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British Journal of Oral and Maxillofacial Surgery 52 (2014) 344349

Morphometric study of the scapular free ap and the free rib

osteomyocutaneous ap
Tolga Taha Snmez a,b, , Andreas Prescher b , Anastasios Kanatas c , Arash Zaker Shahrak a ,
Marcus Gerressen a,d , Matthias Knobe e , Selman Hakki Altuntas f , Ali Modabber a ,
Timm Walter Steiner a , Ralf Smeets g , Alireza Ghassemi a , Frank Hlzle a
a

Department of Oral and Maxillofacial Surgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
Institute of Molecular and Cellular Anatomy, Prosection, Medical Faculty, RWTH Aachen University, Aachen, Germany
c Department of Oral and Maxillofacial Surgery, Leeds Teaching Hospitals and St James Institute of Oncology, Leeds Dental Institute, Leeds,
United Kingdom
d Department of Oral and Maxillofacial Surgery, Heinrich-Braun-Hospital, Location Zwickau, Zwickau, Germany
e Department of Orthopedic and Trauma Surgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
f Department of Plastic Reconstructive and Aesthetic Surgery, Medical Faculty, Sleyman Demirel University School of Medicine, Isparta, Turkey
g Department of Oral and Maxillofacial Surgery, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
b

Accepted 6 January 2014

Available online 28 January 2014

Abstract
The scapula free flap is often the first choice for reconstruction of bony defects of the facial skeleton. However, the vascularised rib as part
of a free rib osteomyocutaneous flap may be a suitable second choice. We have investigated the morphology and clinical dimensions of the
7th rib and the scapula, and the ability of the available bone to carry dental implants. The age and sex of the cadaver, and the donor side,
were also recorded. The dimensions of the scapulas and 7th ribs (n = 130 of each) from 65 cadavers were measured at 4 different points using
osteometric methods. Examination showed that bone from the scapula and 7th rib were sufficient for placement of implants. The 7th rib
gave reliable measurements for both height and width, and a consistent relation between compact and cancellous bone. Although the scapula
provided adequate compact and cancellous bone, there were variations depending on the segment of bone chosen. Bones from male cadavers
were more suitable for implantation. In both the scapula and the 7th rib ageing had a significant adverse effect in only one dimension. Most
points of measurement have satisfactory bony dimensions for insertion of dental implants.
2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Scapula; Rib; Oral and maxillofacial implant-carrying bone reconstruction; Morphometric and morphological bone measurements

Introduction
Defects in the bone of the facial skeleton can be reconstructed successfully using free vascularised autogenous
bony flaps.1,2 Anatomical reconstruction with adequate bone

Corresponding author at: Department of Oral and Maxillofacial Surgery,

Medical Faculty, RWTH Aachen University, Pauwelsstrasse 30, 52074
Aachen, Germany. Tel.: +49 241 8035966; fax: +49 241 8082430.
E-mail addresses: ttahas13@gmail.com, ttahas@directbox.com,
tsoenmez@ukaachen.de (T.T. Snmez).

for the insertion of dental implants is essential for optimal functional and aesthetic outcomes, with restoration
of speech and chewing.2,3 The free vascularised rib flap
is rarely used in clinical practice. The free rib osteomyocutaneous flap was first used in the head and neck by
Serafin et al.,4 and their results were later confirmed by
other studies.57 The latissimus-serratus-rib free flap has
also been used successfully as a second choice of free
flap.8,9 Since the early 1980s the osteocutaneous scapular
flap has been the free flap of choice for reconstructions
of combined bone and soft-tissue defects because it can

0266-4356/$ see front matter 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.bjoms.2014.01.005

