Use of hydroxyapatite for reconstruction after surgical removal of intraosseous hemangioma in the zygomatic bone

Computer guided resection and reconstruction of intra-osseous zygomatic hemangioma: Case report and systematic review of literature

OBJECTIVES

to systemically integrate the available data on various published treatment strategies for intraosseous hemangioma of the zygoma in an updated comprehensive systematic review, and to present a new case of treated resection and immediate reconstruction using computer guided patient specific composite graft.

CASE PRESENTATION

A 29 years old female patient with intraosseos zygomatic hemangioma treated using computer guided resection and immediate reconstruction. The resection was performed using a resection template constructed based on preoperative 3D planning. The reconstruction was performed using ramus bone graft and titanium mesh. The patient was followed up for 3 years with no complications.

METHODS

An electronic search was performed on 3 data bases; additional hand search of bibliographies of selected articles was performed. Eligibility criteria include human studies presenting intraosseous zygomatico-orbital hemangioma with clearly reported therapeutic strategies.

RESULTS

53 articles with 73 cases were included. The lesion was highly prevalent in females compared to males (2.28:1). Fifth decade represents the highest prevalence with mean age of 44.1 ± 1.8 years. The main patient concern was swelling and facial deformity. Total tumor resection can assure no recurrence, while partial resection and curettage are associated with high recurrence rate.

Autogenous Bone Marrow Aspirate Coated Synthetic Hydroxyapatite for Reconstruction of Maxillo-Mandibular Osseous Defects: A Prospective Study

PURPOSE

This prospective study was conducted to evaluate the bone regeneration capacity of synthetic hydroxyapatite mixed with autogenous bone marrow aspirate when used as a bone graft substitute in maxillo-mandibular osseous defects.

METHODS

This study included nine patients with histopathalogically proven benign osteolytic lesions in maxilla and mandible that were treated with enucleation or marginal resection followed by bone marrow aspirate coated synthetic biphasic hydroxyapatite (hydroxyapatite and beta tricalcium phosphate) graft placement. Incorporation of graft was assessed based on Irwin's radiologic staging. The efficacy of graft to form new bone was radiologically evaluated by observing the sequential changes of density at grafted site using gray scale level histogram which was processed in adobe photoshop 7.0 elements. Clinical assessment of recipient and donor sites was done.

RESULTS

Based on Irwin's radiologic staging, at 6 month follow up period, obvious incorporation of graft with new bone was observed. Sequential changes in bone density measured by gray scale histogram revealed initial resorption followed by replacement of BMA coated hydroxyapatite with new bone formation. None of the patients eventually had complications like infection, wound dehiscence, graft loss at recipient sites at 6 months follow up period.

CONCLUSION

Autogenous bone marrow aspirate in combination with synthetic hydroxyapatite is an effective option for accelerating bone regeneration in small to moderate sized jaw bone defects. This mixture provides all the three critical elements needed for bone regeneration (osteogenesis, osteoinduction and osteoconduction) with an added advantage of obviating donor site morbidity.

Zygomatic Intraosseous Hemangioma: Case Report and Literature Review

Intraosseous hemangiomas are uncommon intrabony lesions, representing approximately 0.5 to 1% of all intraosseous tumors. Their description varies from "benign vasoformative neoplasms" to true hamartomatous proliferations of endothelial cells forming a vascular network with intermixed fibrous connective tissue stroma. These commonly present as a firm, painless swelling. Intraosseous hemangiomas present more commonly in females than in males and most likely occur in the fourth decade of life. The most common etiology of intraosseous hemangioma is believed to be prior trauma to the area. They have a tendency to bleed briskly upon removal or biopsy, making preoperative detection of the vascular nature of the lesion of significant importance. There are four variants: (1) capillary type, (2) cavernous type, (3) mixed variant, and (4) scirrhous type. Generally most common in the vertebral skeleton, they can also present in the calvarium and facial bones. In the head, the most common site is the parietal bone, followed by the mandible, and then malar and zygomatic regions. Intraosseous hemangiomas of the zygoma are rare entities with the first case reported in 1950 by Schoenfield. In this article, we review 49 case reports of intraosseous hemangioma of the zygoma, and also present a new case treated with excision followed by polyether-ether ketone implant placement for primary reconstruction.

