JOURNAL
OF SURGICAL
21, 339-344 (1976)
RESEARCH
Bone Formation
from
Periosteal
Possible J. GOLAN,
M.D.,
Grafts
Effect
and Investigation
on the
of Calcitoninl
Y. SHAPIRA, D.M.D., N. BEN-HUR, AND L. DOLLBERG, M.D.
M.D.,
FACS,
Department of Plastic and Maxillofacial Surgery and Department of Pathology, Shaare Zedek Hosptial. Jerusalem, Israel Submitted for publication February 20, 1976
Achieving satisfactory bony closure of the the periosteum lining the mandibular arches. cleft palate is one of the difficult problems in The skin was closed by fine silk sutures. Four rabbits received no postoperative plastic surgery. Different methods are commonly used, including “Maxillary Or- treatment. To the other five, 1.6 MRC units (Armour, France) was retaining dentures, expansion of IM calcitonin thopedics,” dentures, and bone grafts at various stages of administered daily for 8 weeks, starting on the treatment. In this study we intend to the first day after the operation. evaluate the use of free periosteal grafts for The development of bone in the graft was formation of new bone, a method which assessed by serial radiographic examinations might be applicable in the surgical treatment at the following intervals: before the operaof cleft palate. The possible effect of tion 1 week, 2 weeks, 1 month, and every exogenous calcitonin on this process was month following after the operation. Five investigated. months after the operation, the animals were sacrificed, and the new bone exposed in the MATERIALS AND METHODS leg muscles and between the mandibular Nine young rabbits, weighing ap- arches was examined, and histological proximately 7.50 g, were used. For specimens were studied. anesthesia, sodium Pentothal was used, in a RESULTS dose of 30 mg/kg. After preparation of the Bone formation was achieved in all rabbits. skin, both tibia1 bones were exposed and a graft of periosteum, measuring approx- Figures l-6 include typical examples of the imately 2 x 0.5 cm was stripped from each new bone achieved in two animals, in the leg bone by a scalpel. To each graft, two metal muscles and between the mandibular arches. markers were attached for easy identification Within 2 weeks after the transplantation, on X-ray examination. the first radiographic evidence of bone could One graft was transplanted into a small be detected. The new bone increased rapidly in size and pocket created in the muscles of the lateral aspect of the tibia. The muscle was closed by density during the first 10 weeks and much fine catgut sutures, and the overlying skin more slowly during the following period. This phenomenon of relative slowing down in the was closed by fine silk sutures. The other graft was transplanted between development of the new bone was more the mandibular arches, in a small tunnel pronounced in the leg grafts than in the mancreated in the muscles of the floor of the dibular grafts. mouth. The periosteal graft was sutured to The importance of direct contact of the graft with bone is demonstrated in Figs. 7 and 8. In this case, one side of the graft was detached from the mandibular arch. The ‘Presented at the 14th Meeting of the Israel Association of Plastic and Reconstructive Surgeons, 1975. result was a wide, dense bone on the sutured 339 Copyright 8~8 1976 by Academic Press, Inc. All rights of reproduction in any form reserved.
FIGS. l-3. Animal No. 7. X-ray photographs of the new bone formation in the leg muscles. The new bone is located between the two metal markers. Fig. 1. Two weeks after the transplantation. Fig. 2. Four weeks after the transplantation. Fig. 3. Twelve weeks after the transplantation.
FIGS. 4-6. Animal No. 8. Fig. 4. X-ray photograph of the mandibular arches, 1 week after the transplantation. The metal markers are seen in place. There is no evidence yet of new bone formation. Fig. 5. X-ray photograph of the mandibular arches, 12 weeks after the transplantation. Arrow points to the new bone. Fig. 6. The specimen after sacrificing the rabbit, 5 months after the transplantation. Arrowhead points to the new bone.