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T.T. Snmez et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 344349

provide bone, muscle, and skin paddles in 3-dimensional

configurations.10,11
An important objective of oral rehabilitation after bony
reconstruction is a stable, implant-supported, prosthesis.12
Satisfactory osseointegration of an implant requires a width
of bone sufficient to incorporate the length of the dental
implant in the viable bony flap.1214 However, there is no
reported universally adopted guidance on the optimal anthropometric properties of the rib and the scapula.15,16 Methods
for measuring implantable bone segments are also not adequately detailed in cadaveric studies for the microsurgical
era.10,17,18
The clinical applicability of free vascularised rib flaps has
been assessed in a few anatomical studies in which the authors
have tried to work out the optimal characteristics of these
bony flaps and their ability to provide a stable base for dental implants.1923 However, we know of only one study that
has compared the dimensions and biomechanical properties
of the rib with those of other donor sites.22 Most other studies have been small, and the comparisons reported were not
paired from the same cadavers, which is important for morphometric studies. In addition, the impacts of age, sex, and
donor side were not adequately investigated.
We aimed to study the bony morphology of scapular
and free rib osteomyocutaneous flaps and their implantable
bony dimensions to find out whether they fulfil the minimum
requirements for osseointegration of dental implants. We also
assessed the impact of age, sex, and donor side on these flaps.

345

Fig. 1. Reference marks for measurements. Sites of chosen measurement

points in the scapula (left, dorsal view) and rib (right, inferior view). X = the
costal tubercle.

of the rib was marked as measurement point 1. The distance

from the upper margin to the lower margin in a straight line
was defined as the height, and the distance from the outer to
the inner surface in a straight line was defined as the width,
as described by Martin and Saller (Figs. 1 and 2).16
The morphology of the bone was macroscopically
assessed and documented at both donor sites (Fig. 2). Then,
to evaluate the overall ability of the scapula and rib to withstand placement of dental implants, all measurements above
our cut-off values that were 5.5 mm or wider and 10 mm or

Materials and methods

We obtained samples of bone from central European adult
cadavers (n = 65) at the Institute of Anatomy, RWTH
(Rheinisch-Westflische Technische Hochschule) University, Aachen. A total of 130 samples of 7th rib and 130
samples of scapula were taken bilaterally from 37 (57%)
female and 28 (43%) male cadavers. Specimens ranged in
age from 50 to 95 (mean 78) years. We used 4 measurement
points on each bone sample to make 520 measurements of
the width and height of the scapula and 520 of the width and
height of the rib (Fig. 1).
On the lateral border of the scapula, measurement point
4 was marked 2 cm inferior to the infraglenoid tuberculum
and measurement point 1 was marked 2 cm superior to the
inferior angle (Fig. 1). We defined height as the distance in a
straight line from the lateral margin of the lateral border to the
transitional zone of a thin, transparent, bony lamella of the
infraspinal fossa (transverse diameter). The transitional zone
was defined for each measurement point on each scapula. The
width at each point was defined as the distance in a straight
line, perpendicular to the height (Fig. 2).
We used the pair of 7th ribs for our measurements. On each
rib we marked the costal tubercle (X on Fig. 1), and at a point
8 cm lateral to the costal tubercle we then marked measurement point 4. A point 8 cm ventral to this point on the body

Fig. 2. The lateral border of the scapula (left) and the rib (right) from both
sites of the same cadaver. Bones are shown in cross-sections with the side of
origin. The figure integrates measurement points, sides, and surfaces. Morphology of the bone and the relation between compact and cancellous bone
is seen in cross-sections of measurement points (MPs) 14/bony segment.

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Table 1
Mean (SD) and range of height and width (mm) of scapulas (n = 65) and ribs
(n = 65). Two scapulas and 2 ribs were harvested from each cadaver. Each
bone had 4 measuring points (n = 520).
Measurement
Scapula
Width
Height
Rib
Width
Height

Mean (SD)

Range

10.9 (3.8)
12.3 (4.9)

4.422.4
4.628.7

6.7 (1.3)
13.2 (1.7)

4.312.1
8.518.8

Table 2
Overall ability by sex to withstand placement of a dental implant at each
measurement point on the lateral borders of scapulas and 7th ribs, which
had to be 5.5 mm or more wide and 10 mm or more high. Data are expressed
as percentages.
Measurement point

