CASE REPORT
Mandible Augmentation for Osseointegrated
Implants Using Tissue Engineering Strategies
Ming-Huei Cheng, M.D.,
M.H.A.
Eric M. Brey, M.D.
Betul Gozel Ulusal, M.D.
Fu-Chan Wei, M.D.
Taipei, Taiwan; and Chicago, Ill.
D
esigning flaps that meet the specific func-
tional and geometric requirements of
oromandibular defects often requires sig-
nificant amounts of donor tissue and complex
surgical procedures. In addition, the use of au-
tologous tissue may be hindered by limited avail-
ability and the associated donor-site morbidity.
Extensive work is underway in the development
of tissue-engineered substitutes, but clinical ap-
plication in the reconstruction of large defects
remains a long-term goal.1 However, tissue-
engineering approaches can enhance current
reconstructive procedures. Scaffold-guided tis-
sue regeneration is one of the key approaches to
tissue engineering.2– 4 This method involves seed-
ing porous, biodegradable matrices with donor
cells (e.g., cultured osteoblasts or bone marrow
stromal cells) and/or growth factors (e.g., bone
morphogenetic proteins), and then implanting
the scaffolds to induce and direct the growth of
new, healthy tissue. The ability to control scaf-
fold geometry could result in engineering tissues
with the exact three-dimensional geometry of
the patient’s defect.
Experimental work in sheep has shown that
prefabricated chambers packed with morcellized
bone graft and implanted adjacent to the osteo-
genic surface of the periosteum yields three-
dimensional bone flaps.2– 4 Durable and transfer-
able vascularized tissue units of defined shapes
could be fabricated. Morcellized bone graft was
used because it can be considered the ideal bio-
material for bone formation, as it provides a
degradable scaffold of matrix proteins, viable
From the Department of Plastic and Reconstructive Surgery,
Chang Gung Memorial Hospital, and Department of Bio-
medical Engineering, Illinois Institute of Technology.
Received for publication October 28, 2004; accepted March
17, 2005.
Copyright ©2006 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000221120.11128.1a
www.PRSJournal.com
cells, and bioactive proteins in the exact stoichi-
ometry found in mature bone.3
In this study, we present a clinical case in
which a similar procedure was used to fabricate
an osseous flap for augmenting mandible height
during reconstruction. A molded polymethyl-
methacrylate tissue chamber was used to explore
the feasibility of using autogenous iliac mor-
cellized bone graft in a 58-year-old patient to
engineer a bone flap. Further, the “take” and
long-term durability of the engineered bone
block were assessed after its transfer for mandi-
ble reconstruction and osseointegrated implant
insertion.
CASE REPORT
A 58-year-old man with advanced buccal squamous cell car-
cinoma (T2N2M0) underwent wide tumor excision and right
modified radical neck dissection in another hospital. The com-
posite defect, involving the right segmental mandible and a
through-and-through buccal defect, was reconstructed with a
pectoralis major myocutaneous flap and a reconstruction plate.
The surgical procedure was followed by 6000 cGy of radiother-
apy. Eleven months after the surgical procedure, he was re-
ferred to our clinic with severe trismus (interincisal distance: 0
cm) (Fig. 1). After removal of the reconstruction plate and
bilateral release of the contracture in the buccal regions, triple
flaps were planned to reconstruct the resultant defects. A free
anterolateral thigh cutaneous flap (12 ⫻ 6 cm) and a radial
forearm flap (5 ⫻ 2 cm) were used to resurface the right buccal
and commissure and left buccal defects, respectively; a free
fibula flap was used to reconstruct the mandible. Complete
healing with satisfactory mouth opening was attained, and the
patient demanded teeth after a follow-up period of 1 year.
However, despite solid union of the vascularized fibula flap with
the mandible, the height was inadequate, at 5 mm high and 50
mm long, for further dental rehabilitation (Fig. 2). Additional
reconstruction with free flaps was hampered due to difficulty
finding an adequate recipient vessel because of the three pre-
vious free flaps. In addition, the patient refused another major
operation. The case was therefore considered for reconstruc-
tion with a three-dimensional scaffold-guided bone flap.
Preformed hollow rectangular chambers were fabricated
from dental-grade polymethylmethacrylate, as described
previously.4 Briefly, the chambers were enclosed on five sides
and open on one side, with inner dimensions of 1 ⫻ 1 ⫻ 5 cm
(Fig. 3). The three-dimensional shape of this chamber was
1e

