Bone Grafting in Orthognathic Surgery: a Systematic Review

Int. J. Oral Maxillofac. Surg. 2019; 48: 322–331

https://doi.org/10.1016/j.ijom.2018.08.014, available online at https://www.sciencedirect.com

Systematic Review

Orthognathic Surgery

1,2 1

A. Alyahya , G. R. J. Swennen

Division of Maxillofacial Surgery, Department

Bone grafting in orthognathic

of Surgery, General Hospital St-Jan Bruges-

Ostend, Bruges, Belgium; Department of

Oral and Maxillofacial Surgery, King Abdulaziz

surgery: a systematic review Medical City, National Guard, Riyadh, Saudi

Arabia

A. Alyahya, G. R. J. Swennen: Bone grafting in orthognathic surgery: a systematic

review. Int. J. Oral Maxillofac. Surg. 2019; 48: 322–331. ã 2018 International

Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights

reserved.

Abstract. Bone grafting has been used in orthognathic surgery to ﬁll the gaps created

by jaw repositioning, with the intention of improving healing and stability. Since

the majority of orthognathic cases have a satisfactory result, the decision to graft

or not is a clinical dilemma. A systematic review of the literature was performed

on the use of bone grafts in orthognathic surgery. A search of PubMed,

MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials

yielded 1927 articles published up until 2018. An additional 10 articles were

retrieved through manual searching of the reference lists and citations. After title

and abstract screening, 58 articles were potentially eligible; full-text screening

excluded 10 of these. Thus 48 articles were included in this review. The present

literature highlights the beneﬁts of grafting bony gaps during orthognathic surgery

in terms of healing, stability, and aesthetic outcomes. Generally, there was no

difference between the various types of bone graft, although calcium phosphate

cement and hydroxyapatite were found to increase the rate of infection. The

Key words: orthognathic surgery; bone graft-

conclusion of this review is that there remains a lack of evidence in the literature

ing; systematic review.

regarding the grafting of osteotomy sites in orthognathic surgery. Guidelines are

proposed based on the present evidence; however, future research is needed to Accepted for publication 28 August 2018

validate these. Available online 18 September 2018

Orthognathic surgery has become routine served adverse effects of jaw repositioning respectively . Hence, bone grafting at the

clinical practice worldwide for the treat- are unfortunately not uncommon. Inade- osteotomy site in orthognathic surgery has

ment of dentomaxillofacial deformities by quate bone contact after large mandibular been performed to overcome these adverse

oral and maxillofacial surgeons. The most movements and inferior repositioning of effects.

common surgical orthognathic procedures the maxilla or the chin may result in The purpose of this systematic review

are the Le Fort I osteotomy, bilateral compromised bony union with potential was to evaluate current evidence on the

sagittal split osteotomy (BSSO), and gen- subsequent skeletal relapse . In addition, a grafting of bony osteotomy sites in orthog-

ioplasty. Since the introduction of these resultant bony defect after sagittal split nathic surgery, especially with regard to

procedures, extensive research has been and chin osteotomies may be clinically improvement of the surgical outcomes in

done towards improving the surgical noticeable to the patient, with aesthetic terms of bony healing, stability, complica-

results. Despite the good and predictable implications in the region of the buccal tions, and the prevention of aesthetic

outcomes of orthognathic surgery, ob- sagittal corticotomy or paramedian chin, defects.

Bone grafting in orthognathic surgery 323

Table 1. Search terms. pendent reviewers were involved in the

Primary key words Secondary key words search and screening process, and all stud-

ies were included or excluded by consen-

Orthognathic Grafting, Bone

sus.

Orthognathic surgery Bone Grafting

A modiﬁed Cochrane data collection

Corrective jaw surgery Bone Graft*

Jaw surgery Transplantation, Bone form with items related to the topic of

Maxillary osteotomy Replacement Material, Bone this systematic review was used by the

Lefort/Le Fort Replacement Materials, Bone reviewers to extract the relevant data .