Point 1
Male
Female
Point 2
Male
Female
Point 3
Male
Female
Point 4
Male
Female

Scapula 5.5 mm or more

wide and 10 mm or
more high

Rib 5.5 mm or more

wide and 10 mm or
more high

100
95.9

99.2
91.9

99.6
93.9

98.7
90.8

84.4
77.1

92.9
84.1

84.4
76.4

91.6
84.8

higher were taken for each measurement point and compared

for both sexes (Tables 1 and 2, Fig. 4), as considered to be
acceptable for successful osseointegration of an implant.1214
Any measurement point with both height and width above the
cut-off values was implantable (Table 2).
Our statistical analyses were made with the help of SPSS
for Windows (Version 15.0, SPSS Inc, Chicago, IL). We
used the one-sample Kolmogorov Smirnov test for normality. Parametric or non-parametric tests were selected
according to the distribution of variables. Students t test
or the MannWhitney U test were used to compare variables between 2 groups. Descriptive statistics for continuous
variables were reported as mean (SD) or median (range),
and frequency and percentages were reported for categorical
variables. Pearsons correlation coefficient was calculated to
assess the relations between variables. Probabilities of less
than 0.05 were accepted as significant.

Results
The mean (SD) height and width of both the scapula and
the rib satisfied the dimensional requirements for successful osseointegration of implants (5.5 mm or more wide and
10 mm or more high) (Fig. 3, Tables 1 and 2).1214 The mean
values for height at both donor sites were clearly above the

Fig. 3. Diagram showing the mean width and height (mm) at 4 measurement
points on the scapula and rib in men and women.

necessary value for length, with the mean height of the rib
being slightly greater. The mean values for the width of the
scapula were greater than those for the rib and were above the
necessary value for width for both donor sites (Fig. 3). These
bony dimensions and the relation of compact to cancellous
bone are apparent in cross-section (Fig. 2).
The morphology of ribs tended to be more consistent
across bony segments from measuring points 14 (Fig. 2).
The height:width proportion of each bony segment changed
minimally from ventral to dorsal, with a relative increase
in width. However, the morphology of the lateral border of
the scapula showed characteristic propagation towards the
infraglenoid tubercle with a decrease in height (Fig. 2). At
the dorsal end, an inverse morphological structure emerged
so that this bone became both narrower and taller. The difference between the range of values of both dimensions is
therefore greater in the scapula than in the rib (Table 1). The
minimum values of both dimensions of the rib were slightly
lower than the acceptable values for placement of an implant.
Measuring points 1 and 2 in male scapulas gave adequate
bone for implants in all cases (Table 2), whereas at points 3
and 4 the dimensions of the scapula were not implantable in
just 84.4% of male scapulas. In male ribs, implants could have
been placed in between 91.6% and 99.2%. The bony morphology of the rib was relatively constant over the entire length
from measuring points 14. There were significant sex differences in the width of ribs (female ribs 88.99, p < 0.0001),
height of ribs (female ribs 14.94, p = 0.0002), width of scapula
(female scapula 85.92, p < 0.0001) and height of scapula
(female scapula 48.25, p < 0.0001), with male bones being
larger. The relations between sex and the measured dimensions of scapulas and ribs are shown in Fig. 3.

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347

Fig. 4. Diagrams showing the relations between age (years) and height of the scapula (r = 0.26) (left) and age (years) and width of the rib (r = 0.32) (right).

Our results also showed that age negatively correlated both

with width of rib (r = 0.32, 95% CI 0.527 to 0.088) and
height of scapula (r = 0.26, 95% CI 0.474 to 0.018)
(Fig. 4). We found no significant differences between the
donor sides.

Discussion
This study is to our knowledge one of the largest cadaver
series ever conducted.1823 The scapula, the iliac crest, and
the fibula have each been rated highly for use in mandibular reconstruction.19 In other osteometric studies, the scapula
has been considered equivalent to the iliac crest as a donor
site, and in some aspects it may even be superior for placement of implants.21 In the present study we explored the
dimensions of implantable bone of the 7th rib and the lateral
border of the scapula for suitability during dental implantation (Table 2). We also considered the paired harvesting of
bones from the same cadaver, which allowed statistical comparison of differences in the side from which the bone was
taken.
We found that the morphology of the lateral border of the
scapula was such that it rotated around its own axis in a half
spiral. Consequently, as one moved towards the infraglenoid
portion of the lateral border, the height of harvestable bone
decreased while the width increased (Figs. 1 and 2, Table 1).
For this reason the anthropometric measurements do not
reflect the clinically relevant bony dimensions of the lateral
border, and a specific measuring technique is required.15,16
The anthropometric measurements for measuring the height
and width of the rib have previously been reported to be
clinically acceptable.16
A minimal vertical height of 10 mm with 1 mm of transversal bone around the implant is typically considered acceptable
for successful osseointegration of implants.1214 According to previous publications, an implant 3.5 mm in diameter
requires a segment of bone with an overall minimum width