Chondromyxoid fibroma of zygoma in an elderly patient: A rare presentation

Chondromyxoid fibroma (CF) is a benign bone tumor of cartilaginous origin and is considered the least common of cartilage-derived neoplasms. The lesion's most frequent location is in long bones, while involvement of craniofacial skeleton is extremely unusual. It generally appears in the second and third decade of life and most frequent in men. We present the case of a 68-year-old female with a CF of the zygomatic region. The resection of the tumor and reconstruction of the defect is described.

External bone remodeling after injectable calcium-phosphate cement in benign bone tumor: two cases in the hand

Bone remodeling commonly occurred after fracture and curettage benign bone tumor. A lot of previous articles reported "internal" trabecular bone remodeling. There were no previous clinical reports about "external" cortical bone remodeling. We present here 2 clinical cases of "external" bone remodeling after injectable calcium-phosphate in benign bone tumor in the hand. In two cases of benign bone tumor, we performed complete removal of the tumor and immediate filling of the metacarpal bone with injectable calcium-phosphate cement Arexbone(®) from the mechanical viewpoint. With respect to the shape of the calcium-phosphate, by using an injection-type, calcium-phosphate is adhered uniformly to the bone cortex by injecting, remodeling has been promoted. After 5 and 8years, both cases were no recurrences, and the shape of the metacarpal looked close to the contralateral side. These findings supposed to be concerned with potential self-healing and self-protection mechanism in human body.

Intraosseous venous malformation of the zygoma: A case report and literature review

INTRODUCTION

Venous malformations of the zygoma are rare. Historically, venous malformations have been misrepresented as "hemangiomas". The International Society for the Study of Vascular Anomaly (ISSVA) classification is a reasonable classification that leads to appropriate clinical diagnosis and treatment strategies. Collaboration between surgeons, radiologists, and pathologists is necessary for accurate diagnosis and management.

PRESENTATION OF CASE

We present here a case of an IOVM in a 59-year-old woman who was treated with a multidisciplinary approach. Superselective arteriography and embolization were effective for diagnosis as well as for prevention of large hemorrhage during surgery. En-bloc resection of the zygoma was performed within hours after embolization and autologous calvarial bone graft was used for primary reconstruction.

DISCUSSION

We performed a literature review consisting of reviewing 52 cases of IOVM of the zygoma discussing optimal material for reconstruction of the defect for intraosseous venous malformation of the zygoma nationally and internationally.

CONCLUSION

The combination of surgery and preoperative angiography makes it possible to prevent high risk of hemorrhage. For primary reconstruction of the zygoma, use of autologous calvarial bone can maintain the volume and reconstruct the natural malar contour.

Craniofacial reconstruction with bone and biomaterials: review over the last 11 years

This review aims to compare bone grafts and different biomaterials for reconstruction of craniofacial bones in congenital defects, after trauma, and after tumour surgery. A Pubmed search was performed and publications over the last 11 years describing reconstructions of craniofacial bones in non-load-bearing areas were reviewed. Only human studies using bone grafts and biomaterials were included. Studies on skull base reconstruction, distraction osteogenesis, free and pedicled bone flaps and bone-anchored epithesis were excluded. Out of 83 studies, three were prospective, 65 retrospective and 15 studies were case reports. There were seven comparative studies found and some efforts on statistical analysis were made. Except for a few studies, the statistical significant differences in outcomes were found to be related to size and location of bone defects rather than reconstruction method and biomaterial used. An increasing number of alloplastic materials have been available as alternatives to the gold standard autologous bone transplantation for craniofacial bone repair. Comparative studies with statistical analyses on differences in success rates between different biomaterials or bone grafts for specific indications are needed.

Intraosseous hemangiomas

Intraosseous hemangiomas are classified as benign tumors of vascular nature. Some authors describe them as hamartomas. They originate and expand inside bone structures. They are usually congenital, rarely of posttraumatic origin. In the Maxillo-Facial Surgery departments of the Universities of Rome "La Sapienza" and "Tor Vergata," from 1990 to 2004, 11 cases of intraosseous hemangioma have been diagnosed. In 6 cases, the neoplasm localized in the zygomatic region; in 3 cases, at the mandible level; in 1 patient, in the maxillary site; and in 1 patient, in the frontal bone. Literature review and the case of a male patient affected by left orbitozygomatic hemangioma are described.