Le Fort osteotomy Bone Substitute Included articles were categorized based

LeFort osteotomy Substitute, Bone

on the measured outcome (healing, stabil-

Le Fort I osteotomy Substitutes, Bone

ity, aesthetic defect, and complications),

Mandibular osteotomy

osteotomy site (Le Fort I, BSSO, genio-

Bilateral sagittal split osteotomy

plasty, and zygoma), and type of publica-

Sagittal split osteotomy

tion (case series, cohort study, and clinical

Sagittal split ramus osteotomy

trial) (Table 3). A ﬂowchart of the search

Sagittal split ramal osteotomy

Vertical subsigmoid osteotomy strategy and selection process according to

Ramus osteotomy the PRISMA criteria is provided in Fig. 1. BSSO SSO SSRO Results

BSSRO

The primary search identiﬁed 1927

IVRO

papers. Title and abstract screening ex-

EVRO

Genioplasty cluded 1825 records, and the citations and

reference lists of the remaining 102 papers

Chin osteotomy

Chin repositioning led to the addition of 10 new papers. The

Zygoma osteotomy secondary search failed to identify any

Malar bone osteotomy relevant additional papers. Abstract

Cheek bone osteotomy screening excluded 54 papers and another

10 papers were excluded after full-text

reading. Finally, a total of 48 papers were

Table 2. Inclusion and exclusion criteria. included in this systematic review (Fig. 1).

Inclusion Exclusion The 10 excluded articles were found to be

poorly reported case reports (n = 6), re-

All original reports regarding bone grafting in Letters and review articles

view articles (n = 2), and studies with

orthognathic surgery Reports in languages other than English

follow-up of less than 6 months (n = 2).

Published in the English language literature Follow-up of less than 6 months

Published up until January 2018 Animal or laboratory studies Most of the included articles were ob-

Follow-up of more than 6 months Cleft or syndromic cases servational studies. Eleven cohort studies,

Human studies Pre-prosthetic osteotomies 30 case series, three case reports, and only

Non-syndromic subjects Augmentation bone grafts four clinical trials were identiﬁed. The

Poorly reported studies where data extraction

primary measured outcome was healing

is not possible

or union of the osteotomy site (n = 35

studies), followed by stability (n = 22

studies). Two studies evaluated the effect

Materials and methods syndromic, non-cleft orthognathic osteot- of the grafting material on nerve heal-

4,5

omy sites, with a follow-up period of more ing . Another article assessed the effect

A systematic review of the literature on 6

than 6 months, published up until January of bone grafting on condylar position ,

bone grafting in orthognathic surgery was

2018. All studies on osteotomies for pre- while the risk of developing an inferior

performed in accordance with the Pre-

prosthetic reconstruction or bone augmen- mandibular border defect after BSSO with

ferred Reporting Items for Systematic

tation were excluded (Table 2). or without bone grafting was investigated

Reviews and Meta-analyses (PRISMA) 7

The primary search was done in the in one study . The maxilla at the Le Fort I

criteria. A pilot search with initial key

PubMed, MEDLINE, and Embase data- level was the most grafted osteotomy site,

words related to bone grafting in orthog-

bases and the Cochrane Central Register while chin extrusion with an interposi-

nathic surgery was ﬁrst done in PubMed

of Controlled Trials. A secondary search tional graft and ramus osteotomy came

(National Library of Medicine, NCBI),

was done of the grey literature (http:// next, followed by a few reported cases

and related articles were checked for rele-

www.opengrey.eu/) and clinical trials reg- of zygomatic osteotomy sites. Porous hy-

vant key words. All terms were analyzed

istry (https://clinicaltrials.gov/). All arti- droxyapatite (HA) was the most common-

with medical subject headings (MeSH)

cles were screened by title and abstract ly used grafting material, followed by

and the ﬁnal list was revised to ﬁt the

and all irrelevant reports were excluded. autogenous and allogeneic bone. Only a

inclusion and exclusion criteria (Table

The reference lists of remaining articles few reports used bovine bone, calcium

1). The search strategy was reviewed by

were screened for similar studies. Google phosphate cement, and bioactive glass.

a health information specialist and was

Scholar was then used to search for cita- The reported complications regarding

limited to the English language literature.