342
JOURNAL
OF SURGICAL
RESEARCH:
side and a slender, less dense bone on the detached side. Very similar findings were found in another animal. During the follow-up period, no sign of bone resorption was observed in the new bone in the leg or in the mandibular grafts. On histology, the bone formed from the grafts was found to have a typical normal architecture of compact bone (Fig. 9). No differences in rate or size of bone development were found between the rabbits who were treated by calcitonin and those who were not treated. The histological findings, too, were identical in the two groups. DISCUSSION As far back as 1867, Ollier [3, 71 proved that transplanted periosteum of young animals is capable of producing bone and that its deeper layer, the cambium, is responsible for this process. The importance of the cambium was
VOL. 21, NO. 5, NOVEMBER
1976
stressed by Burman and Umansky [2]. In the first half of this century, some authors [9] claimed that the periosteum of mature animals does not possess this capability. Lacroix [6] proved the latter to be incorrect. However, only little clinical importance has been attributed in recent years to the possibilities of bone formation by free periosteum 131. In 1965, Skoog [l I] suggested the use of periosteum for early bony repair of cleft palate. He used local rotation flap of periosteum from the maxilla to the cleft. In 1972, Ristila et al. [lo] suggested the use of free periosteal graft for the same purpose. The free graft seemed more practical for the following reasons: (a) The technical difficulties in developing periosteal flap in the maxillary region, close to the cleft. (b) The possible interference with the future growth of the maxilla [5]. (c) As the continuity of blood supply in a narrow-based maxillary flap
FIGS. 7-8 Animal No. 7. Fig. 7. X-ray photograph of the mandibular arches, 8 weeks after the transplantation. In this case, the periosteal graft was detached from the right mandibular arch with its metal marker. The result seen here (arrow points to the new bone) was a wider new bone on the sutured side and a slender bone on the detached side. Fig. 8. The specimen after sacrificing the rabbit, 5 months after the transplantation. Arrow points to the new bone.
GOLAN
ET AL.:
BONE FORMATION
FROM
PERIOSTEAL
GRAFTS
343
FIG. 9. Histology of new bone from between the mandibular arches of animal No. 8 Carl'04 (head poinl .s to new bone). Ma1:ure compact bone, surrounded by muscle and connective tissue. H & E, x 150.
is doubtful, this rotation flap eventually functions as a free graft. The above-mentioned points justified, in our view, further investigation on the use of free periosteal graft rather than the use of local periosteal flap. The results of our study prove that new bone is easily formed by the use of free periosteal graft. The importance of direct contact between the periosteal graft and the periosteum lining the bone in the recipient area should be stressed. Such contiguity of periosteum assures rapid and constant bone formation. This is probably the reason for the continuous growth of the mandibular grafts, in contrast to the relative slowing in growth of the leg grafts. In an experimental study, Knize [4] showed improved results in bone grafts after
administration of calcitonin. Calcitonin is derived from neural crest cells. These C-cells are found in the thyroid gland of mammals [8]. Its main action is on bone, by inhibition of bone resorption by osteoclasts and promotion of bone formation by osteoblasts [l, 121. In our study, calcitonin had no visible effect on the growth rate or the size of the new bone. The histological picture was the same for bone formed in rabbits treated and not treated with calcitonin. It is posssible that the radiographic follow-up was too rough to observe minor differences. However, these facts do not exclude a possible transient effect of the calcitonin on the developing bone. Such transient effect could not be evaluated histologically without influence on bone formation.
344
JOURNAL
OF SURGICAL
RESEARCH:
It seems to us that free periosteal graft could be used more often under proper indications, in cases where continuity of bone is to be achieved. In the field of plastic surgery, it could be of great help in restoration of bony defects in cleft palate and in traumatic defects of the hard palate or the skull. The question of using calcitonin as adjuvant in clinical autotransplantation of periosteal graft is still an open one. SUMMARY Autotransplantation of free periosteal grafts from the tibia to leg muscles and to the mandibular arches was performed in young rabbits, for the creation of new bone. The development of bone was followed up by serial radiographic examinations and by histological examination after sacrificing the animals. Calcitonin, which may increase bone mass by inhibiting bone resorption, was administered postoperatively to four rabbits. Bone formation was achieved in all rabbits. No effect of administration of calcitonin on bone mass could be demonstrated. Clinical applications of free periosteal grafts are suggested.
ACKNOWLEDGEMENTS We are greatly indebted to Miss E. Chriki and to the Department of Medical Photography for technical assistance and to Laboratoire Armour-Montagu (Paris) for supplying the calcitonin.
VOL. 21, NO. 5, NOVEMBER
1976
Supported by a grant from the B. de Rothschild Foundation for the Advancement of Science in Israel.