Three-dimensional reconstruction after removal of zygomatic intraosseous hemangioma

INTRODUCTION

Intraosseous hemangioma, especially in the zygomatic area, is a very rare pathologic condition among the osseous tumors of the head and neck area. Clinical presentation includes a painless mass with progressive growth and hard consistence. Diagnosis is performed by means of computed tomography (CT). Treatment includes radical en bloc surgical excision with healthy bone margins in order to avoid blood loss. Previous embolization is not necessary. Bony defect reconstruction must be performed to avoid secondary deformities.

CASE REPORT

We present a case report of a 30-year-old female presenting a progressive painless swelling in the malar and zygomatic regions. CT scan demonstrated a right zygomatic lesion that extended into the orbital floor and lateral orbital wall, affecting also the zygomatic arch. The biopsy revealed an intraosseous hemangioma. Treatment was performed including an en bloc resection with healthy bony margins and primary reconstruction with calvarian bone graft in association with galea-pericranium flap.

Sinus augmentation using human mesenchymal stem cells loaded into a beta-tricalcium phosphate/hydroxyapatite scaffold

OBJECTIVE

Implant placement in the posterior maxilla may often be contraindicated because of insufficient bone volume and presence of the maxillary sinus. In these situations, sinus floor augmentation frequently has been proposed as the best treatment. This clinical study was based on the hypothesis that the clinical effectiveness of adult mesenchymal stem cells (MSCs) loaded to the biphasic scaffold.

METHODS

In this report, the clinical and radiographic results are presented on 6 consecutively treated patients using MSCs in combination with biphasic hydroxyl apatite/ beta-tricalcium phosphate (HA/TCP) for sinus elevation. All the patients in the study had less than 3 mm initial bone height in the posterior maxillary area (IBH). MSCs were cultured and expanded from bone marrow aspirate for each patient. Three months after sinus elevation, radiographic evaluation was performed for the patients and the secondary bone height was measured (SBH(1)). In the second stage surgery, 30 implants were placed. Trephine bur was used as a pilot drill and a core biopsy was obtained from each implant site. Prosthetic rehabilitation of the patients was performed after 4 months. Secondary bone height was measured 9 months after implant placement (SBH(2)).

RESULTS

Of 30 implants, 28 (93%) were considered clinically successful. Two implants were removed due to mobility at the time of surgical exposure. Histologic evaluation of the biopsy specimens revealed numerous areas of osteoid and bone formation HA/TCP, with no evidence of inflammatory cell infiltrate. Mean bone regenerate was 41.34%. Clinically, no complications were observed, and all implants were considered clinically osseointegrated after 4 months. Mean bone height was measured 3 and 12 months after sinus grafting (mean of SBH(1)= 12.08 mm and mean of SBH(2)= 10.08 mm).

CONCLUSIONS

These clinical and histological findings suggest that sinus grafting with HA/TCP in combination with MSCs provide a viable therapeutic alternative for implant placement. The findings suggest that the addition of MSCs to bone derivative/substitute materials may enhance bone formation in the maxillary sinus area. Of course more studies with the control groups are needed for the evaluation of this method as a clinical solution for the patients.

Intraosseous hemangiomas of the facial bone

BACKGROUND

Hemangiomas arising in the soft tissue are common in the head and neck region, but intraosseous hemangiomas of the facial bone are rare.

METHODS

The authors conducted a retrospective study investigating the clinical features, management, and outcomes for seven patients with facial bone hemangiomas.

RESULTS

Three of the hemangiomas arose in the orbital bones, two arose in the mandible, one arose in the frontal bone, and one arose in the zygoma. The mean follow-up was 3 years 9 months. During the first operation, total tumor resection was performed for two symptomatic patients, and partial resection with superficial osteotomy was performed for the remaining five individuals with facial contour deformity. Three patients who underwent partial resection achieved long-term aesthetically satisfactory results without recurrence; the other two developed recurrent tumors and underwent subsequent en bloc resection. No evidence of recurrence was observed in cases where primary or secondary complete tumor resections were performed.