tions for each article (snowballing). The bone grafting osteotomy sites were infec-

The inclusion criteria encompassed origi-

full text of all eligible articles was read tion, exposure or rejection, sinusitis, and

nal human studies on grafting of non-

and a ﬁnal decision was made. Two inde- chronic inﬂammation. Porous HA was the

324 Alyahya and Swennen = 23) local infection n 1 exposure of thetreated graft conservatively autogenous group 8 local infections with exposures None None infections, and 2 malocclusions rejection None severe pain, 1 hardware failure, 2 notching of inferior border, 3 occlusal relapse, 1 allodynia requiring continuous meds group with rejection a 1 year None months months months biopsy and 1 year CBCT > Healing More than 6 months 1 non-union in control ) Outcome measured Follow-up Complications n Control group 297 20 Healing Average of 6.4 111 Healing + stability 5 years 5% ( Maxilla (incl. segmental) Study sample 141 Maxilla, mandible, and chin 19Maxilla paranasal and orbital Healing rim ChinChinBSSO 1–6 yearsMaxilla and chin 32 1 infection in the 32 113 48 Healing Healing Healing Healing 6 months 6 months 3–12 months T2: 2 months; T3: 6 None None 4 sinusitis, 2 local Maxilla, mandible, and chin 3chin (20), and zygoma (9) Healing + stability 2 years None -TCP -TCP cement-TCP cement BSSO Maxilla 40 47 Healing + Healing nerve + effect nerve effect 1 year 1 year None None b a a allograft mandibular angle) and fibrin glue angle) bone allograft with variable others site) Cohort study Autogenous (iliac) vs. Case seriesCase series Freeze-dried allograft HACase series HACase Maxilla series AutogenousCase (medial reportCase series Bio-Oss (bovine bone) DemineralizedCase bone series matrix Autogenous MaxillaCohort (mandibular study Midpalatal maxilla Demineralized 18 freeze-dried Cohort study Maxilla, mandible, and chin Demineralized bone matrix 18 19Case reportCase series Autogenous (same chin site) HA Healing 1 ChinCase (porous series block)Case series HACase and series fibrin Healing glue HACohort and Healing study fibrin glue Allograft Maxilla, mandible, and chinClinical trial 49 Bio-Oss (bovine Zygoma 18 bone) months Healing ZygomaCase series 2 Average Maxilla of Bioactive 9.3 glass NR S53P4 Chin 9 infections (50%) Healing BSSO 6Case months series 20Case report 37 Bio-OssCase (bovine Healing series bone) Autogenous (NR)Clinical trial 9 HAClinical (porous trial block) BSSO NR 27 months 19Case series Healing ChinCase 25 series Healing Fresh Chin frozen allograft 9 Autogenous monthsCase (from series same 9 local Healing infections with HA Chin Healing 20 At least None Healing 1 year 6 years 1 6 7 months 1 for sinusitis the 1 year Healing Maxilla 3 10 33 (398), sinusitis months BSSO (18), Healing Healing 3 wound 1 dehiscence, sinusitis 2 Healing + stability 6 months 14 months 12 months None None None 10 11 32 25 39 19 26 27 30 38 40 17 14 22 18 21 63 33 41 36 4 5 29 16 28 15 . Characteristics and main outcomes of the included studies regarding healing, stability and complications. Holmes 1988 Hiatt 1987 Kim 2014 Moenning 1989 Mommaerts 1999 Posnick 2015 Ragaey 2017 Zeller 1986 Ueki 2012 Braun 1984 Wessberg 1980 Ueki 2013 Healing and stability Bertossi 2013 Healing Allard 1987 Table 3 First author, year Study design Type of bone used Surgical site Sample ( Lee 2013 Lee 2014 Cottrell 1998 Epker 1976 Honda 2005 Haas Junior 2016 Lye 2008 Matsushita 2010 Mommaerts 1995 Stoor 2017 Trevisiol 2012 Rohner 2013