REFERENCES r, Aliapoulios,
M. A., Goldhaber, P., and Munson, P. L. Thyrocalcitonin inhibition of bone resorption induced by parathyroid hormone in tissue culture. Science 151:330, 1966. 2. Burman, M. S., and Umansky, M. An experimental study on free periosteal transplants wrapped around tendon./. BoneJoint Surg. 12:579, 1930. 3. Converse, J. M. Surgical Treatment of Facial Injuries, p, 1444. Williams & Wilkins, Baltimore, 1974. 4. Knize, D. M. The influence of periosteum and calcitonin on onlay bone graft survival. Plast. Reconstr. Surg. 53:190, 1974. Kremenak, C. R., Huffman, W. C., and Olin, W. H. 5’ Maxillary growth inhibition by mucoperiosteal denudation of palatal shelf bone in non-cleft beagles. Clejt Palafe J. 7:8 17, 1970. 6. Lacroix, P. L’Organization des OS. Liege, Belgium, 7 1949. ,_ Oilier, L. Trait6 Experimental et Clinique de la Regeneration des OS et de la Production ArliJicit?le du Tissu Osseux. Masson, Paris, 1867. 8. Pearce, A. F. G., and Carvalheira, A. F. Cytochemical evidence of an ultimobranchial origin of rodent thyroid C cells. Narure (London1 214:929, 1967. 9. Pollock,
G. A., and Henderson, M. S. Value of Periosteum in bone grafting operation. Proc. Staf Meet. Mayo C/in. 15:443, 1940. 10. Ristila, V., Alhoupuro, S., and Rintala, A. Bone formation with free periosteum. Stand. J. Plasf. Reconstr. Surg. 6:5 1, 1972. I I. Skoog, T. The use of periosteum and surgicel for bone restoration in congenital clefts of the maxilla. Stand. J. Plast. Reconstr. Surg. 1:113, 1967. 12. Wase, A. W., Solewski, J., Rickes, E., and Seidenberg, J. Action of thyroacalcitonin on bone. Nature (London)214:388, 1967.
OF SURGICAL
21, 339-344 (1976)
RESEARCH
Bone Formation
from
Periosteal
Possible J. GOLAN,
M.D.,
Grafts
Effect
and Investigation
on the
of Calcitoninl
Y. SHAPIRA, D.M.D., N. BEN-HUR, AND L. DOLLBERG, M.D.
M.D.,
FACS,
Department of Plastic and Maxillofacial Surgery and Department of Pathology, Shaare Zedek Hosptial. Jerusalem, Israel Submitted for publication February 20, 1976
Achieving satisfactory bony closure of the the periosteum lining the mandibular arches. cleft palate is one of the difficult problems in The skin was closed by fine silk sutures. Four rabbits received no postoperative plastic surgery. Different methods are commonly used, including “Maxillary Or- treatment. To the other five, 1.6 MRC units (Armour, France) was retaining dentures, expansion of IM calcitonin thopedics,” dentures, and bone grafts at various stages of administered daily for 8 weeks, starting on the treatment. In this study we intend to the first day after the operation. evaluate the use of free periosteal grafts for The development of bone in the graft was formation of new bone, a method which assessed by serial radiographic examinations might be applicable in the surgical treatment at the following intervals: before the operaof cleft palate. The possible effect of tion 1 week, 2 weeks, 1 month, and every exogenous calcitonin on this process was month following after the operation. Five investigated. months after the operation, the animals were sacrificed, and the new bone exposed in the MATERIALS AND METHODS leg muscles and between the mandibular Nine young rabbits, weighing ap- arches was examined, and histological proximately 7.50 g, were used. For specimens were studied. anesthesia, sodium Pentothal was used, in a RESULTS dose of 30 mg/kg. After preparation of the Bone formation was achieved in all rabbits. skin, both tibia1 bones were exposed and a graft of periosteum, measuring approx- Figures l-6 include typical examples of the imately 2 x 0.5 cm was stripped from each new bone achieved in two animals, in the leg bone by a scalpel. To each graft, two metal muscles and between the mandibular arches. markers were attached for easy identification Within 2 weeks after the transplantation, on X-ray examination. the first radiographic evidence of bone could One graft was transplanted into a small be detected. The new bone increased rapidly in size and pocket created in the muscles of the lateral aspect of the tibia. The muscle was closed by density during the first 10 weeks and much fine catgut sutures, and the overlying skin more slowly during the following period. This phenomenon of relative slowing down in the was closed by fine silk sutures. The other graft was transplanted between development of the new bone was more the mandibular arches, in a small tunnel pronounced in the leg grafts than in the mancreated in the muscles of the floor of the dibular grafts. mouth. The periosteal graft was sutured to The importance of direct contact of the graft with bone is demonstrated in Figs. 7 and 8. In this case, one side of the graft was detached from the mandibular arch. The ‘Presented at the 14th Meeting of the Israel Association of Plastic and Reconstructive Surgeons, 1975. result was a wide, dense bone on the sutured 339 Copyright 8~8 1976 by Academic Press, Inc. All rights of reproduction in any form reserved.
