’s ability to position the mandible for ideal facial
proportions, and for the relief of airway obstruction (i.e.,
opening of the retroglossal space). An advancement genio­
plasty to further enhance aesthetics and lip function is also
generally beneficial to manage microgenia (see Chapter 19).
If the surgeon “over-advances” the chin as a “skeletal com­
pensation” for the inadequate orthodontic removal of
incisor flaring, then further facial disproportion (i.e., a
deepening of the labiomental fold with an overly prominent
pogonion) is likely to occur (see Chapters 37 and 40).
Another aspect of dental compensation frequently seen
in the individual with mandibular deficiency is a deep bite
and an accentuated curve of Spee. In this case, first bicuspid
extractions are often beneficial. At the time of mandibular
advancement with incomplete flattening of the curve of
Spee, the occlusion may be placed in a “tripod” relationship.
After surgery, the resulting mid-arch open bites are closed
by extruding the bicuspids with vertical elastics. These mid-
arch open bites are generally more efficiently managed after
surgery, when the lower anterior facial height is increased
and the mandible has been advanced. After surgery, the
expanded intraoral volume no longer creates the same
degree of anterior and lateral tongue forces that oppose the
orthodontic correction of the curve of Spee and the closure
of extraction sites. The reduction in bite force early after
surgery also assists with the rapid leveling process.
If interarch-width discrepancies are present—as they are
in approximately one third of cases—then simultaneous Le
Fort I osteotomy with segmentation (i.e., into two or three
segments) is generally carried out to widen and correct the
maxillary arch form (see “Management of Transverse Maxil­
lary Deficiency” later in this chapter). When only minimal
upper arch width deficiency exists and no other reasons
warrant maxillary osteotomy, mandibular narrowing to
balance the arches can be considered. This may be accom­
plished by completing a vertical midline osteotomy between
the mandibular central incisors. The use of this option for
mandibular narrowing is usually a distant second choice (vs.
maxillary expansion) for the resolution of interarch discrep­
ancies. Adding width to the upper jaw is generally preferred
for the airway and to enhance smile aesthetics (i.e., for the
relief of dark buccal corridors).
Maxillary Deficiency with Relative Mandibular Excess
Growth Pattern (Skeletal Class III)
Findings
In a patient with maxillary deficiency and relative mandibu­
lar excess, the normal dental compensations generally
include maxillary incisor protrusion and upright or retro­
clined mandibular incisors (see Chapter 20).
Orthodontic Approach in Conjunction with
Orthognathic Surgery
With this common dentofacial growth pattern, the extrac­
tion of the first bicuspids in the maxillary arch to uncrowd
and reposition the incisors (approximately 120 degrees to

595
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
of >14 years) should be managed surgically.* This can be
done with either “surgical assistance” followed by rapid
expansion using an in-place palatal appliance (the process
known as surgically assisted rapid palatal expansion [SARPE])
and then orthodontic realignment or by segmental Le Fort I
maxillary osteotomies in conjunction with standard ortho­
dontics. The latter approach is carried out when clinically
indicated as a one-stage procedure in combination with
vertical, horizontal, and other needed surgical repositioning
of the maxilla (these two approaches are discussed in more
detail later in this chapter). The magnitude of segmental
maxillary expansion that a surgeon is comfortable achieving
is dependent on that clinician’s experience and the unique
aspects of the specific patient’s palatal anatomy.
Proffit and colleagues reported that individuals who are
seeking evaluation for orthognathic surgery have a 30%
incidence of transverse jaw discrepancies.252 True (absolute)
transverse discrepancy exists when one or both of the pos­
terior maxillary segments are in a crossbite when the casts
are placed into a normal overjet and overbite position after
the relief of dental compensation. This will tend to unmask
arch-width discrepancies in patients with Class II malocclu­
sions and correct a percentage of those in patients with Class
III malocclusions. True transverse arch discrepancies are
frequently seen in patients with 1) Class II retrognathic
mandibles 2) long face Class II anterior open bites 3) those
with previous thumb-sucking habits resulting in anterior
open bite and 4) patients with cleft palates and maxillary
deficiency.
Vanarsdall and colleagues have defined transverse skeletal
discrepancies through measurements that are made on
posteroanterior cephalometric radiographs.314 The authors
measured maxillary (skeletal) width from the jugular point
on one side to the jugular point on the other side. They
compared this measurement to the skeletal lower arch width
measured from the antegonial notch on one side to the
antegonial notch on the other side. From these two mea­
surements, the determination of a differential index can be
made. These researchers suggested that a preferred differen­
tial index should be approximately 20 mm in the adult
Caucasian individual. Preadolescent patients will normally
have a lower differential index. The authors believe that an
adult with a differential of 30 mm has a significant trans­
verse problem. According to Vanarsdall and colleagues, a
differential index that varies by more than 5 mm from these
values requires correction in the maxilla to establish a long-
term stable occlusion and satisfactory periodontal health.314
With the advent of three-dimensional cone beam computed
tomography imaging, the more accurate measurement of
the transverse maxillary width is likely available. Further
research is required to confirm normal values for maxillary
and mandibular arch width.
Gingival recession in any given individual is likely to have
multifactorial causes. Tooth position within the alveolar
upper jaw. This avoids the extrusion of the anterior teeth
and the buccal tipping of the posterior dentition. Given the
usual degree of dysmorphic maxillary alveolar bone, attempts
to level the dentition solely through orthodontic mechanics
(i.e., via incisor extrusion and molar intrusion) are
periodontally unsound; they may result in incisor root
resorption, and they are prone to late dental relapse with
recurrent malocclusion (see Fig. 17-9).
Surgical segmentation of the maxilla between the lateral
incisors and the cuspids and then parasagittally through the
hard palate is generally performed to achieve the desired
arch width, the leveling of the curve of Spee, and the adjust­
ment of incisor inclination. The canine and lateral incisor
roots are naturally divergent, so there is no need (or advan­
tage) for the orthodontist to create a space to “make the
segmental surgery safe” (see Chapter 15). There is little risk
of causing intraoperative injury within the periodontal liga­
ment space or to the tooth roots or of creating periodontal
pocketing when completing the interdental osteotomies in
these locations.
To review, the orthodontic correction of the maxillary
arch form with vertical mechanics (i.e., the extrusion of the
incisors and molar intrusion) and dental expansion (i.e.,
molar tipping) in a patient with a long face anterior open-
bite malocclusion is unstable. It is likely to be injurious to
the periodontium, with labial bone loss and gingival reces­
sion in the molar region, and it is more likely to result in
the blunting of the incisor root apices. In addition, attempt­
ing closure of the anterior open bite via the orthodontic
extrusion of the incisors would accentuate the gummy
smile, further flatten the appearance of the face in profile,
and not address the lip incompetence.
Management of Transverse
Maxillary Deficiency: Techniques
and Relapse Patterns
Background
The orthodontic management of isolated transverse maxil­
lary deficiency in children and adolescents with an open
palatal suture by rapid palatal expansion (RPE) and conven­
tional orthodontic techniques is generally possible, although
stability can be troublesome.* In the non-growing individ­
ual, if standard orthodontic techniques are used for expan­
sion beyond a few millimeters, they will produce either
buccal tipping of the maxillary molars or lingual tipping of
the mandibular molars with an unstable long-term occlu­
sion and the potential for injury to the periodontium. The
molars will likely relapse palatally, thereby causing clockwise
rotation of the mandible with recurrent anterior open bite.
The literature confirms that a transverse maxillary defi­
ciency that presents after palatal suture closure (i.e., an age
*References 6, 17, 23, 67, 70, 73, 96, 122-125, 133, 151, 168, 185, 199,
200, 268, 269, 277, 282, 283, 306, 322, 323, 337
*References 13, 21, 25, 31, 32, 42, 56, 59, 60, 62, 64-66, 167, 171, 176,
225, 235, 238, 252, 260, 284, 299, 303, 314

596 SECTION 2  Planning, Surgical Technique, & Complications
interdental osteotomy (generally between the incisors) was
required. The immediate activation of an in-place palatal
expander in the operating room to verify the completion of
the osteotomies is also required to confirm the reliability of
postoperative skeletal expansion.
By the 1970s, the biologic safety of a Le Fort I osteotomy
in segments and the ability to then three-dimensionally
reconfigure the segments directly in the operating room
without the need for post surgical orthodontic expansion
was proven in experimental primate studies and through
successful use in clinical practice (see Chapter 2). This
led to questions about the value of SARPE as a first-
stage procedure for the patient with a dentofacial deformity
who also requires maxillary horizontal and vertical
adjustments.
Interestingly, it is estimated that only a limited percent­
age of dentofacial deformity patients have a transverse inter­
arch disharmony in isolation. Arch-width narrowing is
generally associated with other maxillary discrepancies (e.g.,
vertical, horizontal, dental midline to facial midline, occlu­
sal plane, and cant), and it is often seen in combination
with deformities of the mandible. For the limited cases in
which an isolated maxillary transverse deficiency does occur,
the use of SARPE followed by orthodontic alignment makes
intuitive sense.
For the patient to undergo a two-stage orthognathic
surgical approach (i.e., first-stage SARPE followed by defin­
itive orthognathic surgery 6 to 12 months later) for the
management of a multivector maxillary deformity, signifi­
cant value would have to be demonstrated. Variables to
consider include the following: (1) the potential for intra­
operative and postoperative complications (2) the risks of
multiple rounds of general anesthesia and multiple recovery
periods (3) the direct financial costs to the patient, to his
or her family, and to the health care system (4) the necessary
patient and family time commitment (5) the facial aesthetic
effects and (6) the potential for relapse and the stability of
the occlusion. Most clinicians agree that the single-stage
approach (i.e., Le Fort I osteotomy in segments) has clear
advantages when considering each of these variables, except
for differences of opinion related to potential relapse and
the stability of the occlusion. The patient described in
Figure 17-13 could be considered a case that would cause
one to favor a two-stage approach, because the end result is
favorable. However, in retrospect, the family and the treat­
ing clinicians viewed this case as involving an inefficient
approach to the correction of the individual’s presenting
dentofacial deformity. The two-stage approach required
1) two separate general anesthetics and recoveries 2) an
extended and more elaborate course of orthodontics; and
3) an increased financial burden to the family in the form
of additional surgeon and hospital fees. Also, The SARPE
procedure resulted in a degree of root resorption, and the
Le Fort I osteotomy (Stage II) was made more difficult by
the earlier SARPE procedure (Stage I). The intraoperative
view (see Figure 17-13, F ) shows the resulting fenestrated
maxillary walls after the SARPE procedure.
process is an important factor, especially in the patient who
is biologically susceptible to recession (i.e., with limited
attached gingiva; see Chapters 5 and 6). According to Vana­
rsdall and colleagues, the most common risk factors for the
gingival recession of the maxillary posterior dentition
include 1) friable attached gingiva 2) genetic factors 3)
emotional stress 4) inadequate labial bone and 5) buccally
tipped maxillary posterior teeth (i.e., dental compensa­
tion).314 These factors will cause the periodontium to
“receive” rather than “transmit” forces, with likely contin­
ued bone loss and gingival recession occurring over time.
Vanarsdall and colleagues suggest that periodontal sus­
ceptibility to breakdown has a relationship to the position
of the teeth within the arch and to the relationship of the
opposing teeth when they are in occlusion (see Chapters 5
and 6).314 The initial experimental work of these researchers
shows a decrease in the numbers of pathogenic bacteria
around the teeth after the teeth have been aligned into a
more natural position (i.e., to more closely agree with
Andrews’ Six Keys to Normal Occlusion). With good dental
alignment, the numbers of harmful bacteria were brought
below the threshold at which damage to the periodontal
tissues frequently occurs. It is also believed by many clini­
cians that the achievement of maxillomandibular occlusal
harmony (i.e., the correction of molar inclination and cross­
bites) tends to improve long-term dental and skeletal stabil­
ity after orthognathic surgery (see Chapters 5 and 6).
History of SARPE and Segmental Osteotomies
to Correct Maxillary Arch Deficiencies
The recorded history of transverse maxillary expansion
dates back to the mid-1800s, when Angle reported the use
of a jackscrew appliance in a 14-year-old girl to create
space for a labially displaced canine.9 This form of arch
expansion was frequently used in children, adolescents,
and adults until Hass reported that, after the age of 18
years, it was not possible to open the mid-palatal arch with
appliance distraction forces because of the presence of
bridging bone spicules across the suture and the increased
rigidity of contiguous bones.124 It is now generally accepted
that RPE without “surgical assistance” is clinically success­
ful only until the age of approximately 14 years and in the
presence of open sutures. Attempting orthopedic expan­
sion beyond this age is likely to result in the tipping and
extrusion of teeth followed by dental relapse after the
removal of the appliance.
The first recorded use of “surgical separation” of a fused
mid-palatal suture for the management of transverse maxil­
lary deficiency was by Brown.49-51 Since that initial report,
the clinical approach that includes the completion of maxil­
lary osteotomies followed by orthodontic appliance expan­
sion has continued to evolve. By the 1980s, it was recognized
that a full Le Fort I osteotomy but without down-fracture—
including the separation of the nasal septum from the
maxilla and the separation of both pterygomaxillary
sutures—in combination with a parasagittal palatal and