Bone grafting in orthognathic surgery 325 rted; scarring) > 1 infection and 4 rejection infection ( None group; 5.3% infections in control group groups 1 year (12–136 1 years Infection around 5% in all months > months) > border defect Condylar position 1–2 months None 12 Healing + stability 12–36 months 1 local infection Control group 30 Maxillasegmented maxilla (3), and maxilla 80 (7) Maxilla Healing + stability 1 year 10 None Healing + stability 14.5 monthsMaxilla None BSSO 15BSSO Stability 501 Study sample 30 6 Inferior months mandibular None -TCP cement Maxilla 45-TCP, beta-tricalcium phosphate; BSSO, bilateral sagittal split osteotomy; CBCT, cone beam computed tomography; HA, hydroxyapatite; NR, not repo Stability 12 months None a b bone material (Osteoplant- Flex) matrix (1 ml) andbovine 20 bone mg collagen– protein extracts propeller graft) membrane segment of mandible) Cohort study Xenogeneic spongiotic Case seriesCase series AllograftCase series HACase (porous series block) HA (porous block) Frozen heads of femurCase series Maxilla and HA chinCase Mandibular Maxilla series ramus (2), Maxilla Human demineralized bone Case series 46Case series 6 HA and 12 HA autogenous (porous block) 76Cohort Zygoma study Maxilla, 50Case mandible, NR and series chin 55 Healing Autogenous Maxilla +Case (anterior and stability series iliac) mandibleCase series Maxilla AutogenousCohort (anterior study iliac) Calcium phosphate 6–20 HA 92 cement Chin months (porous Healing block) + stabilityCase series Maxilla Healing + 18 stabilityCohort study HA HealingCohort (porous + study block) stability 16.3 2Case Autogenous (6–46) rejection series (chin) months Maxilla Maxilla 1Case year series 3 HA rejection (porous variable block) 112 4–40 Autogenous Healing (maxilla + Maxilla stability MaxillaCohort Healing study + stability 8 23 Calcium phosphate cement 12 Maxilla months BSSO None Cohort study 1 year Allograft Stability 74 21 + PRP (8 + cleft) collagen Clinical trial Autogenous (proximal 10 rejections 78 + 4 Stability chronic Stability 22 Stability 2 24 infection and 12 1 Stability months rejection 196 Stability 1 year 6 Stability months 6 months–4 years Donor morbidity Stability 3 Infection infection rate None 15 months None 6 months 8 months 16 months NR NR 18.6% 3 infections rejection in study 46 7 20 64 58 37 31 34 56 52 12 13 8 9 24 53 6 35 54 55 23 59 Not reported, but cases were treated up until 1986 and publication was 1987. a -TCP, alpha-tricalcium phosphate; Rosen 1989 Rosen 1991 Christian 1982 Wolford 1987 Kerawala 2001 Mayrink 2014 Mehra 2001 Ueki 2013 Wardrop 1989 Lee 2015 Waite 1996 PRP, platelet-rich plasma. Eser 2015 a Posnick 2015 Layoun 2003 Others Coppey 2017 Kent 1986 Kuvat 2009 Stability Araujo 1978 Mehra 2002 Cifuentes 2018 Kim 2005 Kang 2010

326 Alyahya and Swennen

Fig. 1. Flowchart of the methodology of the search and selection process using PubMed, Embase, and the Cochrane Library.

most common graft material related to on the data extraction form, were not Two clinical trials were conducted by

these complications. reported in any of the articles included. Ueki et al. comparing the healing of Le

Fort I osteotomy and BSSO in patients

who received alpha-tricalcium phosphate

Discussion Healing 4,5

(a-TCP) versus a control group . After

This systematic review shows that the In orthognathic surgery, healing of the 1 year of follow-up, multi-slice computed

present literature on bone grafting in osteotomy has the same biological basis tomography (MSCT) examination showed

orthognathic surgery mostly consists of as fracture healing. The osteotomy can be that most of the control sites (18/23) had

case series and cohort studies, with only considered as a controlled displaced frac- bony defects at the level of maxillary

a few clinical trials. The level of evidence ture. This displacement creates less bone osteotomy, while all study sides had com-

regarding important clinically relevant contact, which may compromise the union plete bony continuity.