FIGS. l-3. Animal No. 7. X-ray photographs of the new bone formation in the leg muscles. The new bone is located between the two metal markers. Fig. 1. Two weeks after the transplantation. Fig. 2. Four weeks after the transplantation. Fig. 3. Twelve weeks after the transplantation.
FIGS. 4-6. Animal No. 8. Fig. 4. X-ray photograph of the mandibular arches, 1 week after the transplantation. The metal markers are seen in place. There is no evidence yet of new bone formation. Fig. 5. X-ray photograph of the mandibular arches, 12 weeks after the transplantation. Arrow points to the new bone. Fig. 6. The specimen after sacrificing the rabbit, 5 months after the transplantation. Arrowhead points to the new bone.
342
JOURNAL
OF SURGICAL
RESEARCH:
side and a slender, less dense bone on the detached side. Very similar findings were found in another animal. During the follow-up period, no sign of bone resorption was observed in the new bone in the leg or in the mandibular grafts. On histology, the bone formed from the grafts was found to have a typical normal architecture of compact bone (Fig. 9). No differences in rate or size of bone development were found between the rabbits who were treated by calcitonin and those who were not treated. The histological findings, too, were identical in the two groups. DISCUSSION As far back as 1867, Ollier [3, 71 proved that transplanted periosteum of young animals is capable of producing bone and that its deeper layer, the cambium, is responsible for this process. The importance of the cambium was
VOL. 21, NO. 5, NOVEMBER
1976
stressed by Burman and Umansky [2]. In the first half of this century, some authors [9] claimed that the periosteum of mature animals does not possess this capability. Lacroix [6] proved the latter to be incorrect. However, only little clinical importance has been attributed in recent years to the possibilities of bone formation by free periosteum 131. In 1965, Skoog [l I] suggested the use of periosteum for early bony repair of cleft palate. He used local rotation flap of periosteum from the maxilla to the cleft. In 1972, Ristila et al. [lo] suggested the use of free periosteal graft for the same purpose. The free graft seemed more practical for the following reasons: (a) The technical difficulties in developing periosteal flap in the maxillary region, close to the cleft. (b) The possible interference with the future growth of the maxilla [5]. (c) As the continuity of blood supply in a narrow-based maxillary flap
FIGS. 7-8 Animal No. 7. Fig. 7. X-ray photograph of the mandibular arches, 8 weeks after the transplantation. In this case, the periosteal graft was detached from the right mandibular arch with its metal marker. The result seen here (arrow points to the new bone) was a wider new bone on the sutured side and a slender bone on the detached side. Fig. 8. The specimen after sacrificing the rabbit, 5 months after the transplantation. Arrow points to the new bone.