597
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
measurements of dental arch dimensions. Without the use
of posteroanterior (PA) cephalograms, skeletal change
cannot be differentiated from tooth movement. Another
shortcoming is that most studies measure stability from the
end of ortho­dontic treatment rather than from the point of
maximum expansion. The clinical practice of over-expanding
the arch to end up with a satisfactory occlusion at the end
of treatment results in the underestimation of the actual
relapse. With limited data points, most studies cannot dif­
ferentiate skeletal relapse components from dental ones.
One exception is the study by Byloff and Mossaz, which
overcame these limitations by using pre-expansion and
postexpansion PA cephalograms and dental casts as data
points.56 After SARPE, the authors observed a mean
maximum expansion at the first molar of 8.7 mm, with an
average of 36% (3.1 mm) relapse at the time of debanding.
Only 1.3 mm (23%) of this relapse was felt to be skeletal,
with the rest (77%) being dental. Berger and colleagues
also used an improved study design and reported an average
of 2.49 mm (48%) of skeletal expansion in combination
with 2.4 mm (52%) of dental expansion for their patients
when using a SARPE approach.31 Two published meta
studies, which were carried out in 2005 by Koudstaal and
colleagues167 and in 2006 by Lagravere and colleagues,176
both concluded that, until that time, no good evidence
existed regarding the amount of relapse after SARPE.
Chamberland and Proffit studied this controversy, and,
in 2008, they published their initial research.59 They con­
tinued to follow their patients for the long term, and they
also added numbers to the study group (N = 38). Their
study has been recognized for adding significant clarity to
this important subject and is therefore reviewed in the next
section of this chapter.
Skeletal Stability and Relapse of SARPE:
Review of a Benchmark Study
A prospective observational study was carried out by Cham­
berland and Proffit to review the SARPE outcomes in 38
consecutive patients between the ages of 15 and 54 years,
with an observation period that extended to 2 years after
the completion of treatment.60 The data collected by these
authors included measurements taken from both dental
casts and PA cephalograms at the following specific time
intervals:
• Before SARPE or any active orthodontic alignment
• After SARPE and at the completion of orthodontic
expansion
• At the removal of the orthodontic expander (i.e.,
approximately 6 months after SARPE and the com­
pletion of the orthodontic goals)
• Before the final orthognathic procedure (if any was
planned)
• After the final orthognathic surgery and at the end of
orthodontic treatment
• 2 years after the completion of treatment
Complications of the SARPE Procedure:
Review of the Literature
Although SARPE is a commonly considered procedure, the
prevalence of postoperative complications and suboptimal
results is not insignificant.57,72,175,177,182,195,211,254,291,315,329 Wil­
liams and colleagues examined the prevalence of complica­
tions among patients undergoing SARPE.329 This was a
retrospective evaluation conducted on all individuals who
underwent SARPE over a 4-year timeframe (2004 to 2008)
at a single institution. The study sample (n = 120) included
patients with a median age of 29.5 years (range, 22 to 39
years) and was comprised of 51.7% women. Postoperative
complications were divided into two main categories: surgi­
cal and dental. Thirty-three patients (28%) developed surgi­
cal complications and 18 patients (15%) developed dental
or periodontal problems. Asymmetric or inadequate expan­
sion was the most frequent surgical complication, and it was
found in 13.3% (16 out of 120 patients) of the study
cohort. Dental or periodontal problems—including central
incisor discoloration, gingival recession, and periodontal
bone loss—occurred in 15% of the cohort. Two patients
developed catastrophic bone defects with associated loss of
the central incisors as a result of eccentric midline osteoto­
mies followed by infections. The study confirms that major
complications after SARPE are rare, whereas the incidences
of asymmetric and inadequate expansion as well as dental
or periodontal problems are not insignificant. These find­
ings confirm that the SARPE procedure should not be
considered as a risk-free alternative to segmental Le Fort I
osteotomies.
Verlinden and colleagues reported on a large case series
of individuals (n = 73 patients) undergoing SARPE with a
bone-borne appliance.315 Although most of the problems
documented were related to hardware, six patients (8%)
required additional surgery for the correction of an unstable
occlusion or for asymmetric expansion. Among those study
patients who were followed for more than 6 months, gin­
gival recession, periodontal bone loss, a lack of interdental
bone fill, and external apical root resorption were seen in
more than one third of cases. Seitz and colleagues studied
patients who were undergoing SARPE (n = 22) and found
that asymmetric expansion was the most frequent surgical
complication. In another review of SARPE complications,
Carmen and colleagues reported a 28.5% incidence of
significant gingival recession.57
Occlusal Stability and Relapse: Comparing
SARPE versus Segmental Le Fort I Osteotomy
When it comes to a single-stage procedure versus a two-
stage approach to the management of a complex maxillary
deformity, the key aspect of occlusal stability and relapse
has been reviewed in the literature and argued by clinical
proponents on each side. Shortcomings in the study design
of most published research add to the lack of clarity. Most
studies have involved only dental casts or direct

598 SECTION 2  Planning, Surgical Technique, & Complications
expansion phase followed by an inevitable lingual dental
relapse after the device is removed. Approximately 25% of
their patients had more than 3 mm of dental relapse,
whereas 42% had between 1 mm and 3 mm. A full 66%
of patients experienced more than 2 mm of dental relapse
over the long term (i.e., 2 years after debonding).
Stability and Relapse: Comparing SARPE in
Adults versus RPE in Prepubertal Children
The literature confirms that, in the prepubertal child or the
adolescent with an open palatal suture, a loss of about one
third of the maximum expansion occurs across the first
molars after non-surgical RPE. PA cephalograms performed
for prepubertal patients with palatal implant markers who
underwent RPE demonstrate that approximately 50% of
the expansion achieved is skeletal, with the remainder being
dental. This can be compared to Chamberland and Proffit’s
adult SARPE data.59,60 Those authors demonstrated a mean
of 3.47 mm of skeletal expansion and 2.25 mm of dental
expansion (i.e., 5.12 mm of total expansion) at the first
molars. They then documented a 30% relapse, the majority
of which was dental. Therefore, a comparable 30% overall
relapse in both the SARPE (adult) group and the RPE
(prepubertal) group was found to occur. Interestingly, in the
SARPE group, the maintenance of skeletal expansion was
greater than that achieved in the RPE group.
Stability and Relapse in Adults: Comparing
SARPE versus Segmental Le Fort I Osteotomies
The best data regarding stability after transverse expansion
with segmental Le Fort I osteotomies were reported for 32
patients by Phillips and colleagues.215 Chamberland and
Proffit compared the segmental Le Fort I osteotomy group
of Phillips and colleagues to their SARPE study patients.59,60
They used a subgroup of Phillips and colleagues’ patients
who had undergone levels of maxillary expansion that were
equivalent to those of their own SARPE patients. A com­
parison of the findings demonstrated the following: 1) the
mean relapse across the first molars was greater for the Le
Fort I group, but the difference was not statistically signifi­
cant; and 2) the mean relapse across the canines was greater
for the SARPE group and was statistically significant.
With reference to the SARPE (two-stage) approach
versus the Le Fort I segmental (single-stage) approach for
the correction of complex maxillary deformities (i.e. com­
bination of arch-width, vertical, and horizontal deformi­
ties), the author’s conclude:59,60
• Current data do not support the conclusion that
SARPE procedures produce more stable expansion
than Le Fort I segmental osteotomies.
• Published data regarding both PA cephalograms
and measurements of dental models confirm the
potential for postoperative relapse that is primarily
dental rather than skeletal after transverse maxillary
All study patients had a transverse discrepancy of 5 mm
or more and were beyond the level of maturity at which
palatal expansion without surgery would be possible. The
surgical technique involved all bone cuts required for a Le
Fort I osteotomy, including the separation of the pterygoid
junctions, the nasal septum, and the mid-palatal suture as
well as an osteotomy between the central incisors. During
surgery, the expansion device was activated to achieve a 1- to
1.5-mm separation of the maxillary central incisors. After
latency (7 days), the device was activated twice daily
(0.5 mm/day). The patients were monitored twice weekly
until the planned expansion was achieved 12 to 20 days later.
All patients were expanded 2 mm beyond the desired final
position. The expansion device was kept in place for approxi­
mately 6 months after the completion of orthodontic goals.
Interestingly, the research data confirm that almost the
entire measured relapse was dental rather than skeletal. At
49 months after the SARPE procedure, the maintained
expansion at the first molars had relapsed to approach the
skeletal expansion (i.e., 4.6 mm total molar expansion
[dental and skeletal] as compared with 3.6 mm skeletal
expansion). The skeletal expansion that was measured at
both the jugula and the nasal cavity was statistically stable.
All patients were maximally expanded 2 mm beyond the
desired final position on the basis of the researchers’ assump­
tions that a degree of relapse was inevitable. This overcor­
rection ensured that, despite a measured dental relapse of
30%, none of the patients showed posterior crossbite at the
completion of treatment. One can conclude that, despite
retention attempts, over the long term the teeth drift back
into the basal bone (see Chapters 5 and 6).
The authors also compared their relapse and stability
results with other published SARPE studies. Their measured
30% relapse rate was found to be less than the 36% relapse
reported by Byloff and Mossaz.56 Alternatively, their 30%
documented relapse rate was higher than that reported by
either Berger and colleagues31 or Pogrel and colleagues.238
As previously stated, most SARPE studies—including these
two—do not report relapse from a starting point of maximal
expansion. However, not doing so will underestimate the
level of actual relapse and may explain the differences
reported.
Chamberland and Profit showed that, when a SARPE
procedure is carried out with the use of optimal surgical and
orthodontic techniques, maxillary expansion that is about
47% skeletal and 53% dental can be expected.59,60 The
skeletal expansion that occurred with SARPE followed by
strict orthodontic maintenance mechanics for approxi­
mately 5 months proved to be statistically stable. The overall
relapse rate (30%) was almost totally attributable to lingual
retraction (dental relapse) of the posterior teeth. As stated,
the authors recommend a 2-mm excess expansion in antici­
pation of dental relapse. For example, in the case of a desired
8-mm first molar expansion, 10 mm of surgical expansion
at the molars is recommended. The researchers documented
the advantage of compensating for the inevitable buccal
tipping of the posterior maxillary teeth during the