of 5.5 mm.1923 The rib was not as wide as the scapula, but
the mean values remained above 5.5 mm (Fig. 2 and Table 1),
suggesting that it was nevertheless suitable.
The rib offers advantages beyond consideration of width as
it is higher, it has a constant ratio of compact:cancellous bone,
and bony morphology is relatively constant (Figs. 1 and 2).
The thick, compact bony structure improves the primary
stability of an implant while the cancellous part facilitates
better osseointegration.13,14 The scapula contains rich cancellous bone towards the inferior angle, while the compact
bone widens in the lateral part as the cancellous area narrows
(Fig. 2). In comparison, the harvestable region of bone in
the 7th rib has an almost constant compact:cancellous bony
relation across segments.
The descriptive statistics of both donor sites showed that
the mean height and width of bone was adequate (Table 1).
However, some bony segments of the scapula fell below
the required width and height that are acceptable for safe
placement of implants. This is an important consideration
for anyone contemplating the use of scapula as an implantcarrying bone flap. On the one hand the high maximum values
alone would justify this use, but on the other, not all measured bony areas were adequate. In male bones the overall
suitability for placement of implants was 84.4% at measuring points 3 and 4, and almost complete at points 1 and 2
(Table 2), so shorter and wider implants can be inserted in
the lateral half of the harvested bone. The dorsal part (including the inferior angle to the harvested bone) better satisfies the
requirements for safe placement of dental implants (Fig. 2).
Alternatively, as one clinical study suggested, greater bony
dimensions could be achieved by integrating the medial and
the lateral border of the same microvascular flap.11 This may
be an alternative to double-barrelled fibular flaps.
To our knowledge this is the first study to show clearly
such contrasting morphometric information about these 2
dimensions over several measurement points. Such information is likely to have been missed because in previous
research fewer measurement points were used, and the

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T.T. Snmez et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 344349

predefined margins of the height of scapular bone were set to

a predefined width.1823 In comparison we individually measured the height of each scapula. For example Shimizu et al.23
calculated heights of 1928 mm for the lateral border of the
scapula and widths of 912 mm, using 3 measurement points.
Another pilot study24 used a different measuring guide, and
reported heights in the range of 13.219.5 mm and widths
of 7.59 mm. Beckers et al.19 found the mean width to be
9.7 mm, which allowed an effective height for insertion of an
implant of 13.2 mm.
Unlike the scapula, the rib has a minimum height of
8.5 mm (with sufficient width), which is perfectly acceptable
for implantation using currently available implant systems
(Tables 1 and 2). Seikaly et al.22 reported that 89% (n = 22)
of ribs satisfied the requirements (10 mm 5.75 mm in this
study) for safe placement of implants. As our study assessed
the overall ability to withstand placement of a dental implant
separately at each measuring point, we have been able to
make precise statements for each bony region (Table 2). We
therefore found, in contrast to their results, that the overall
ability of the 7th rib to withstand placement of an implant
ranged from 91.6% to 99.2% in male subjects. The bony
morphology of the 7th rib can therefore be characterised as
relatively constant for the placement of implants across all
4 measuring points (Fig. 2). This is the major advantage of
using the 7th rib. It has consistent morphological dimensions
along the whole length of the available bone with no need to
compromise any osteotomies to rotate each bony segment.
The impacts of age, sex, and side are extremely important in clinical practice. Despite their importance, these
factors have rarely been investigated in previous morphometric studies.1821 As expected, our statistical evaluation
showed that there were significant differences between the
sexes across all dimensions of both scapula and rib, with
mens bones being larger (Fig. 3, Tables 1 and 2). It is
interesting that the adverse impact of ageing on the values
measured at both donor sites was statistically confirmed in
only one dimension for each bone, with the width of the rib
and the height of the scapula diminishing with increasing age
(Fig. 4). This finding may allow the placement of suitable
dental implants in these bones, even though the patients are
old.