questions is listed in Table 4. Overall, at the osteotomy site. In the case of inferi- In a cohort study done by Lee et al. ,

the studies showed that the use of bone or repositioning of the maxilla or chin, healing of the BSSO gap grafted with

grafts in orthognathic surgery was advan- there may even be a state of gap healing. demineralized bone matrix (DBM) was

tageous, but more clinical trials are needed Rohner et al. conducted a split-mouth compared with no grafting in 48 patients.

to provide solid evidence. The studies trial on nine patients who had a Le Fort I In serial postoperative cone beam comput-

included varied in purpose, site, and ma- osteotomy with advancements of 5 mm or ed tomography examinations at 1 week, 3

terial used. Moreover, similar studies were less. One side was grafted with Bio-Oss months, and 6 months, the study group

reported by similar groups of authors, Collagen and the other side was left with- showed a continuous increased bone vol-

leading to the risk of overlapping or re- out a graft and served as a control. After 6 ume in comparison to the control group. In

8–13 16

peated data . Unfortunately, two im- months, all of the grafted sites had healed 2008, Lye et al. examined different types

portant clinical variables, ‘operating without a defect, whereas three of the of bone graft with or without DBM at Le

time’ and ‘costs’, which were included control sites had ﬁbrous gap healing. Fort I and chin osteotomy sites in a very

Bone grafting in orthognathic surgery 327

Table 4. Level of evidence.

Question Answer Level of evidence Reference

Does bone grafting promote osteotomy healing?

Le Fort I osteotomy Yes I Rohner 2013

BSSO Yes I Ueki 2012

29 28 30

Chin osteotomy Yes IV Kim 2014 , Lee 2013 , Posnick 2015

11 56

Zygoma osteotomy Yes IV Mommaerts 1999 , Layoun 2003

Does bone grafting affect condylar position? No I Kang 2010

Does bone grafting decrease skeletal relapse?

53 52

Le Fort I osteotomy Yes III Waite 1996 , Araujo 1978

BSSO – – No reports

23 27

Chin osteotomy Yes IV Kim 2005 , Bertossi 2013

Zygoma osteotomy Yes IV Layoun 2003

Does bone grafting decrease the risk of an inferior border Yes III Cifuentes 2018

defect in BSSO?

Does bone grafting increase the infection rate?

53 15 55

Autogenous, allogeneic, xenogeneic No III Waite 1996 , Lee 2014 , Eser 2015

Calcium phosphate paste Yes III Coppey 2017

37 39

Porous HA Yes IV Wolford 1987 , Moenning 1989

a-Tricalcium phosphate No I Ueki 2012, Ueki 2013

b-Tricalcium phosphate No III Ragaey 2017

Does bone grafting increase costs and time? – – No reports

heterogeneous sample. In Le Fort I One case series reported a high inci- of relapse is observed, especially with

1,42–

patients, the DBM group had slightly in- dence of infection (50%) with allogeneic inferior repositioning of the maxilla

creased complications, such as sinusitis grafts in patients where wire ﬁxation was . Improving the quality of bone union by

and infection. Another cohort study eval- used at the maxillary osteotomy sites . In ﬁlling the osteotomy gaps with bone graft

uated the use of beta-tricalcium phosphate a retrospective study, Coppey et al. com- probably provides better long-term stabil-

(b-TCP) at Le Fort I osteotomy sites in pared two groups of 196 patients who ity . Many studies comparing the stability

141 patients and compared these patients underwent BSSO with or without calcium of maxillary osteotomies with or without

to 297 controls . After 6 months, all study phosphate paste. They observed an in- bone grafts have been conducted in cleft

47–51

group osteotomy sites had healed very creased rate of infection in the calcium patients . In this systematic review, in

well, while one case of non-union was phosphate paste group of more than three which cleft patients were not included,

seen in the control group. The latter case times the rate in the control group. On the several cohort studies evaluated different

was a large advancement (8 mm) in a other hand, the two clinical trials con- types of bone regarding stability. In a

4,5 52

smoker patient. ducted by Ueki et al. mentioned above, cohort study, Araujo et al. compared