599
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
based on the risk and morbidity of two surgeries
versus the risk and morbidity of a one-stage multiseg­
mented Le Fort I osteotomy for arch expansion and
the other necessary vertical or anteroposterior changes
required for the correction of the individual’s specific
dentofacial deformity.
• Clinicians should also take into account that the
SARPE procedure will result in areas of fibrous union
and defects at the maxillary osteotomy sites. If a Le
Fort I is later required to complete the reconstruction,
the previous SARPE procedure may add to the com­
plexity of the operation (see Fig. 17-13).
Conclusions
There are inherent challenges to both the orthodontic
movement of teeth within the alveolar process and the
surgical repositioning of the jaws within the facial soft-tissue
envelope. Such challenges include the orthodontist’s treat­
ment philosophy; the mechanics used to reposition the
teeth; the surgeon’s treatment philosophy; and the tech­
niques used to complete the osteotomies and secure them.
Other important factors include the initial surgical healing
requirements, which take into account patient-specific
health-related factors, as well as the difficulties associated
with the long-term maintenance of the mechanically relo­
cated teeth, jaws, and jaw segments.
Despite the potential for skeletal and dental relapse,
when sound biomechanical and aesthetic principles are fol­
lowed, the frequent patterns of dentofacial deformity and
their associated malocclusions can be safely and reliably
corrected and maintained in most cases.
expansion (i.e., RPE, SARPE, or Le Fort I segmental
osteotomies).
• Relapse after the arch width initially achieved by
SARPE is comparable to that of other expansion pro­
cedures (i.e., segmental Le Fort I osteotomy in adults
and RPE in children).
• Published data show that, with properly executed
SARPE and a strict maintenance protocol for approxi­
mately 6 months, the relapse is almost entirely dental
(i.e., 33% dental relapse). At the end of treatment,
there is, on average, a net expansion of 67% of the
total change.
• With non-surgical expansion carried out in growing
individuals (i.e., RPE), the expectation is that only
50% of the total change will be skeletal. No data from
sequential PA cephalograms exists for Le Fort I seg­
mental expansion.
• Given the similarity of relapse in intermolar width
between SARPE and Le Fort I segmental techniques,
routine overcorrection and strict maintenance for 6
months after surgery should be considered part of the
protocol.
• When surgery to reposition the maxilla vertically or
anteroposteriorly is also required, the routine perfor­
mance of a preliminary SARPE procedure followed
later by a Le Fort I osteotomy with the intention of
obtaining better transverse stability does not appear
to be warranted.
• According to published literature, the decision to use
a two-stage surgical approach (i.e. first stage SARPE)
versus a single-stage Le Fort I segmental surgical
approach should not be based on the expected stabil­
ity of the transverse expansion. Instead, it should be
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605
CHAPTER 17  Malocclusion after Orthodontics and Orthognathic Surgery: Prevention and Treatment Pitfalls
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607

18
Grafts Frequently Used During
Orthognathic Surgery and for
Adjunctive Procedures
JEFFREY C. POSNICK, DMD, MD
• Bone Grafting: Definitions and Options
• Grafting Interpositional Defects and Gaps of
the Mandible and the Maxilla
• Grafting Condyle and Ascending Ramus
Defects
• Cartilage Grafting for Nasal Reconstruction
• Alloplastic Grafts and Implants for the
Augmentation of the Facial Skeleton
• Conclusions
use the graft material as a framework upon which to spread
and generate new bone. The selected graft material for the
management of a bone defect should at the very least be
osteoconductive.
Osteoinduction involves the stimulation of osteopro­
genitor cells to differentiate into osteoblasts that then begin
new bone formation (Fig. 18-1, B). The most widely studied
types of osteoinductive cell mediators are bone morpho­
genic proteins (BMPs). A bone graft material that is both
osteoconductive and osteoinductive will serve as a scaffold
for existing osteoblasts, and it will also stimulate the forma­
tion of new osteoblasts, thereby theoretically promoting the
faster integration of the graft.
Osteogenesis occurs when vital osteoblasts that originate
from the bone graft material itself contribute to new growth
along with bone growth generated via the mechanisms of
osteoinduction and osteoconduction. Fresh autogenous
bone graft has the capability of supporting new bone growth
by all three means (i.e., osteogenesis, osteoinduction, and
osteoconduction). Because all three mechanisms may not
be required at the particular recipient site to establish suc­
cessful healing, it should be possible in many circumstances
to select a non-autogenous graft, thereby avoiding the need
for harvesting donor bone from the patient and still achiev­
ing success.
The sheer volume of bone grafting procedures carried out
in the United States and throughout the world has created
a relative shortage of available musculoskeletal donor tissue
that is traditionally used for reconstructive autografts and
allografts. This opportunity has stimulated corporate inter­
est in supplying what is seen as a growing market for bone
replacement materials. Currently, these graft alternatives are
subjected to varying degrees of regulatory scrutiny; their
true effectiveness in patients is not known until validated
clinical trials are eventually carried out.
In general, it is known that osteoconductive materials
work well when filling defects of non-critical size that would
normally be expected to heal. However, when more
Bone Grafting: Definitions and Options
During maxillofacial surgery, grafting is a procedure that
replaces missing structures with tissues from the patient’s
own body or with artificial, synthetic, or natural substi­
tutes.24,33,40,50,56,60,62,69-71,78,106,111,112 It is estimated that more
than 500,000 bone-grafting procedures are performed
annually in the United States, and these numbers easily
double globally. Approximately half of the procedures that
involve grafts relate to spinal fusion. The exact number of
grafts used in head and neck reconstruction is not known,
but it is significant.
Bone grafting is possible because bone—unlike most
other biologic tissues—has the ability to regenerate
completely if it is provided with space into which it can
grow.3-5,7,13,29,34,49,64,65,83,125-128 As native bone grows, it will
generally replace any resorbable graft material in its path,
which results in a fully integrated region of new bone.
The biologic mechanisms that provide a rationale for
bone grafting are osteoconduction, osteoinduction, and
osteogenesis.
Osteoconduction occurs when the graft material serves
as a scaffold that facilitates new growth from the native bone
(Fig. 18-1, A). Osteoblasts from the margin of the defect

608 SECTION 2  Planning, Surgical Technique, & Complications
• Figure 18-1  A, Osteoconduction. A photomicrograph of a bone biopsy, where NFB surrounds the pre-existing
bone and the residual of FFB. NFB presents features of mature bone, with well-organized lamellae and numer­
ous small osteocytic lacunae. B, Osteoinduction. Peripheral region of the graft at 10 days. New bone formation,
with primary bone tissue from the bone graft (BG) fragment and the parietal bone. A from Acocella A, Bertolai
R, Nissan J, Sacco R: Clinical, histological and histomorphometrical study of maxillary sinus augmentation using
cortico-cancellous fresh frozen chips. J Craniomaxillofac Surg 39:192–199, 2011. B from Esteves JC, Borrasca
AG, Aranega AM, et al: Histomorphometric analysis of the repair process of autogenous bone grafts fixed at
rat calvaria with cyanoacrylate. J Appl Oral Sci 19:529–534, 2011.
BG
A
B
FFB
FT
NFB
NFB
challenging defects are present, either fresh autologous bone
graft or grafts with an osteoinductive agent appear to be
necessary or are at least preferable for favorable healing.
Types of Bone Grafts
Bone Autografts
Fresh autogenous cancellous and corticocancellous bone are
benchmark graft materials that allograft and bone substi­
tutes attempt to match in their in vivo performance.2,25,117-124
They incorporate all of the aforementioned properties, and
they have no associated risk of viral transmission. They are
incorporated into surrounding bone through creeping sub­
stitution. Unfortunately, the availability of an autograft for
a specific need may be limited, and the harvest may be
associated with donor site morbidity.10
Bone Allografts
The advantages of bone allografts that are recovered from
deceased human donor sources include their availability in
various shapes and sizes, the avoidance of the need to sac­
rifice host structures, and the lack of donor-site morbidity.
Bone allografts are distributed through regional tissue banks
and by a variety of reputable orthopedic medical device
companies. The grafts are not without controversy, particu­
larly because of their association with the transmission of
infectious agents. It is essential to know the tissue bank
provider’s methods of handling the allografts to understand
infectious disease issues and the potency of the graft mate­
rial. Allografts should be compared with autogenous bone
grafts with reference to their structural strength, osteocon­
duction, osteoinduction, and osteogenesis.
Bone Graft Substitutes
The ideal bone graft substitute is biocompatible, bioresorb­
able, osteoconductive, osteoinductive, structurally similar
to bone, easy to use, and cost-effective. A growing number
of bone graft alternatives are commercially available for
orthopedic and, to a lesser extent, head and neck use.
They are used in the reconstruction of cavitary bony defi­
ciencies (i.e., interpositional defects) and for augmentation
purposes.
Not all bone graft alternatives perform equally well. This
presents a challenge to the orthognathic surgeon. It is
important to appreciate the varied but repetitively seen
graft-healing environments related to orthognathic surgery,
including the following: (1) an interpositional defect at the
chin osteotomy site; (2) an interpositional defect at the Le
Fort I osteotomy site; (3) an interpositional defect at the
ramus of the mandible osteotomy site; (4) the augmentation
needs of the chin, the angle of the mandible, the zygomas,
the perinasal area, and the infra-orbital rim; (5) a radiated
tissue bed that requires osteotomy site healing; and (6) the
proximity of the Le Fort I osteotomy site to the maxillary
sinus. Each recipient environment will present with differ­
ent graft-healing needs. Therefore, the validation of any
bone graft alternative in one clinical site will not necessarily
predict its performance in another location.
The clinician should seek a high burden of proof when
using clinical or preclinical studies to justify the use of an
osteoinductive graft material and the choice of one alterna­
tive over another. Only human trials can best determine the
efficacy of a bone graft substitute and its site-specific effec­
tiveness. Whenever feasible, surgeons should practice
evidence-based medicine and tailor the treatment of their
patient according to published medical literature and the
levels of evidence claimed.
U.S. Food and Drug Administration approvals of bone
graft substitutes for human use include the following:
The use of premarket-approved rh-BMP-2 (Infuse Bone
Graft; Medtronic, Minneapolis, Minn) as an autograft

609
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
and clinical studies for the specific sites to be used
during clinical practice should be considered.
Grafting Interpositional Defects and
Gaps of the Mandible and the Maxilla
Autogenous Iliac (Particulate Cancellous)
Graft Donor Site (
Video 8)
Iliac (hip) particulate cancellous bone remains the preferred
graft material for the management of congenital cleft
defects of the alveolus, the palate, and the floor of
the nose.1,9,12,15,26,28,46-48,52,63,66,77,82,90,115 This is especially true
when the canine tooth is expected to erupt through the graft
(i.e., cleft defect); when a tooth will be orthodontically
moved into the grafted site; or when a dental implant will
later be placed (Fig. 18-2). The cleft defect that requires a
graft may be on one side (i.e., with unilateral cleft lip and
palate) or on both sides (i.e., with bilateral cleft lip and
palate). Previous attempts at grafting a bone deficiency may
have failed as a result of an unsuitable graft material being
selected; a soft-tissue deficiency or poor flap management;
or inadequate postoperative management or patient coop­
eration (see Chapters 32 and 33).
Donor site discomfort in the anterior iliac region is
generally caused by the injury or contusion of the sur­
rounding muscles on the medial (i.e., external oblique,
internal oblique, and rectus abdominis) and lateral (i.e.,
medial gluteus) sides of the bone.* In a thin individual
with a minimal fat layer and without baseline ankle,
knee, or lumbar region arthritis or myalgia who is rela­
tively young (i.e., <50 years), only minimum discomfort
should occur. However, there are reports of complications
associated with anterior iliac crest graft harvesting,
in­cluding gait disturbance, paresthesia, superficial infec­
tions, hematoma, poor cosmesis, and chronic donor
site pain.6,20,41,42,53,57,81,92,103-105,110,113,114,131 The experienced
surgeon can harvest the graft rapidly and efficiently. There
is no need for the placement of a drain, minimal blood loss
(i.e., <50 cc) is expected, and the head and neck region will
have been simultaneously prepped and draped.
Step-by-Step Approach (Fig. 18-3)
Preparation and Draping
• An endotracheal tube is placed and secured in accor­
dance with the patient’s head and neck reconstruction
needs.
• Ophthalmic ointment and corneal shields are placed for
eye protection.
• The patient is supine on the operating room table.
• The patient’s arm is tightly tucked to his or her side.
• Betadine solution is used for both hip and head and neck
preparation.
replacement for spinal fusion and the treatment of open
tibia fractures. This substance has also been approved
for maxillary sinus augmentation and localized alveo­
lar ridge augmentation.
The use of rh-BMP-7 (OP-1 Implant; Olympus Biotech,
Hopkington, Mass) as a humanitarian device. This sub­
stance has been approved as an autograft substitute
for the non-union of long bones.
The use of rh-BMP-7 (Op-1 Putty; Olympus Biotech,
Hopkington, Mass) as a humanitarian device alternative
to autograft in compromised patients. This substance
is approved for patients who require revision postero­
lateral lumbar spinal fusion or for those in whom
autologous bone and bone marrow recovery (i.e.,
harvesting) are not feasible or are not expected to
promote fusion.
The specific applications of bone substitutes, as described
previously, have demonstrated clinically useful osteoinduc­
tive capabilities in humans. They have paved the way for
broader clinical applications in the future. The recom­
mended methods for the clinical application of these bone
substitutes include direct placement into the surgical site,
but the results have been more promising when the growth
factors have been administered in combination with sub­
strates to facilitate timed-release delivery or to provide a
material scaffold for bone formation.
Please review the following salient points when consider­
ing the use of bone graft substitutes during orthognathic
surgery:
Fresh autogenous cancellous bone and, to a lesser extent,
cortical bone are the benchmark graft materials. Their
shortcomings include limited availability, donor site
morbidity, and the potential for resorption.
The advantages of allogenic bone include its availability
in various sizes and shapes as well as the avoidance of
host donor harvesting. The transmission of infection
(particularly of human immunodeficiency virus) has
been virtually eliminated as a concern when the grafts
are properly treated.
The ideal bone graft substitute is biocompatible, biore­
sorbable, osteoconductive, osteoinductive, structur­
ally similar to bone, easy to use, and cost-effective.
Bone substitute products are currently available on
the market. They vary with regard to their composi­
tion and their claimed mechanism of action.
U.S. Food and Drug Administration approvals of specific
uses of recombinant human growth factors (i.e.,
rh-BMP-2 and rh-BMP-7) for the spine and the long
bones have been made on the basis of demonstrated
bone repair in human trials. Approved head and neck
applications are limited but are likely to increase.
The orthognathic surgeon has choices in the realm of
bone grafting. Selection should be based on reason­
able burdens of proof. Examining the products’ claims
and whether such claims are supported by preclinical
*Reference 8, 10, 16, 21-23, 35, 36, 51, 54, 55, 58, 61, 72-75, 88, 100,
130, 143, 138