CONCLUSIONS

Although complete tumor resection represents a definitive treatment for facial bone hemangiomas, conservative partial resection offers a simple method of restoring facial contour with minimal side effects. Although it appears that recurrence cannot be avoided entirely, partial resection should be considered for patients who seek surgery for cosmetic reasons.

Reconstruction of intraosseous hemangiomas of the midface using split calvarial bone grafts

BACKGROUND

Intraosseous hemangiomas are benign lesions that usually occur in the vertebral column and the calvaria. They are rare in the midface, with only 22 zygomatic and 26 nasal bone hemangioma cases described in the literature. Methods of reconstruction of craniofacial defects after surgical removal of these tumors have been inconsistent.

METHODS

The authors report long-term follow-up in three cases of midface intraosseous hemangiomas all treated in a similar fashion: surgical excision of the tumor with a small margin of normal bone and primary reconstruction using split calvarial bone grafts.

RESULTS

Clinical, photographic, and computed tomographic assessment (cases 1 and 2) documents no recurrence and maintenance of the result with a mean 5-year follow-up. To the authors' knowledge, this represents the longest follow-up of a patient series with hemangiomas of bone treated with primary reconstruction in the plastic surgery literature (Wolfe and Berkowitz did report on a single case with 4-year follow-up without recurrence). We recommend replacing like with like. Primary bone grafting with autogenous cranial bone was used to replace areas where original bone was thin, but full-thickness bone was used in areas where original bone was thick. Full-thickness cranial bone grafts may be superior to split cranial bone with regard to long-term volume maintenance.

CONCLUSIONS

Preoperative computed tomographic scanning should lead to the appropriate diagnosis. Proper diagnosis should lead to appropriate treatment, which includes total excision and primary bone grafting of the defect to prevent soft-tissue contraction.

Bone Formation in Transplants of Human Bone Marrow Stromal Cells and Hydroxyapatite–Tricalcium Phosphate: Prediction with Quantitative CT in Mice

PURPOSE

To determine whether quantitative computed tomography (CT) can be used to estimate the extent of new bone formation in hydroxyapatite-tricalcium phosphate (HA-TCP)-based transplants.

MATERIALS AND METHODS

Bone-forming transplants were generated by attaching cultured human bone marrow stromal cells to aliquots of HA-TCP particles and were placed in subcutaneous pockets in immunocompromised mice. After 8 weeks, the transplants were individually imaged; each scan included a phantom. Overall bone mineral density (BMD) of each transplant was obtained. Hematoxylin-eosin-stained sections of the same transplants were then examined histologically, which is the reference standard for assessing bone formation. The extent of bone in each transplant was scored on a semiquantitative scale ranging from 0 to 4 by three independent blinded observers; the bone score for each transplant was calculated by averaging the three observer scores. BMD was compared with the histologically determined bone score for each transplant. Statistical evaluations included (a) calculation of empiric receiver operating characteristic curves to determine optimum BMD thresholds and (b) determination of the relationship between BMD and bone score, including derivation of Pearson correlation coefficients.

RESULTS

One hundred twenty transplants were evaluated. Average BMD of 600 mg/cm3 K2HPO4 or more was noted in transplants with appreciable bone formation (bone score > or = 3), while average BMD of less than 600 mg/cm3 K2HPO4 was seen in transplants with poor bone formation (bone score < 3) (P <.001). Among transplants with appreciable bone formation, the BMD was proportional to the extent of mineralized matrix present in the new bone.

CONCLUSION

Use of quantitative CT offers a practical approach for the noninvasive determination of new bone formation in mineralizing bone marrow stromal cells and HA-TCP transplants.

Intraosseous hemangioma of the zygoma

Zygomatic hemangioma is an extremely rare, benign, slow-growing tumor occurring mostly in adult women. The radiologic findings are diagnostic. Total excision of the tumor with primary reconstruction of the defect is the preferred treatment modality. We present a case of zygomatic hemangioma and a brief review of the literature.