Allard et al. compared the healing of evaluated the use of self-setting a-TCP in the rate of relapse between 10 patients

maxillary and mandibular osteotomies Le Fort I and BSSO defects and did not who had the maxillary osteotomy plus

using autogenous bone graft versus frozen report any case of infection in either bone graft and 11 controls. The vertical

femoral allogeneic bone in a small sample group. and horizontal relapse in the grafted group

(n = 19) of patients. In general, there was In several case series, porous HA was signiﬁcantly less than that in the

no difference in healing between the two showed an increased rate of infection, control group. In another cohort study,

groups. exposure, sinusitis, and chronic Waite et al. compared two groups of

8,9,35–40

Thus most of the reports appeared to inﬂammation . Most of the case patients with obstructive sleep apnoea

show improved signs of bony healing series of HA were reported by similar who underwent maxillomandibular ad-

when an osteotomy site was grafted com- research groups of surgeons. Bioactive vancement of around 10 mm with or with-

pared to no grafting. Furthermore, differ- glass was used in one case series to graft out chin bone grafts. Using conventional

ent types of bone graft were used with the BSSO defects . The results were not lateral cephalometric analysis, the average

comparable results. encouraging as dehiscence and unex- relapse was 0.7 mm in the grafted patients

plained severe pain were observed in a and 1.8 mm in the control group.

few cases. Ueki et al. evaluated both horizontal

Complications

In general, no grafting material showed and vertical maxillary repositioning with

an increased rate of complications except or without a self-setting a-TCP graft using

Concern for possible complications may

calcium phosphate cement and HA, which resorbable plates and found no signiﬁcant

limit the use of bone grafts in routine

increased the rate of infection. Despite the difference in relapse after 1 year. The

orthognathic surgery. In this systematic

small sample (n = 25), bioactive glass effect of xenogeneic grafts on maxillary

review, the reported complications were

showed different unexplained complica- stability was compared with autogenous

evaluated based on the type of bone and a 55

tions. grafts by Eser et al. in a group of 80

comparison was made with the reported

patients. Both types of graft improved

rate of complications in general during

stability of the maxilla, with no signiﬁcant

orthognathic procedures. Although the

Stability 12

difference between them. Mehra et al.

reports were very limited, autogenous,

compared two groups of cleft and non-

allogeneic, and xenogeneic grafts were The stability of orthognathic surgery

cleft patients who had maxillary osteo-

not found to increase the rate of infection depends on many factors. Despite the

14,15,18–32 tomies with HA bone grafts. The relapse

in orthognathic surgery . use of rigid ﬁxation, a variable amount

328 Alyahya and Swennen

in cleft patients was higher than in non- regeneration and remodelling if left with- Mandible

cleft patients in both the vertical and hori- out bone grafting material. Biological fac-

Few articles on the grafting of BSSO gaps

zontal planes. Other case series reported tors such as a young active or intact

could be included in this systematic re-

the use of different types of bone graft periosteum may succeed in ﬁlling the

view. The BSSO osteotomy design and

with acceptable stability, except in some osteotomy gap, and morphological factors

35,56 anatomy provide a greater bony surface

HA cases . such as thick overlying soft tissues may

interface and better bony union compared

It seems that the skeletal stability of the mask inferior border irregularities. This

to Le Fort I. Relapse in BSSO is more

osteotomy is dependent on the quality of could explain why this aesthetically un-

related to muscle action and dynamic

bone union. Increased bony gaps or com- pleasing complication is relatively under- 62

remodelling of the condyles . However,

promised healing as a result of infection reported.

the resultant bony union may affect the

contributed to the rate of relapse. In HA From the studies included in this sys-

shape of the mandible and cause inferior

cases, the rate of relapse was proportional tematic review, it can be clearly seen that 2

border notching . To a certain degree, this

to the rate of complications. grafting the osteotomy bony gap decreases

notch will not be visible except on radio-

the incidence of this unfavourable out-

graphs or by digital palpation.

come.