610 SECTION 2  Planning, Surgical Technique, & Complications
• Figure 18-2  A child was born with unilateral cleft lip and palate and underwent arch expansion orthodontic treatment. This was followed
by autogenous iliac bone grafting and fistula closure during the mixed dentition. A, Intraoperative view after the elevation of the mucogingival
flap indicating the extent of the cleft defect. B, Harvested autogenous cancellous iliac graft used to fill the cleft defect. C, Occlusal view
early after surgery. D, Later occlusal view with the early eruption of the canine. E, Occlusal and palate view after the eruption of the per­
manent canine through the bone graft. The canine and the other posterior teeth are orthodontically guided anteriorly to close the cleft and
dental gap in the region of the congenitally missing lateral incisor. F, Periapical radiograph indicating normal alveolar ridge formation after
the eruption of the canine through the bone-grafted cleft site.
A
B
C
D
E
F

611
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
A
D
C
B
Incision marked
Incision through skin
Scissor dissect to cartilage
Incision through cartilage cap
• Figure 18-3  Autogenous iliac (particularly cancellous) graft donor site harvesting. A, The planned
incision is parallel and 1 cm lateral to the iliac crest. The incision starts 1 cm posterior to the anterior
superior iliac spine. B, After the injection of local anesthesia, the incision is carried out through the
skin. C, Scissors dissection continues through the subcutaneous tissue and the superficial and deep
fascia while avoiding the cutting and contusion of the gluteus muscle laterally or the abdominal oblique
and transverse abdominis muscles medially. D, With a knife, the cartilaginous cap is split down the
center directly over the crest and down to the marrow cavity.

612 SECTION 2  Planning, Surgical Technique, & Complications
E
J
I
G
F
H
Incision down to marrow
Elevation of cartilage flap
Flaps curette
Curette used to remove
cancellous bone
Defect in ilium
Cancellous bone harvested
E, With a knife, perpendicular relaxing incisions are completed through the cartilage at either end of the main incision.
F, With a periosteal elevator, each half of the cartilaginous cap (i.e., medial and lateral) is elevated off of the underlying marrow space. G, The
cancellous marrow bone is now exposed. H, Exposed cancellous bone is harvested with curettes. I, With the necessary cancellous bone
harvested, a defect in the marrow space can be seen. J, Harvested cancellous marrow bone to be used for reconstruction.
• Figure 18-3, cont’d

613
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
Skin Incision and Flap Elevation
• The incision is carried through the skin, the subcutane­
ous tissue, and the superficial and deep fascia directly
over the iliac crest where the graft is to be harvested.
• The cutting or contusion of the gluteus muscle laterally
or of the abdominal oblique and transverse abdominis
muscles medially is to be avoided. Injury to these muscles
when approaching the iliac crest should be avoided,
because this is the primary cause of buttock and abdomi­
nal wall discomfort after surgery.
Graft Harvesting
Cartilage Cap Over Crest (Patient Typically
<12 Years Old)
• If a cartilaginous cap remains over the crest, it is split
down the center directly over the crest and down to the
marrow cavity. Perpendicular relaxing incisions are com­
pleted through the cartilage at either end of the main
incision. This allows for the lifting of each half of the
• At the hip, the patient is prepped halfway down the
thigh, to the groin, across the abdominal midline, up
to the rib cage, and posterior down the side of the
buttock.
• Draping is completed, with limited exposed skin left
around the planned incision site.
Surgical Markings
• The planned hip region incision (i.e., 3 cm) is located
and marked with a surgical pen before prep and
draping.
• The planned incision is parallel and 1 cm lateral to the
iliac crest. The incision starts 1 cm posterior to the ante­
rior superior iliac spine.
Local Anesthesia
• Xylocaine (1% with 1 : 100,000 epinephrine) is injected
below the skin, directly over the surgical marking, and
down to the periosteum over the iliac crest.
K
N
M
L
Cartilage cap sutured
Fascial layer sutured
Skin closure
Dressing applied
K, The cartilaginous cap is repositioned back in place with interrupted ties
(3-0 Vicryl). L, The deep and superficial fascia layers are closed with interrupted suture ties (3-0
Vicryl). M, Subdermal closure is performed with interrupted suture ties (4-0 Vicryl). The skin is closed
with subcuticular running suture (5-0 Monocryl). N, Steri-Strips and then an occlusive dressing
(Tegaderm) are placed over the skin.
• Figure 18-3, cont’d

614 SECTION 2  Planning, Surgical Technique, & Complications
• A limited number of Steri-Strips are placed directly over
the closed wound.
• A small piece of cut gauze is placed directly over the
Steri-Strips.
• An occlusive dressing (e.g., Tegaderm) is placed over
the skin.
Postoperative Care
• The patient may shower without concern about moisture
getting on the occlusive dressing that is covering the
wound.
• The dressing remains intact for approximately 7 to 10
days.
• After the dressing is removed, no additional bandages
are placed.
Autogenous Iliac (Corticocancellous Bloc)
Graft Donor Site (
Video 9)
When a Le Fort I osteotomy with significant horizontal
advancement and vertical lengthening is carried out, an
interpositional defect (i.e., dead space) is created. Despite
rigid plate and screw fixation of the repositioned maxilla,
inadequate bone contact may jeopardize successful healing
(e.g., fibrous union; see Chapter 16) or leave the upper jaw
prone to skeletal relapse (see Chapter 17). The advantage of
placing an interpositional graft is sometimes obvious and at
other times borderline. When an interpositional graft is
deemed necessary, I prefer to use either autogenous or allo­
genic iliac bone.107 A crafted corticocancellous anterior iliac
(hip) graft is interposed between the pyriform and the zygo­
matic titanium plates that are used to secure the upper jaw
in its new location (Fig. 18-4). The graft is tightly wedged
between the advanced and lengthened anterior maxillary
wall and the more posterior baseline maxillary wall. Any
sharp edges of the inset graft are smoothed using a rotary
drill with a watermelon bur. The graft is then fixed in place
with an additional titanium plate and screws.
Another indication for a corticocancellous bloc graft is
when a ramus osteotomy (e.g., an inverted L or straight
horizontal osteotomy) is completed. After the proximal
segment is seated with the condyle in the glenoid fossa (i.e.,
the terminal hinge position) and the distal mandible is
secured to the maxillary teeth via intermaxillary fixation, a
significant interpositional gap may remain. In these circum­
stances, a crafted corticocancellous iliac graft can be tightly
interposed between the proximal and distal segments with
additional cancellous bone packed into the remaining dead
space. Rigid plate and screw fixation of the osteotomy seg­
ments and the graft is always required (see Chapter 28).
When an anterior maxillary or mandibular segmental
alveolar defect requires reconstruction (e.g., after trauma or
tumor resection), a crafted corticocancellous anterior iliac
graft is generally preferable to other options. After successful
graft healing (i.e., 4 to 6 months), dental rehabilitation
including implant and crown placement may follow (see
Chapter 35).2
cartilage cap (i.e., medial and lateral) off of the underly­
ing marrow space. The lifting of the vascularized cartilage
flaps is accomplished with a periosteal elevator.
• The exposed cancellous bone is then harvested with
curettes.
No Cartilage Cap Over Crest (Patient Typically
>12 Years Old)
• When the iliac crest is mature, no cartilaginous cap
remains. In this case, a window of cortical bone is
removed from the medial aspect of the crest and down
the medial plate for approximately 2 cm. This is an
efficient method for the exposure of the medullary
cavity.
• The subperiosteal dissection of the medial crest and
down the medial plate is followed by the placement of a
toed-out retractor down the medial plate.
• The removal of the cortex is facilitated with the follow­
ing: 1) an oscillating saw with a short fan blade on
a long shaft to cut through the cortex of the medial
plate at the inferior aspect; 2) an oscillating saw with a
wide fan blade on a short shaft to cut through the
cortex of the medial crest; and 3) a reciprocating saw
with a short, straight blade to cut through the cortices
of the medial plate to connect the other two cuts.
• The removal of the window of cortical bone is then easily
accomplished with the use of a chisel and a mallet.
• With the window of cortical bone removed, cancellous
marrow is harvested with curettes.
• The removed cortical bone may also be chopped or used
as an intact cortical graft. There is no advantage to replac­
ing the small cortical bone segment, because the strength
of the crest has not been compromised. The bone defect
will not be visible or palpable through the closed skin
wound. The removed marrow and cortical bone regener­
ate themselves.
Wound Closure
• After adequate graft is harvested, bone wax is used for
hemostasis. The bone wax is not used to fill the cavity;
rather, a thin layer is placed directly over the bleeding
medullary surfaces. Interestingly, the wax does not
prevent the regeneration of bone that will fill the cavity.
• If present, the cartilaginous cap is repositioned and
sutured back into place with interrupted ties (3-0 Vicryl).
If a cap is not present, then the overlying periosteum is
closed with interrupted ties (3-0 Vicryl).
• The deep and superficial fascia layers are closed with
interrupted suture ties (3-0 Vicryl).
• Subdermal closure is performed with interrupted suture
ties (4-0 Vicryl).
• The skin is closed with subcuticular running suture (5-0
Monocryl).
Placement of Dressing
• The skin surface is cleaned with saline. It is then dried,
and benzoin is applied.