GOLAN
ET AL.:
BONE FORMATION
FROM
PERIOSTEAL
GRAFTS
343
FIG. 9. Histology of new bone from between the mandibular arches of animal No. 8 Carl'04 (head poinl .s to new bone). Ma1:ure compact bone, surrounded by muscle and connective tissue. H & E, x 150.
is doubtful, this rotation flap eventually functions as a free graft. The above-mentioned points justified, in our view, further investigation on the use of free periosteal graft rather than the use of local periosteal flap. The results of our study prove that new bone is easily formed by the use of free periosteal graft. The importance of direct contact between the periosteal graft and the periosteum lining the bone in the recipient area should be stressed. Such contiguity of periosteum assures rapid and constant bone formation. This is probably the reason for the continuous growth of the mandibular grafts, in contrast to the relative slowing in growth of the leg grafts. In an experimental study, Knize [4] showed improved results in bone grafts after
administration of calcitonin. Calcitonin is derived from neural crest cells. These C-cells are found in the thyroid gland of mammals [8]. Its main action is on bone, by inhibition of bone resorption by osteoclasts and promotion of bone formation by osteoblasts [l, 121. In our study, calcitonin had no visible effect on the growth rate or the size of the new bone. The histological picture was the same for bone formed in rabbits treated and not treated with calcitonin. It is posssible that the radiographic follow-up was too rough to observe minor differences. However, these facts do not exclude a possible transient effect of the calcitonin on the developing bone. Such transient effect could not be evaluated histologically without influence on bone formation.
344
JOURNAL
OF SURGICAL
RESEARCH:
It seems to us that free periosteal graft could be used more often under proper indications, in cases where continuity of bone is to be achieved. In the field of plastic surgery, it could be of great help in restoration of bony defects in cleft palate and in traumatic defects of the hard palate or the skull. The question of using calcitonin as adjuvant in clinical autotransplantation of periosteal graft is still an open one. SUMMARY Autotransplantation of free periosteal grafts from the tibia to leg muscles and to the mandibular arches was performed in young rabbits, for the creation of new bone. The development of bone was followed up by serial radiographic examinations and by histological examination after sacrificing the animals. Calcitonin, which may increase bone mass by inhibiting bone resorption, was administered postoperatively to four rabbits. Bone formation was achieved in all rabbits. No effect of administration of calcitonin on bone mass could be demonstrated. Clinical applications of free periosteal grafts are suggested.
ACKNOWLEDGEMENTS We are greatly indebted to Miss E. Chriki and to the Department of Medical Photography for technical assistance and to Laboratoire Armour-Montagu (Paris) for supplying the calcitonin.
VOL. 21, NO. 5, NOVEMBER
1976
Supported by a grant from the B. de Rothschild Foundation for the Advancement of Science in Israel.
REFERENCES r, Aliapoulios,
M. A., Goldhaber, P., and Munson, P. L. Thyrocalcitonin inhibition of bone resorption induced by parathyroid hormone in tissue culture. Science 151:330, 1966. 2. Burman, M. S., and Umansky, M. An experimental study on free periosteal transplants wrapped around tendon./. BoneJoint Surg. 12:579, 1930. 3. Converse, J. M. Surgical Treatment of Facial Injuries, p, 1444. Williams & Wilkins, Baltimore, 1974. 4. Knize, D. M. The influence of periosteum and calcitonin on onlay bone graft survival. Plast. Reconstr. Surg. 53:190, 1974. Kremenak, C. R., Huffman, W. C., and Olin, W. H. 5’ Maxillary growth inhibition by mucoperiosteal denudation of palatal shelf bone in non-cleft beagles. Clejt Palafe J. 7:8 17, 1970. 6. Lacroix, P. L’Organization des OS. Liege, Belgium, 7 1949. ,_ Oilier, L. Trait6 Experimental et Clinique de la Regeneration des OS et de la Production ArliJicit?le du Tissu Osseux. Masson, Paris, 1867. 8. Pearce, A. F. G., and Carvalheira, A. F. Cytochemical evidence of an ultimobranchial origin of rodent thyroid C cells. Narure (London1 214:929, 1967. 9. Pollock,
G. A., and Henderson, M. S. Value of Periosteum in bone grafting operation. Proc. Staf Meet. Mayo C/in. 15:443, 1940. 10. Ristila, V., Alhoupuro, S., and Rintala, A. Bone formation with free periosteum. Stand. J. Plasf. Reconstr. Surg. 6:5 1, 1972. I I. Skoog, T. The use of periosteum and surgicel for bone restoration in congenital clefts of the maxilla. Stand. J. Plast. Reconstr. Surg. 1:113, 1967. 12. Wase, A. W., Solewski, J., Rickes, E., and Seidenberg, J. Action of thyroacalcitonin on bone. Nature (London)214:388, 1967.