Aesthetics As mentioned above, the risk factors of

developing a noticeable antegonial notch

The soft tissue response after orthognathic

after BSSO were evaluated by Agbaje

surgery depends mainly on the underlying 57

Maxilla et al. . Patient age >30 years, large man-

skeletal support. The presence of a bony

dibular advancements, and osteotomy

defect at the site of a sagittal split or chin Most of the included studies evaluated the

designs including a discontinuity of the

osteotomy may create aesthetically un- bony healing of Le Fort I osteotomy. The

inferior border of the mandible were found

pleasing antegonial notching, lower bor- anatomy of an osteotomized maxilla with

to increase the incidence of these defects.

der irregularities, or accentuated jowls. a thin bone interface exposed to open

Therefore, they recommended a modiﬁed

These defects become worse if they are maxillary sinuses may raise the concern

sagittal split osteotomy where the lingual

asymmetrical and may require corrective of inadequate bony union. It was ob-

14 part of the inferior border remains with the

surgery. served by Rohner et al. that bone union

2 distal segment. In the experience of the

Lindquist and Obeid observed inferior was good along the osteosynthesis plates

senior author (G.S.), modifying the buccal

border notching and irregularities in con- at the medial piriform and lateral zygo-

corticotomy by placing the inferior border

ventional radiographs in more than 70% of maticomaxillary buttresses. The bony

cut hidden under the masseter muscle will

patients who underwent genioplasty with gaps appeared at the anterior thin wall

57 reduce the incidence of a noticeable notch.

or without BSSO. Agbaje et al. dis- of the maxillary sinus. This could be 7

Cifuentes et al. observed that by grafting

cussed the risk factors of developing a explained by the fact that this thin bone

the osteotomy gap, the incidence of man-

noticeable notch after BSSO. Age, the was resorbed faster than the thick bone at

dibular border notching reduced from

amount of advancement, and the osteot- the buttresses and failed to regenerate due

54.5% to 1.3%.

omy design were the signiﬁcant factors in to ﬁbrous tissue healing. In addition, it

The potential inﬂuence of bone grafting

that study. In a retrospective cohort study, was supposed that the osteosynthesis

7 of the BSSO gaps on condylar position

Cifuentes et al. compared the incidence plates acted as a guided bone regenera- 6

was assessed by Kang et al. in a random-

of inferior border defects in patients who tion membrane and prevented ﬁbrous for-

ized clinical trial. Using three-dimension-

underwent a BSSO or a modiﬁed BSSO mation beneath it. This would explain the

al MSCT analysis, the bone graft group

with or without bone grafts and found that good bony union that was found with

was found not to have improved condyle

these occurred signiﬁcantly less in the different types of bone graft, as most of

26 position compared to the control group.

grafted group. Trevisiol et al. showed these acted as osteoconductive scaf-

5,16,58,59 Hence, although bony healing and skel-

very good bony healing and normal con- folds .

etal stability of BSSO is less of an issue

touring of the inferior mandibular border In some of the case series, graft expo-

compared to the maxilla, its reﬂection on

in 20 BSSO cases with large advance- sure was more common in the mid-palate

the bony shape of the mandibular border is

ments (>8 mm) grafted with Bio-Oss Col- area with thin mucosal coverage and in

of paramount importance for facial sym-

lagen. the pterygomaxillary area where no ﬁxa-

38,39 metry and aesthetics.

The inferior border of the mandible tion of the grafts was done . Sinusitis

(‘the jaw line’) is considered an important and other infections were related to mo-

aesthetic component of the face. It can bility or displacement of the graft mate-

37 Chin

therefore be very unpleasant for patients rial into the sinus . Relapse of inferior

who undergo orthognathic surgery aimed repositioning of the maxilla of up to A chin osteotomy carries the same risk of

at improving their function and aesthetics 100% has been reported in the litera- developing an inferior border defect as

to end up with an aesthetic defect. On the ture . Rigid ﬁxation may provide good BSSO, and in the case of inferior reposi-

one hand, one could assume that an osteot- initial stability, but in the absence of tioning, it carries the same risk of skeletal

omy gap will act like a dead space where adequate bony union, long-term stability relapse as in Le Fort I. Most of the

soft tissue granulation will be faster than is questionable. A bony gap of more than reported cases of graft use in the chin

osteoid deposition. On the other hand, 1 mm may fail to heal despite rigid ﬁxa- were either to grafting of the osteotomy