615
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
(i.e., <50 years old), only minimum muscle contusion and
discomfort should occur. However, there are reports of
complications associated with anterior iliac crest graft har­
vesting, including gait disturbance, paresthesia, superficial
infections, hematoma, poor cosmesis, and chronic donor
site pain.6,20,41,42,53,57,81,92,103,104,105,110,113,114,131 The experienced
surgeon can harvest the graft rapidly and effectively. In
general, there is no need for the placement of a drain,
minimal blood loss (i.e., <50 cc) is expected, and the head
and neck region will have been simultaneously prepped and
draped.
Donor site discomfort in the anterior iliac region is gen­
erally caused by the injury or contusion of the surrounding
muscles on the medial (i.e., external oblique, internal
oblique, and rectus abdominis) and lateral (i.e., medial
gluteus) sides of the bone.* In a thin individual with a
minimal fat layer and without baseline ankle, knee, or
lumbar region arthritis or myalgia who is relatively young
• Figure 18-4  When the extent of horizontal advancement and vertical lengthening of the maxilla after Le Fort I osteotomy are judged to be
significant, then an interpositional bone graft may be required and beneficial for the achievement of precise healing. In these circumstances, I
prefer to use either autogenous or allogenic iliac bone graft. A bloc of corticocancellous bone is crafted and tightly wedged into the gap on
each side. Each graft is inset in between the pyriform rim and zygomatic buttress titanium plates. An additional plate is then contoured to extend
from the anterior maxilla above, across the graft, and then onto the alveolar process of the anterior maxilla. Titanium screws (1.2 mm in diameter)
are then used to secure the plate to the bone. A, Illustrations and B, intraoperative views of interpositional corticancellous iliac graft in a Le Fort
I osteotomy site.
Additional microplate and screws
Iliac graft
B
A
*Reference 8, 10, 16, 21-23, 35, 36, 51, 54, 55, 58, 61, 72-75, 80, 88,
100, 130, 143, 138

616 SECTION 2  Planning, Surgical Technique, & Complications
Graft Harvesting
• With the use of a knife (no. 15 blade), the periosteum
is scored directly over the midline of the crest from just
posterior of the anterior superior iliac spine. The incision
continues posteriorly for a distance that is dependent on
the extent of exposure required for the planned graft.
• Subperiosteal dissection of the medial crest and down
the medial plate continues. A toed-out retractor is placed
down the medial plate.
• The efficient removal of a bloc of corticocancellous bone
graft is accomplished using an oscillating saw (with a
short fan blade on a long shaft and a wide fan blade on
a short shaft) and a reciprocating saw (with a short,
straight blade) to cut through all four bordering cortical
walls.
• The corticocancellous bloc graft is then removed from
the medial aspect of the crest and down the medial
plate. The length of the graft along the crest and its depth
into the medullary cavity are variable, depending on the
patient’s reconstructive needs.
• The actual removal of the corticocancellous bloc is
accomplished with the use of a 10-mm chisel and a twist­
ing motion to fully separate the graft.
• With the bloc graft removed, additional cancellous
marrow is harvested with curettes, as needed.
• The strength of the crest and of the ilium as a whole
should not be compromised by the bloc graft removal.
In general, the bone defect will not be detectable through
the closed skin wound, because the lateral aspect of
crest is preserved. The removed marrow and the cortical
bone will regenerate, often with greater than normal
thickness.
Wound Closure
• After adequate graft is harvested, bone wax is used for
hemostasis. The bone wax is not used to fill the cavity;
rather, a thin layer is placed directly over the bleeding
medullary surfaces. The wax should not prevent bone
regeneration.
Step-by-Step Approach (Fig. 18-5)
Preparation and Draping
• An endotracheal tube is placed and secured in accor­
dance with the patient’s head and neck reconstruction
needs.
• Ophthalmic ointment and corneal shields are placed for
eye protection.
• The patient is supine on the operating room table.
• The patient’s arm is tightly tucked to his or her side.
• Betadine solution is used for both hip and head and neck
preparation.
• At the hip, the patient is prepped halfway down the
thigh, to the groin, across the abdominal midline, up to
the rib cage, and posterior down the side of the buttock.
• Draping is completed, with limited exposed skin left
around the planned incision.
Surgical Markings
• The planned hip region incision (i.e., 3 cm to 4 cm) is
located and marked with a surgical pen before prepara­
tion and draping.
• The planned incision is parallel and 1cm lateral to the
iliac crest. It starts just posterior to the anterior superior
iliac spine.
Local Anesthesia
• Xylocaine (1% with 1 : 100,000 epinephrine) is injected
below the skin, directly over the surgical marking, and
down to the periosteum over the iliac crest.
Skin Incision and Flap Elevation
• The incision is carried through the skin, the subcutane­
ous tissue, and the superficial and deep fascia directly
over the iliac crest where the graft is to be harvested.
• The cutting or contusion of the gluteus muscle laterally
or of the abdominal oblique and transverse abdominis
muscles medially is to be avoided. Injury to these muscles
when approaching the iliac crest is the primary cause of
buttock and abdominal wall discomfort after surgery.
A
B
Handheld instruments
Incision marked and local anesthesia injected
• Figure 18-5  Intraoperative views of the harvesting of autogenous iliac corticocancellous bone. A, The basic
handheld instruments that are used to harvest the graft. B, The planned incision is parallel and lateral to the iliac
crest. It starts just posterior to the anterior superior iliac spine. Local anesthesia is injected below the skin directly
over the surgical marking and down to the periosteum over the iliac crest.

617
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
Continued
Incision marked
Incision through skin
C
D
E
F
Flaps elevated and periosteum scored
Subperiosteal dissection of medial crest and plate
C, The planned incision is shown. D, With a knife, the incision is carried through the skin and the subcutaneous
tissue. The scissors dissection continues through superficial and deep fascia directly over the crest, where the graft is to be harvested. The
contusion of the gluteus muscle laterally or the abdominal oblique and transverse abdominis muscles medially is avoided.
E, With the use of a knife, the periosteum is scored directly over the midline of the crest from just posterior to the anterior superior iliac spine.
The incision continues posteriorly for a distance that depends on the extent of exposure required for the planned graft. F, Subperiosteal dis­
section of the medial crest and down the medial plate continues.
• Figure 18-5, cont’d

618 SECTION 2  Planning, Surgical Technique, & Complications
Oscillating saw through crestal cortex
Oscillating saw through lower cortex
G
H
I
J
Reciprocating saw through third cortex wall
Reciprocating saw through final cortex wall
G, A towed-out wide retractor is placed down the medial plate. The efficient removal of a bloc of corticocancellous bone
graft is performed by first cutting through all four cortical wall borders. An oscillating saw with a wide blade on a short shaft is used to cut through
the wall directly over the medial aspect of the crest. H, An oscillating saw with a short fan blade on a long shaft is next used to cut through the
inferior cortical wall. I, A reciprocating saw with a short straight blade is used to cut through the lateral wall. J, A reciprocating saw with a short
straight blade is used to cut through the last cortical wall.
• Figure 18-5, cont’d

619
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
Continued
Chisel used to release graft
Kocher clamp to remove graft
K
L
M
N
Curette to remove cancellous bone
Thin coat of bone wax for hemostasis
K, The separation and removal of the corticocancellous block is accomplished with the use of a chisel that is 10 mm
in width. After the chisel is in place, a twisting motion is carried out to fully separate the graft. L, The bloc graft is removed with a Kocher clamp.
M, Additional cancellous marrow is harvested with curettes as needed. N, A thin coat of bone wax is placed onto the marrow walls for
hemostasis.
• Figure 18-5, cont’d

620 SECTION 2  Planning, Surgical Technique, & Complications
Periosteum sutured
Suturing of skin
Dressing in place
O
P
Q
rigid plate and screw fixation, inadequate bone contact
across the osteotomy site may jeopardize successful healing
(e.g., fibrous union) or leave the upper jaw or chin prone
to skeletal relapse. When an interpositional graft is deemed
necessary, I prefer to use either autogenous or allogenic
anterior iliac crest. The disadvantage of an autogenous graft
for this purpose relates to the potential for donor site mor­
bidity. The use of porous bloc hydroxyapatite as an inter­
positional bone substitute in specific circumstances has
been advocated by some.11,18,27,30,87,93,94,98,95,97,129,134,139
When bloc hydroxyapatite is used as an interpositional
graft, histologic findings demonstrate fibrovascular and
bone ingrowth into the interstices of the hydroxyapatite
implants. Osteoid tissue is found in a diffuse fashion and
interspersed between the calcified bone and the fibrous
tissue. Osteoclastic activity is not demonstrated within the
implanted bloc. Histologic examination of the bone–
implant interface demonstrates no evidence of the resorp­
tion or remodeling of the bone. Medically packaged porous
block hydroxyapatite is derived from specific marine corals
that have a completely interconnected porous matrix with
a pore size that averages 200 µm. The calcium carbonate
skeleton is converted by the manufacturer to hydroxylated
calcium phosphate. This mineral matrix is architecturally
and chemically similar to the non-vascularized interstitial
matrix of human cortical bone. Therefore, it provides a
reasonable substitute scaffold for the potential ingrowth of
fibrovascular tissue and bone. Unfortunately, the material
has no intrinsic osteoinductive properties.
Coralline-derived porous bloc hydroxyapatite has been
used successfully as an option when an interpositional graft
is needed for chin-lengthening procedures (Fig. 18-6).
Rosen and colleagues as well as other authors have pub­
lished clinical reports of the use of this substance in the
• The periosteum is closed with interrupted suture ties
(3-0 Vicryl).
• The deep and superficial fascia layers are closed with
interrupted suture ties (3-0 Vicryl).
• Subdermal closure is performed with interrupted suture
ties (4-0 Vicryl).
• The skin is closed with subcuticular running suture (5-0
Monocryl).
Placement of Dressing
• The skin surface is cleaned with saline. It is then dried,
and benzoin is applied.
• A limited number of Steri-Strips are placed directly over
the closed wound.
• A small piece of cut gauze is placed directly over the
Steri-Strips.
• An occlusive dressing (e.g., Tegaderm) is placed over
the skin.
Postoperative Care
• The patient may shower without concern about moisture
on the occlusive dressing that is covering the wound.
• The dressing remains intact for approximately 7 to 10
days.
• After the dressing is removed, no additional bandages
are placed.
Alloplastic Graft (Porous Hydroxyapatite
Bloc Implant)
When either a chin osteotomy with significant vertical
lengthening or a Le Fort I osteotomy with significant hori­
zontal advancement or vertical lengthening is carried out,
an interpositional defect (i.e., dead space) is created. Despite
O, The periosteum is closed with interrupted suture ties (3-0 Vicryl). P, After closing the deep and superficial fascia
layers with interrupted sutures (3-0 Vicryl), subdermal and then subcuticular closure are accomplished (5-0 Monocryl). Q, Steri-Strips and then
an occlusive dressing (Tegaderm) are placed over the skin.
• Figure 18-5, cont’d

621
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
C
A
B
“Hydroxyl appetite” interpositional
block graft to lengthen chin
• Figure 18-6  In conjunction with an osseous genioplasty, if significant vertical lengthening is carried out, an interpositional
graft (e.g., autograft, allograft, bloc hydroxyapatite) is crafted and placed in the gap. The graft fills the central gap in between
the fixation plates. I do not find it necessary to place a graft in all of the lateral aspects of the gaps. An additional plate with
screws is generally placed vertically in the midline across the osteotomy site directly over the graft. A, Illustration of a chin
with vestibular incision exposure. The marking pencil indicates the proposed osteotomy. B, Illustration of osseous genioplasty
with an interpositional graft. C, Profile view of a woman with a retrognathic mandible and a vertically short chin. Intraoperative
view of the same patient indicating the completed osseous genioplasty with an interpositional hydroxyapatite graft.
Continued

622 SECTION 2  Planning, Surgical Technique, & Complications
across the osteotomy site may jeopardize successful healing
(e.g., fibrous union) or leave the upper jaw or chin prone
to skeletal relapse. When an interpositional graft is deemed
necessary, autogenous iliac bone offers theoretic wound-
healing advantages, but it carries the potential for donor site
morbidity. The use of allogenic iliac crest as an interposi­
tional human bone substitute in these circumstances has
been advocated and used successfully in clinical practice.
With the use of current U.S. Food and Drug Administra­
tion and American Association of Tissue Banks standards
and regulations, biomedical companies make sterile, freeze-
dried, allogenic iliac crest bone available for use.
These sterile, freeze-dried allografts are processed from
donated human tissue as a result of a gift from an individual
or his or her family. The commercially available allografts
above-mentioned manner with low rates of complications
and rapid healing.93-98 When used as an interpositional graft
after Le Fort I osteotomy (as compared with at a chin oste­
otomy site), higher incidences of infection, sinus displace­
ment, and extrusion have been reported and remain of
concern.139
Allogenic (Human, Sterile, Freeze-Dried) Iliac
(Corticocancellous Bloc) Graft
When either a chin osteotomy with significant vertical
lengthening or a Le Fort I osteotomy with significant hori­
zontal advancement or vertical lengthening is carried out,
an interpositional defect (i.e., dead space) is created. Despite
rigid plate and screw fixation, inadequate bone contact
Or
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g atatatatatatatatatatata hicicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C.
C.
C Pos
os
os
os
o nicicicicicick
D
E
D, Profile views of the same patient shown before and after sagittal ramus
osteotomies (horizontal advancement) and osseous genioplasty (vertical lengthening with interposi­
tional hydroxyapatite graft). E, Oblique facial views before and after reconstruction (see Fig. 25-2).
• Figure 18-6, cont’d