Fig. 1. Interincisal distance of the patient was 0 cm 11 months
after the initial ablative surgery and radiotherapy for buccal
tumor.
designed to achieve the optimal height for osseointegrated
teeth implantation. A 7-mm polyethylene cuff was bonded with
medical-grade silicone adhesive around the perimeter of the
open side, to allow suture fixation in vivo. The chamber was
placed in a 100°C water bath after fabrication to remove re-
sidual monomer and volatile residues. The chamber was ster-
ilized in ethylene oxide gas.
A total of 5 cc of cancellous bone graft was harvested from
Fig. 2. Radiologic view of the neomandible, demonstrating inadequate height 1
year after reconstruction with the vascularized fibula flap.
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Plastic and Reconstructive Surgery • July 2006
Fig. 3. Hollow rectangular chambers were fabricated from dental-
grade polymethylmethacrylate that was enclosed on five sides and
open on one side, with inner dimensions of 1 ⫻ 1 ⫻ 5 cm.
the right iliac crest and packed into the polymethylmethacrylate
chamber. After the chamber was packed with morcellized bone
graft, the polyethylene cuff was sutured to the periosteum with
its open side exposed to the osteogenic surface of the perios-
teum to create an enclosed space. After 8 weeks of implantation,
solid bone was found in the polymethylmethacrylate chamber
extending from the periosteum. The chamber implantation
time was based on extensive animal studies that determined that
maximum bone graft formation occurs at 8 weeks after
implantation.4 The engineered bone graft, along with the peri-
osteum, was harvested and transferred to augment the mandi-
ble height. The native mandibular bone was burred slightly to
allow good bone contact for vascular connections. Donor iliac
periosteum was sutured to the recipient mandibular perios-
teum to allow a rapid establishment of blood supply to the bone.
At a 1-year follow-up, the engineered bone remained viable
(Fig. 4) and the bone height had increased up to 5 mm (Fig.
5). Three osseointegrated dental implants, 4 mm in diameter
and 10 mm in height, were inserted into the engineered bone.
Implants were fixed firmly. The histologic samples revealed
adequately regenerated compact bone with numerous haver-
sian systems and mature osteocytes (Fig. 6). Unfortunately, the
patient died due to hepatocellular carcinoma before placement
of the dental implants. However, the most recent examination
at 16 months revealed well-retained osseointegrated implants in
the engineered bone (Figs. 7 and 8).
Volume 118, Number 1 • Mandible Augmentation

Fig. 4. Perioperative view of the viable engineered bone 1 year

after implantation.
Fig. 6. Histological appearance of the engineered bone exhib-
iting a compact bone configuration with mature osteocytes and
DISCUSSION
numerous haversian canals (hematoxylin and eosin, ⫻100).
Tissue engineering is a multidisciplinary/in-
terdisciplinary field that integrates the principles
of biology and engineering to develop tissue sub-
stitutes to restore, maintain, or improve the func-
tion of diseased or damaged human tissues.5 It is
a broad field that includes the patient’s own body
to regenerate damaged tissues or replacing the
patient’s cells or organs with living tissue grown in
vitro to functionally replace living organs or tis-
sues. Tissue engineering was initially defined as a
field in the late 1980s and is now well established
and progressing rapidly. In this unique case, iliac
bone graft was used to guide generation of a bone
flap of a defined three-dimensional geometry that
was successfully transferred to a recipient site. This Fig. 7. Well-retained implants 4 months after implantation into
approach was based on tissue-engineering studies the engineered bone.
in which the patient’s own regenerative capacity
was manipulated to grow a segment of vascularized
bone with a predetermined geometry using min- trition. Adult bones are surrounded by perios-
imal donor tissue. teum that assists in new bone formation and neo-
The most critical aspects of successful transfer vascularization through its population of
of a tissue flap in vivo are blood supply and nu- progenitor cells and rich plexus of vessels located

Fig. 5. Radiologic view of the engineered bone (arrows) with an approximate

thickness of 5 mm.
3e

Fig. 8. Four-month postoperative view.
in the inner (cambium) layer.6 Periosteum can
form new bone after it has been stripped from
mature bone as long as its vascular supply remains
intact.7 In this study, the periosteum was chosen to
promote formation of a bone flap because of its
extensive blood supply and osteogenic potential.
By transferring the flap with the periosteum to the
periosteum of the vascularized fibula, bone flap
take was facilitated. This procedure leads to an
increase in thickness (1 mm to 5 mm). Although
histologic analysis indicated that the osteocyte
number was less than that in mature compact
bone, at the long-term follow-up (16 months),
implants were well retained, with no loosening or
bone resorption around the implants.
This is a preliminary study of successful man-
dible augmentation with a bone graft fabricated
using techniques found in tissue-engineering re-
search. Although a completely tissue-engineered
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Plastic and Reconstructive Surgery • July 2006
bone graft has not been used clinically, this case
provides an example of how tissue-engineering
approaches can be used to improve current clin-
ical protocols. Of course, many studies are war-
ranted before routine clinical application will be
possible. A waiting period of 8 weeks may create a
potential disadvantage, and more clinical research
is required to develop methods for improving the
quality of the engineered bone. Since the engi-
neered bone units are presumed to be well
vascularized,3 future studies may explore the po-
tential feasibility of harvesting them as vascular-
ized flaps.
Ming-Huei Cheng, M.D., M.H.A.
Department of Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital
5, Fu-Hsin Street, Kwei-Shan
Tao–Yuan 333, Taiwan
micro.cheng@msa.hinet.net
minghueicheng@hotmail.com
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