61 14

additional bone resorption can be expected tion . In the study by Rohner et al. site or augmentation grafts. Only grafting

at the level of the osteotomy bony edges mentioned above, even a maxillary ad- of the osteotomy sites was considered in

and in the area where the periosteum was vancement of less than 5 mm could fail to this systematic review. The fact that there

reﬂected. Hence, it is unlikely that any form bone at the level of the anterior wall are no masticatory forces on the chin

intraoperative palpable or noticeable of the maxillary sinus, although this is not explains the overall good bony healing.

osteotomy gaps will undergo better bony relevant for stability. In the included studies, interpositional

Bone grafting in orthognathic surgery 329

grafting to increase the vertical height was Finally, it is recommended that the fol- technique in large mandibular advancements

the most common indication for grafting lowing clinically relevant variables be reduces the risk of persisting mandibular

of chin osteotomies. Almost all cases included in further studies regarding this inferior border defects. J Oral Maxillofac

Surg 2018;76(1). 189.e1–e6.

reported excellent healing and stability, research topic: (1) complications rate, (2)

8. Rosen HM. Porous, block hydroxyapatite as

regardless of the type of bone additional operating time, and (3) costs

19,23,25,27–30,63 an interpositional bone graft substitute in

used . towards grafting osteotomy sites in

orthognathic surgery. Plast Reconstr Surg

orthognathic surgery.

1989;83(6):985–90. discussion 91–93.

Zygoma 9. Rosen HM, Ackerman JL. Porous block hy-

Acknowledgement. We thank Lies Pottel droxyapatite in orthognathic surgery. Angle

Zygomatic osteotomy is considered an

(clinical research coordinator) for her help Orthod 1991; (3):185–91. discussion 92.

additional procedure that can be added

10. Mommaerts MY, Abeloos JV, De Clercq CA,

and suggestions regarding the search pro-

to the orthognathic armamentarium to

cess. Neyt LF. The ‘sandwich’ zygomatic osteot-

improve the aesthetic outcome. The zygo-

omy: technique, indications and clinical

matic ‘sandwich’ osteotomy proposed by

10 results. J Craniomaxillofac Surg 1995;

Mommaerts et al. makes it possible to (1):12–9.

Funding. None.

combine this osteotomy with the Le Fort I 11. Mommaerts MY, Nadjmi N, Abeloos JV,

osteotomy at the same stage. In their two Neyt LF. Six year’s experience with the

10,11

consecutive studies , zygomatic osteo- zygomatic ‘‘sandwich’’ osteotomy for cor-

tomies with interpositional porous HA Competing interests. None. rection of malar deﬁciency. J Oral Maxillo-

blocks were used to increase the lateral fac Surg 1999;57(1):8–13. discussion 4–5.

prominence of the malar area. Only a few 12. Mehra P, Wolford LM, Hopkin JK, Castro V,

cases of postoperative sinusitis were ob- Ethical approval. Not required. Frietas R. Stability of maxillary advance-

served, which is the same complication ment using rigid ﬁxation and porous-block

hydroxyapatite grafting: cleft palate versus related to HA as reported in other stud-

37,64 56

non-cleft patients. Int J Adult Orthodon

ies . Layoun et al. reported 18 cases Patient consent. Not required.

Orthognath Surg 2001;16(3):193–9.

of zygomatic osteotomies with autoge-

13. Mehra P, Castro V, Freitas RZ, Wolford LM.

nous and porous HA grafts. Three of the

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grafting in genioplasty procedures. Int J Oral Saudi Arabia

Tel.: +966 50 4169769

Maxillofac Surg 1986;15(6):665–8. Address:

E-mail: [email protected]

64. Wardrop RW, Wolford LM. Maxillary sta- Abdulmalik Alyahya

Department of Oral and Maxillofacial Sur-

bility following downgraft and/or advance-

gery

ment procedures with stabilization using

King Abdulaziz Medical City

rigid ﬁxation and porous block hydroxyapa-