623
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
flap; or a sagittal split ramus osteotomy with proximal
segment repositioning (see Chapters 27, 28, 35, and 36).
For a patient who requires condyle and ascending ramus
reconstruction, these options are not likely to give equiva­
lent results. Clinical judgment and experience are required
to assess the defect and the patient-specific factors (i.e., age,
medical condition, quality of the recipient bed, and dental
rehabilitation needs) before recommending the option that
is best suited to the individual’s reconstructive needs.
When a costochondral graft reconstruction is chosen, the
harvesting of a portion of the sixth or seventh rib with a
limited cartilaginous cap from the contralateral chest wall
(of the recipient site) generally provides the best contour
and morphology for the deficient mandible.
Step-by-Step Approach
Preparation and Draping
• Nasotracheal intubation (i.e., RAE tube) is completed
and secured in accordance with the patient’s head and
neck reconstruction needs.
• Ophthalmic ointment and corneal shields are placed for
eye protection.
• The rib to be harvested is palpated and identified.
• Betadine solution is used for both chest wall and head
and neck preparation.
• The patient is prepped below the rib cage, past the chest
midline, superior to the nipple, and laterally to the
midaxillary line.
• Draping is completed, with limited skin exposure left
parallel to and on all sides of the planned incision.
Surgical Markings
• The planned incision (i.e., ≈4 cm) is located and marked
with a surgical pen directly over the rib for harvesting
before preparation and draping.
Local Anesthesia
• Xylocaine (1% with 1 : 100,000 epinephrine) is injected
into the soft tissue below the planned incision and to the
depth of the rib to be harvested.
Skin Incision and Flap Elevation
• With the use of a knife (no. 15 blade), the incision is
carried through the skin, the subcutaneous tissue, the
fascia, and the muscle directly over the rib to be
harvested.
• Superior and inferior flaps are elevated to provide deep
exposure of approximately 6 cm of bone and 2 cm of
adjoining cartilage.
Graft Harvesting
• The periosteum is scored directly over the mid portion
of the long axis of the rib to be harvested but not through
bone or into the cartilaginous cap.
• Curved and straight elevators are used to dissect in the
subperiosteal plane circumferentially around the rib to
be harvested.
are generally processed with the use of patented and pro­
prietary technology. The tissue is first disinfected and then
terminally sterilized with the use of gamma radiation. The
donor tissue should be screened and deemed suitable with
reference to infectious disease test results, available donor
medical history, and behavioral risks assessments. The phys­
ical assessment of the donor—including a review of relevant
medical records and autopsy or coroner reports, if available—
is preferred. Although few reports that critically evaluate the
use of allogenic bone grafts specifically for orthognathic
procedures are found in the literature, the successful use of
these grafts for site-specific orthopedic procedures is well
documented. In current clinical practice, when an interpo­
sitional graft is required at either the chin or the Le Fort I
osteotomy site, I generally present both the autogenous and
allogenic iliac crest graft options to the patient. If the patient
is more than 50 years old or if he or she has hip, knee, or
lumbar disc disease, I generally prefer the allogenic bone
graft option. For a patient with a cleft maxilla that requires
simultaneous fistula closure, I generally prefer autogenous
bone. In most others circumstances, patient preference is a
major factor.
Grafting Condyle and Ascending
Ramus Defects
Autogenous Rib (Costochondral) Donor Site
When the condyle and portions of the ascending ramus have
been removed (e.g., after tumor or trauma) or are congeni­
tally absent (e.g., in a patient with hemifacial microsomia
with Kaban type IIB malformation), there will be a limited
number of reconstructive options to choose from, including
an autogenous costochondral graft; an artificial total joint
replacement; an autogenous vascularized fibular composite
The use of an autogenous costochondral graft for
the reconstruction of a deficient condyle and ascending
ramus in an individual at or after skeletal maturity
remains the author’s preferred approach for patients
with Kaban type IIB and type III mandibular
malformation with hemifacial microsomia (see Chapter
28; Fig. 18-7). For a patient with a posttraumatic
deformity (e.g., after condyle fracture), when the
deficient condyle cannot be managed by the sagittal
splitting the ramus of the mandible with proximal
segment relocation into the glenoid fossa, then an
autogenous costochondral graft is also generally the
author’s preferred approach (see Chapter 35). When
the defect of the mandible or the glenoid fossa is more
extensive and combined with soft-tissue hypoplasia or if
the patient has undergone radiation therapy, then an
autogenous vascularized crafted fibular composite flap is
generally preferred (see Chapter 28). For an adult patient
with a history of recurrent ankylosis, an artificial total
joint replacement maybe the preferred recommendation.

624 SECTION 2  Planning, Surgical Technique, & Complications
• Figure 18-7  A, Illustrations of hemifacial microsomia (type IIB mandibular malformation) that show the presenting
skeletal deformities and what the skull looks like after reconstruction is carried out. B, A patient has a costochondral
graft inserted through a coronal (scalp) incision to reconstruct a condyle ascending ramus deficit. Stabilization of the
graft occurs with an extended miniplate and screws placed through a Risdon (neck) incision. Part A modified from
an original illustration by Bill Winn.
B
Costochondral
graft
A
• A curved subperiosteal dissector (e.g., Doyen) is then
inserted underneath and around the rib. This instrument
is used to further strip and gain exposure in the subperi­
osteal plane, including underneath the cartilaginous cap.
• For protection, the retractor (e.g., Doyen) is placed deep
and directly underneath the location for incising the
cartilaginous cap.
• A knife (no. 15 blade) is then used to incise the full
thickness of the cartilaginous cap, including not more
than 1 cm of cartilage attached to the bone.
• The retractor (e.g., Doyen) is removed, and the rib cutter
is inserted to cut and completely separate the rib
according to the length of bone required for the purposes
of reconstruction. The graft is removed.
Wound Closure
• The wound is checked for hemostasis and any exposure
into the lung cavity; this is done by filling the wound
with saline. The anesthesiologist introduces maximum
end tidal volume and holds the area under pressure with
the Valsalva maneuver. With the confirmation of no
pneumothorax, wound closure is accomplished.
• The periosteal sleeve is approximated with interrupted
suture ties (3-0 Vicryl).

625
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
Or
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C
D
E
C, Right oblique facial views of a teenaged boy with hemifacial microsomia
(type IIB) before and after reconstruction. D, Frontal facial views before and after reconstruction.
E, Profile computed tomography scan views of the same patient before and after reconstruction that
demonstrate mandibular malformation and costochondral graft reconstruction.
• Figure 18-7, cont’d

626 SECTION 2  Planning, Surgical Technique, & Complications
• The deep and superficial fascia layers are closed with
interrupted suture ties (3-0 Vicryl).
• Subdermal closure is performed with interrupted suture
ties (4-0 Vicryl).
• The skin is closed with subcuticular running suture (5-0
resorbable).
Placement of Dressing
• The skin surface is cleaned with saline. It is then dried,
and benzoin is applied.
• A limited number of Steri-Strips are placed directly over
the closed wound.
• A small piece of cut gauze is placed directly over the
Steri-Strips.
• An occlusive dressing (e.g., Tegaderm) is placed over
the skin.
Postoperative Care
• A postoperative chest radiograph is used to confirm that
there is no injury to the lungs.
• The patient may shower without concern about
moisture on the occlusive dressing that is covering the
wound.
• The dressing remains intact for approximately 7 to 10
days.
• When the dressing is removed, no additional bandages
are placed.
Cartilage Grafting for Nasal
Reconstruction
Over the last several decades of cosmetic rhinoplasty, the
paradigm has shifted from aggressive reductive procedures
to augmentation procedures. More attention is now focused
on the use of grafts to augment deficiencies and the appro­
priateness of the graft material selected for each indication.
When surgically altering the shape of the nose, two frequent
reconstructive concerns are inadequate structural integrity
and volume. These problems are generally best addressed
with the use of cartilage grafts taken from a limited number
of donor sources, such as the septum, the conchal bowl of
the ear, or the rib cartilage. The choice of grafts and of the
techniques used to place them remain both an art and
science (see Chapter 38).14,31
Autogenous Nose (Septal) Cartilage
Donor Site
Septal cartilage is generally reasonably straight and resilient;
it provides structural support similar to that of the native
nasocartilaginous framework. The septal cartilage can be
contoured, carved, and sutured into an exact location. Sig­
nificant resorption, infection, or warping is uncommon
unless the cartilage is subjected to high-tension forces or
crushing during preparation. Preferred uses for septal carti­
lage in nasal reconstruction often include caudal struts,
lower lateral cartilage (LLC) crural grafts, spreader grafts,
and tip grafts (e.g., shield grafts) to increase projection or
definition (Fig. 18-8).38,39
A main disadvantage of the use of septal cartilage in nasal
reconstruction is the limited amount that is often available.
Anterior to the vomer and perpendicular plate of the
ethmoid, septal cartilage can be harvested without concern,
but always with the maintenance of the anterior structural
support of the cartilaginous septum (i.e., adequate dorsal
and caudal struts) to prevent dorsal or caudal collapse. In
most individuals, unless the septal cartilage has been previ­
ously removed through submucous resection or is absent for
other reasons (e.g., infection, congenital condition, ische­
mic necrosis), adequate cartilage can generally be harvested
to serve as a caudal strut graft (i.e., to provide tip support);
spreader grafts (i.e., to widen the nasal valves or to straighten
the cartilaginous dorsum); LLC support (i.e., for the cleft
or “pinched” nose); or as additional tip augmentation (see
Chapters 29, 32, 33, 35, and 38).
Step-by-Step Approach (Fig. 18-9)
Preparation and Draping for Rhinoplasty
• Orotracheal intubation (i.e., RAE tube) is placed as
required for the rhinoplasty procedure. The tube is taped
to the chin to prevent dislodgement.
• Ophthalmic ointment and corneal shields are placed for
eye protection.
• If the patient’s hair is long, it is tied in a ponytail.
• Betadine solution is used for the preparation of the scalp,
forehead, external ears, face, and neck. (Do not use soap,
alcohol, Hibiclens, and so on.)
Draping is completed, with exposure of the forehead,
the external ears, the face, and the neck down to the clavi­
cles left in the operative field as per the routine for
rhinoplasty.
Surgical Marking
The columella (stair-step) incision and the bilateral rim
(marginal) intranasal incisions are located and marked with
a surgical pen before prep and draping.
Local Anesthesia
• Xylocaine (1% with 1 : 100,000 epinephrine) is injected
deep into the skin within the soft-tissue envelope of the
nose as is routine for rhinoplasty.
• Xylocaine (1% with 1 : 100,000 epinephrine) is injected
on each side of the septum, deep to the mucosa and
superficial to the cartilage.
• Cocaine-soaked pledgets (5 cc of 4% solution) are placed
in each nasal cavity.
Skin Incision and Flap Elevation
• The columella skin is incised, and the intranasal rim
incisions are made.
• The nasal soft-tissue envelope is elevated with Stevens
scissors as required for an open rhinoplasty procedure.

627
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
• Insert the swivel knife, and incise the septal cartilage
for graft harvesting and for submucous resection as
indicated.
• Remove the incised septal cartilage graft.
Crafting of Graft
• Use a knife (no. 15 blade) to carve out and craft the
required grafts (e.g., caudal strut, LLC reconstruction,
spreader grafts, tip augmentation) from the full piece of
harvested septal cartilage.
Wound Closure
• After the completion of the septorhinoplasty procedure,
the closure of wounds is performed per routine
rhinoplasty.
Graft Harvesting
• Separate the lower lateral cartilages with Stevens scissors.
Dissect down to and identify the anterior aspect of the
caudal septal cartilage. Use a sharp periosteal elevator
(e.g., Cottle) to initiate the submucosal dissection on
each side of the caudal edge of the septal cartilage. Extend
the submucosal dissection inferior to the maxilla and
posterior to the vomer. Continue the subperiosteal dis­
section as required for the resection of the deviated bony
septum.
• Use a knife (no. 15 blade) to initiate a caudal and dorsal
septal incision through the quadrangular cartilage for the
insertion of a swivel knife. The incision is located to
maintain approximately 10 mm of caudal and 10 mm
of dorsal septal cartilage.
• Figure 18-8  A, Profile views of a teenaged girl before and after rhinoplasty with the use of a septal
(caudal strut) cartilage graft to improve tip position and projection as described in Fig. 18-9. B, Oblique
facial views before and after reconstruction.
Or
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Or
Or
Or
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O thththththththththththth
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g atatatatatatatata hicicicicicicic Su
Su
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Surg
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C Pos
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g atatatatatatatatatatatatatatata hicicicicicicicicicicicic Su
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Orththththththththththth
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g atatatatatatatatatatatatatatatatatatata hicicicicicicicicicicicicicicic Su
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C Pos
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gnatatatatatatatatatatatatatatatatatathicicicicicicicicicicicicicicicicic Su
Su
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S rg
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C.
C.
C.
C Pos
os
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o nicicicicick
A
B

628 SECTION 2  Planning, Surgical Technique, & Complications
Removal of portion
of ethmoid bone
Reduction of dorsal cartilage “hump”
Removal of portion of quadrangular cartilage
Reduction of caudal cartilage excess
Caudal strut graft
Removal of
portion of vomer
A
Caudal strut graft sutured in place, lower lateral cartilages
are then sutured together and over the top of the graft
B
• Figure 18-9  A, Illustrations that demonstrate the location of the harvesting of a septal cartilage graft
and B, of the graft’s placement as a caudal strut.

629
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
Autogenous Ear (Conchal) Cartilage Donor Site
Conchal cartilage may be required for augmentation during
secondary rhinoplasty when prior harvest, trauma, infec­
tion, or a genetic deficiency has rendered the nasal septal
framework deficient and unavailable as a graft source.76,79
In these cases, conchal cartilage may be the default option
for non-structural nasal reconstruction applications. The
conchal cartilage is pliable, resilient, flat, and thin. The
conchal bowl may also have the natural contour to fit a
specific nasal reconstructive need. Histologically, auricular
cartilage is elastic hyaline. The flat base of the conchal bowl
serves as the donor site and is harvested through a postau­
ricular skin incision without leaving a noticeable aesthetic
change in the external ear. The conchal bowl is composed
of two components: the superior cymba and the inferior
cavum. These are divided by the conchal extension of the
helical root. The conchal bowl is bordered by the helical
root and the external auditory meatus. Human anatomic
dissection confirms the dimensions of the conchal bowl: it
has a thickness of 1.9 mm to 4.4 mm; a maximum width
of 1.9 cm to 2.9 cm; and a maximum height of 1.9 cm to
• To approximate the columella skin (i.e., the stair-step
incision), a single dermal suture is placed (5-0 Vicryl).
• Columella skin closure is performed with interrupted
suture ties (6-0 nylon).
• Intranasal wound closure is performed with interrupted
ties (5-0 chromic).
Placement of Dressing
• The placement of dressings is routine as per the septo­
rhinoplasty procedure.
• Flexible splints (e.g., Reuter Type-Medtronic USA INC,
Jacksonville, FL.) are generally placed on each side of the
septum and secured together with a single suture tie (3-0
nylon).
• Antibiotic ointment (e.g., Bactroban) is generally injected
into each nostril cavity.
• Packing (e.g., folded Telfa) is generally inserted equally
into each nostril cavity.
• Tape (e.g., a Steri-Strip) is placed over dorsum of nose
as per rhinoplasty procedure.
• A custom splint (e.g., Aquaplast) is molded over the
dorsum of nose as per rhinoplasty.
C
Septal cartilage harvested
Inferior section of removed septal cartilage
(can be used as LLC-graft)
Superior section of removed septal cartilage
(can be used as LLC-graft)
Middle section
Caudal “strut” graft
C, Intraoperative views of removed septal cartilage that can be used for grafts to reconstruct the nose. The cartilage
can be crafted as a caudal strut, spreader grafts, a lower lateral cartilage augmentation graft, and as tip onlay grafts.
• Figure 18-9, cont’d

630 SECTION 2  Planning, Surgical Technique, & Complications
3.1 cm that can be harvested. During the harvesting of a
conchal graft, the sidewalls are preserved to maintain the
structural stability of the ear. A conchal graft can be useful
for the reconstruction of the LLC (e.g., cleft nasal deformity,
overresected iatrogenic deformity); spreader grafts (i.e.,
when minimal structural support is required); or nasal tip
augmentation (i.e., when the underlying support is ade­
quate). It is almost always a second or third donor site choice
when nasal structural support is required, because it lacks
sufficient strength to be used routinely as either a dorsum
or caudal strut framework. In most cases, septal cartilage is
preferred for these indications. For situations in which sig­
nificant stretching of the overlying soft-tissue envelope is
required to achieve tip projection (e.g., cocaine saddle defor­
mity, bilateral cleft nasal deformity, Binder nasal deformity),
a rib cartilage graft will best provide the needed framework
support (see Chapters 29, 32, 33, 35, and 38).
Step-by-Step Approach
Preparation and Draping
• Orotracheal intubation (i.e., RAE tube) is placed as
required for the rhinoplasty procedure. The RAE tube is
taped to the chin to prevent dislodgement.
• Ophthalmic ointment and corneal shields are placed for
eye protection.
• If the patient’s hair is long, it is tied in a ponytail.
• Betadine solution is used for the preparation of the scalp,
forehead, external ears, face, and neck. (Do not use soap,
alcohol, Hibiclens, and so on.)
• Draping is completed, with exposure of the forehead,
the external ears, the face, and the neck down to the
clavicles left in the operative field as per the routine for
rhinoplasty.
Surgical Marking
• The postauricular skin incision is located and marked
with a surgical pen before preparation and draping.
• The incision is centered on the long axis of the ear from
the superior helical rim to the lobe. Stop the incision
approximately 1 cm short of the superior and inferior
margins of the ear.
Local Anesthesia
• Xylocaine (1% with 1 : 100,000 epinephrine) is injected
into the postauricular sulcus between the mastoid fascia
and the ear cartilage.
Skin Incision and Flap Elevation
• With the use of a knife (no. 15 blade), the full thickness
of the skin is incised along the surgical markings.
• Stevens scissors are used to elevate the medial postauricu­
lar flap. The incision is made on the surface of the post­
auricular cartilage and then down to the mastoid fascia.
Graft Harvesting
• The place at which the flat and curved portions of the
conchal bowl meet is identified.
• The planned incision is marked to follow the natural
curve of the conchal cartilage at the location at which
the flat bowl begins.
• With a fresh knife (no. 15 blade), the full thickness of
the conchal cartilage is incised at the surgical marking,
without perforation through the anterior skin.
• With the use of a sharp periosteal elevator (e.g., Cottle),
the incised cartilage is freed from the tightly attached
overlying anterior skin along the flat portion of the
conchal bowl.
• A decision about the volume of the conchal cartilage
graft required is made.
• The conchal bowl is incised at the desired location to
achieve graft requirements.
• Hemostasis and the integrity of the anterior auricular
skin are confirmed.
Wound Closure
• Several interrupted sutures and then running and locking
resorbable sutures are placed for skin closure (5-0
chromic). This prevents the need for postoperative suture
removal.
Placement of Dressing
• A thick coat of antibiotic ointment is placed in the post­
auricular fold and over the anterior ear skin surface.
• A sheet of gauze (e.g., Xeroform) is placed in the post­
auricular groove and also on the anterior skin surface.
• Two or three pieces of dry “fluff” gauze are placed over
the anterior surface of the ear.
• Gauze rolls (e.g., Kerlix) are used as a wrap to hold the
fluff gauze and to apply gentle pressure. The gauze dress­
ing is looped around the anterior neck and the forehead
to secure it.
• An Ace wrap is loosely placed as an outer layer of the
head and ear dressing.
• The whole dressing is removed without replacement 5 to
7 days later.
Postoperative Care
• After the ear dressing is removed, the patient is encour­
aged to shower and shampoo the hair, the external ears,
the face, and the neck once or twice daily as per the
rhinoplasty routine.
• The donor ear is dabbed dry (i.e., not rubbed) after
washing.
• No vigorous sports activities are allowed during the early
phase of healing (i.e., approximately 4 to 6 weeks) as per
rhinoplasty.
Autogenous Rib (Cartilage Only) Donor Site
(
Video 10)
When significant structural support is required for either
the caudal septum or dorsum of the nose within a tight
soft-tissue envelope, neither conchal nor septal cartilage
will generally be adequate. In these cases, autogenous rib

631
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
understanding and managing cartilage warping.31 He sug­
gested the use of “balancing cross sectional carving along
the long axis of the cartilage as a way to limit/prevent
warping.” The general approach when carving costal carti­
lage involves symmetrical removal from both sides and then
using the central core of the cartilage for reconstruction and
augmentation whenever feasible. In vitro studies suggest
that the full distortion of the graft may be demonstrated
within 30 minutes of carving. At a minimum, using Gib­
son’s balanced carving principles and waiting 15 minutes
before graft placement are likely to uncover warping ten­
dencies in a majority of cases. We often use internal stabi­
lization of the dorsal strut (and, less often, of the caudal
strut) via the placement of a Kirschner wire (K-wire; no. 35
cartilage will frequently be the graft material of choice (Fig.
18-10) (see Chapters 29, 32, 33, 35, and 38).37,59,68,84-86,108,109
Costal cartilage is available in abundance, it undergoes
minimal postoperative resorption, and it is relatively easy
to carve into a strut graft. Its perceived donor site harvesting
difficulties often dissuade surgeons from choosing it;
these include the need for a small scar on the anterior lower
chest wall as well as concerns about pneumothorax and
postoperative pain. With meticulous surgical technique,
these potential disadvantages are generally overcome.
However, somewhat unpredictable occasional graft warping
that may jeopardize the long-term aesthetic results when
used as either a dorsal or caudal strut remains a concern.
Gibson’s experimental studies provide the principles for
• Figure 18-10  Facial views of a teenager who was born with unilateral cleft lip and palate before
and after cleft jaw reconstruction followed by cleft rhinoplasty. The nasal reconstruction involved the
use of a rib cartilage (caudal strut) graft as described in Figure 18-11. A, Profile facial views before
and after reconstruction. B, Oblique facial views before and after reconstruction.
Or
Or
Or
Or
Orthththththtr ogn
gn
gn
gn
gn
g atatatatatatathicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry
ry
ry
ry
ry; J.C.
C.
C.
C Pos
osnicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O thththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatathicicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C Pos
os
os
os
os
osnicicick
Or
Or
Or
Or
O ththththththtr ogn
gn
gn
gn
gn
g atatatatatatatatatathicicicicicicicicicic Su
Su
Su
Su
Su
Su
Su
Su
Su
Surg
r ery
ry
ry
ry
ry
ry; J.C.
C.
C.
C. Pos
os
osnicick
Or
Or
Or
Or
Or
Or
Or
Or
Or
Or
O ththththththththththth
r ogn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
gn
g atatatatatatatatatatatatatatatatatatatatatatatatatatatatatathicicicicicicicicicicicic Su
Su
Su
Su
Su
Su
S rg
r ery
ry
ry
ry; J.C.
C Pos
os
osnicicick
A
B

632 SECTION 2  Planning, Surgical Technique, & Complications
• Betadine solution is used for the preparation of both the
hip and the head and neck. (Do not use soap, alcohol,
Hibiclens, and so on.)
• The patient is prepped below the rib cage, past the chest
midline, superior to the nipple, and laterally to the
midaxillary line.
• Draping is completed, with limited skin exposure left
parallel to and on all sides of the planned incision.
Surgical Markings
• The planned incision (i.e., ≈4 cm) is located and marked
with a surgical pen directly over the rib cartilage to be
harvested before preparation and draping.
Local Anesthesia
• Xylocaine (1% with 1 : 100,000 epinephrine) is injected
into the soft tissues below the planned incision and to
the depth of the rib cartilage to be harvested.
Skin Incision and Flap Elevation
• With the use of a knife (no. 15 blade), the incision
is carried through the skin, the subcutaneous tissue,
and the fascia directly over the rib cartilage to be
harvested.
• Superior and inferior flaps are elevated to provide access
to the rib cartilage.
• This should provide exposure of approximately 4 cm of
rib cartilage.
Graft Harvesting
• The perichondrium is scored directly over the mid
portion of the long axis of the rib cartilage to be
harvested.
• Curved and straight elevators are used to dissect in the
subperichondrial plane circumferentially around the car­
tilage to be harvested.
• A curved subperichondrial dissector (e.g., Doyen) is
inserted underneath and around the rib cartilage. This
instrument is used to gain further exposure in the sub­
perichondrial plane.
• A retractor (e.g., Doyen) is placed deep and directly
underneath the location for the incising of the cartilage
graft. A knife (no. 15 blade) is then used to incise the
full thickness of the cartilage.
• The retractor (e.g., Doyen) is then repositioned just
below the other end of the cartilage at the location for
incision. The knife (no. 15 blade) is used to incise the
cartilage.
• The cartilage graft is removed.
Wound Closure
• The wound is checked for hemostasis and any exposure
into the lung cavity; this is done by filling the wound
with saline. The anesthesiologist introduces maximum
end tidal volume and holds the area under pressure with
the Valsalva maneuver. With the confirmation of no
pneumothorax, wound closure is accomplished.
threaded) through the spine of the graft (see Chapters 29,
35, and 38).
Definitive rhinoplasty will be required for the recon­
struction of the residual bilateral cleft lip nasal deformity at
some point after the early teenage years. A “short” columella
generally defines the presenting nasal deformity in the indi­
vidual with bilateral cleft lip and palate (see Chapter 33).
A crafted autogenous rib cartilage caudal strut provides the
structural support to adequately stretch the columella skin
and the soft-tissue envelope for favorable tip projection (see
Fig. 18-10). The graft is stabilized to the base of the maxilla
with a short, buried K-wire (no. 35 threaded). The LLCs
are then sutured together over the top of the rib cartilage
caudal strut to form the most superficial aspect of the tip
(see Chapter 38).
For the reconstruction of the severe posttraumatic or
congenital saddle nose deformity, rib cartilage often has
advantages as compared with bone in that it restores at least
a degree of springiness to the cartilaginous vault and tip; it
is considered easier and less morbid to harvest; and it is not
prone to resorption (see Chapter 35). A rib cartilage dorsal
strut may extend from the radix to the nasal tip or just from
the inferior aspect of the nasal bones to the tip. A K-wire
may be inserted through the spine of the dorsal strut to
prevent warping; this is done before graft inset. The dorsal
strut is combined with a separate rib cartilage caudal strut,
which extends from the base of the maxilla to the tip. A
short buried K-wire secures the caudal strut to the base
of the maxilla. The two grafts are then sutured together
to form the new tip. The LLCs are sutured together and
then over the top of the grafts to establish the most super­
ficial aspect of the tip (see Chapter 38). The soft-tissue
envelope is redraped over the reconstructed cartilaginous
vault and tip.
For the correction of the cocaine-induced or iatrogenic
saddle deformity of the nose, a rib cartilage graft is typically
crafted into two struts (see Chapter 38). The first is a caudal
strut that extends from the base of the maxilla to the new
nasal tip. Assuming adequate height of the nasal bones
(i.e., the osseous vault), the second graft (i.e., the dorsal
strut) is inset deep and then flush with the bony dorsum.
The dorsal strut extends to the new nasal tip. Each cartilage
graft is secured in place at its point of insertion, and the
grafts are then sutured to each other where they join at
the tip. The LLCs are sutured together and then over the
top of the grafts to form the most superficial aspect of the
tip (see Fig. 18-9). The soft-tissue envelope is redraped
over the reconstructed cartilaginous vault and tip (see
Chapter 38).
Step-by-Step Approach (Fig. 18-11)
Preparation and Draping
• Orotracheal intubation (i.e., RAE tube) is placed as
required for the rhinoplasty procedure. The RAE tube is
taped to the chin to prevent dislodgement.
• The specific rib to be harvested is palpated and
identified.

633
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
A
B
Chest
wall
midline
Xyphoid
notch
C
D
E
F
G
Incision marked
Local anesthesia injected
Skin incision
Scissors dissection down to cartilage
Perichondrium scored
Elevator used for subperichondrial dissection
Doyen used for subperichondrial dissection
• Figure 18-11  Intraoperative views of autogenous rib (cartilage only) donor site harvesting. A, The planned incision is marked directly over
the rib cartilage to be harvested (≈4 cm incision length) before prepping and draping. B, Local anesthesia (Xylocaine 1% with epinephrine)
is injected in the soft tissues below the skin and to the depth of the rib cartilage to be harvested. C, With a knife, the incision is carried
through the skin and the subcutaneous tissue. D, Scissors dissection continues through the fascia directly over the rib cartilage. E, The
perichondrium is scored with a knife directly over the mid portion of the long axis of the rib cartilage to be harvested. F, Curved and straight
elevators are used to dissect in the subperichondrial plane circumferentially around the cartilage. G, A curved dissector (Doyen) is inserted
underneath and around the rib cartilage. The Doyen is used to gain further exposure in the subperichondrial plane.
Continued

634 SECTION 2  Planning, Surgical Technique, & Complications
H
I
J
K
L
Cutting proximal end of cartilage
Cutting distal end of cartilage
Cartilage graft
Defect checked for hemostasis
Water in wound prior to Valsalva maneuver
H, A retractor is placed directly underneath the location for the full-thickness incision of the cartilage. A knife is then
used to incise the full thickness of the cartilage on one end. I, A retractor is placed on the other end of the cartilage, and the knife is used
to incise the cartilage. J, The cartilage graft is removed. K, After the removal of the cartilage graft, the defect is inspected for hemostasis.
L, The wound is filled with saline, and the anesthesiologist introduces maximum end tidal volume and holds the area under pressure with
the Valsalva maneuver. This confirms that no pneumothorax is present.
• Figure 18-11, cont’d

635
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
M
N
O
P
R
Q
Caudal
strut
crafted
Additional graft material crafted
Perichondrial layer suture
Fascia layer closure
Skin closure
Occlusive dressing
Cartilage graft prior to crafting
M, The perichondrial sleeve is approximated with interrupted suture ties (3-0
Vicryl). N, The deep and superficial fascia are closed with interrupted ties (3-0 Vicryl). O, Subdermal
closure and then subcuticular closure are accomplished (5-0 Monocryl). P, Steri-Strips and an occlu­
sive dressing (Tegaderm) are placed over the skin. Q, The harvested rib cartilage is crafted to suit the
purposes of the recipient site. R, A crafted caudal strut graft can be seen. Additional grafts have also
been crafted that can be used to reconstruct specific deficits (i.e., lower lateral cartilages, additional
tip grafts, dorsal grafts).
• Figure 18-11, cont’d

636 SECTION 2  Planning, Surgical Technique, & Complications
seemingly most favorable for the augmentation of the facial
skeleton are those made of porous polyethylene. Histologi­
cally, fibrous ingrowth into the polyethylene pores without
capsule formation represents the key attribute of this par­
ticular material. The implants are placed in the subperiosteal
plane and then preferably fixed in their new location to the
underlying skeleton with titanium screws. Systemic antibi­
otics are administered perioperatively to limit the risk of
infection. Technique-sensitive decisions regarding favorable
sites for implant placement, preferred incision locations,
extent of soft-tissue dissection, the size and shape of the
implant selected, the crafting of the implant, the method
of fixation, and postoperative wound management are all
important factors for the limiting of morbidity and the
achievement of desired results. Alloplastic implant extru­
sion, migration, infection, underlying bone resorption, and
unsatisfactory aesthetic results all remain of concern.142,140,141
Augmenting the skeleton to camouflage facial dysmor­
phology with the use of porous polyethylene implants has
been championed by Yaremchuk.140-142 That author and
others have demonstrated the effectiveness of this alloplastic
graft approach for craniofacial reconstructive procedures
and for purely facial aesthetic augmentation in specific clini­
cal settings. The use of these implants in load-bearing loca­
tions as interpositional grafts or for purposes of nasal
augmentation have consistently fallen short of the mark.
Conclusions
As part of maxillofacial surgery, grafting is a procedure that
replaces missing structures with material from the patient’s
own body or with an artificial, synthetic, or natural substi­
tute. When structures are deficient in the individual with a
maxillofacial deformity, either additional bone or cartilage
may be required. The grafting of interpositional defects or
gaps of the mandible and maxilla is performed with autog­
enous bone, allogenic grafts, or alloplastic materials. The
replacement of a condyle or an ascending ramus is generally
done with autogenous costochondral graft, but vascularized
fibular composite flaps and alloplastic joint replacements are
additional options to consider. Nasal reconstruction is gen­
erally carried out with autogenous cartilage (e.g., septum,
ear, rib) or, in some cases, autogenous bone. The use of
alloplastic grafts for the augmentation of the facial skeleton
is occasionally indicated. With adherence to basic biologic
and aesthetic principles, an understanding of the individu­
al’s reconstructive and aesthetic needs, the development of
a systematic treatment plan, and the maintenance of metic­
ulous surgical technique, grafts can generally be used suc­
cessfully to solve complex maxillofacial problems.
• The perichondrial sleeve is approximated with inter­
rupted suture ties (3-0 Vicryl).
• The deep and superficial fascia layers are closed with
interrupted suture ties (3-0 Vicryl).
• Subdermal closure is with interrupted suture ties
(4-0 Vicryl).
• The skin is closed with subcuticular running suture
(5-0 resorbable).
Placement of Dressing
• The skin surface is cleaned with saline. It is then dried,
and benzoin is applied.
• A limited number of Steri-Strips are placed directly over
the closed wound.
• A small piece of cut gauze is placed directly over the
Steri-Strips.
• An occlusive dressing (e.g., Tegaderm) is placed over
the skin.
Postoperative Care
• The patient may shower without concern about moisture
on the occlusive dressing that is covering the wound.
• The dressing remains intact for approximately 7 to 10
days.
• When the dressing is removed, no additional bandages
are placed.
Alloplastic Grafts and Implants for the
Augmentation of the Facial Skeleton
Porous Polyethylene Augmentation Implants
Specific patterns of skeletal dysmorphology may lead
the individual to request and the surgeon to agree to
augmentation and camouflage procedures for the sole
purpose of enhancing facial aesthetics.17,33,67,98,116,132,133,135,137
To avoid the need for graft harvesting and to limit con­
cerns about the resorption of the graft over time, con­
sideration of the use of alloplastic synthetic materials
remains attractive. Alloplastic materials have been used
to enhance and augment the facial skeleton over the years
have included silicon, Biocoral, Biofax, Proplast, Teflon,
Plasti-Pore, Seramic, polyamide-mesh, hydroxyapatite,
Gore-Tex, methyl methacrylate, and porous polyethylene.
These materials have been used with varying levels of
success.18,19,30,32,33,43-45,89,91,99,101,102,136 Their intrinsic biomedi­
cal properties generally fall short of ideal, but they may be
adequate in specific clinical settings.
Of the currently available alloplastic synthetic implants
that are commercially available, the materials that are

637
CHAPTER 18  Grafts Frequently Used During Orthognathic Surgery and for Adjunctive Procedures
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