Conict of interest
The authors have no financial interest to declare in relation
to the content of this article.

Ethics statement
The use of human cadavers is not considered to be human
subject research as human subjects must be by definition living individuals. No additional ethical approval is needed to

use of cadavers for purposes of science and research in

Germany.

Acknowledgments
We thank Wolfgang Graulich, Andre Dring and Sarah
Nsser, Prof. Cengizhan Acikel and Prof. Fatih Zor from
FAVOR Laboratories of GATA for statistical support, Prof.
Saman Warnakulasuriya, Dr. Robert Sykes and Dr. David
Mitchell for their grateful editorial supports.

References
1. Urken ML, Buchbinder D, Costantino PD, et al. Oromandibular reconstruction using microvascular composite flaps: report of 210 cases. Arch
Otolaryngol Head Neck Surg 1998;124:4655.
2. Holzle F, Wolff KD, Mohr C. Reconstructive oral and maxillofacial
surgery. Dtsch Arztebl Int 2008;105:81522.
3. Gurlek A, Miller MJ, Jacob RF, Lively JA, Schusterman MA. Functional
results of dental restoration with osseointegrated implants after mandible
reconstruction. Plast Reconstr Surg 1998;101:6509.
4. Serafin D, Villarreal-Rios A, Georgiade NG. A rib-containing free flap
to reconstruct mandibular defects. Br J Plast Surg 1977;30:2636.
5. Bhathena HM, Kavarana NM. Primary reconstruction of head and neck
cancer with anterior rib, osteomyocutaneous composite flap. Head Neck
1992;14:1837.
6. Penfold CN, Davies HT, Cole RP, Evans BT, Hobby JA. Combined
latissimus dorsi-serratus anterior/rib composite free flap in mandibular
reconstruction. Int J Oral Maxillofac Surg 1992;21:926.
7. Song R, Lu C, Song Y, Liu J. Repair of large mandibular defects with
vascularized rib grafts. Clin Plast Surg 1982;9:738.
8. Trignano E, Fallico N, Nitto A, Chen HC. The treatment of composite
defect of bone and soft tissues with a combined latissimus dorsi and
serratus anterior and rib free flap. Microsurgery 2013;33:17383.
9. Kim PD, Blackwell KE. Latissimus-serratus-rib free flap for oromandibular and maxillary reconstruction. Arch Otolaryngol Head Neck Surg
2007;133:7915.
10. Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland
R. The osteocutaneous scapular flap for mandibular and maxillary reconstruction. Plast Reconstr Surg 1986;77:53045.
11. Nkenke E, Vairaktaris E, Stelzle F, Neukam FW, Stockmann P, Linke
R. Osteocutaneous free flap including medial and lateral scapular crests:
technical aspects, viability, and donor site morbidity. J Reconstr Microsurg 2009;25:54553.
12. Adell R, Lekholm U, Rockler B, Branemark PA. A 15-year study of
osseointegrated implants in the treatment of the edentulous jaw. Int J
Oral Surg 1981;10:387416.
13. Brnemark PI. Osseointegration and its experimental background. J Prosthet Dent 1983;50:399410.
14. Breine U, Branemark PI. Reconstruction of alveolar jaw bone. An experimental and clinical study of immediate and preformed autologous bone
grafts in combination with osseointegrated implants. Scand J Plast
Reconstr Surg 1980;14:2348.
15. Gallino M, Santamaria E, Doro T. Anthropometry of the scapula: clinical
and surgical considerations. J Shoulder Elbow Surg 1998;7:28491.
16. Martin R, Saller K. Textbook of anthropology. Stuttgart: Fischer; 1957
[in German].
17. Hui KC, Zhang F, Lineaweaver WC, Moon W, Buncke GM, Buncke
HJ. Serratus anterior-rib composite flap: anatomic studies and clinical
application to hand reconstruction. Ann Plast Surg 1999;42:1326.
18. Van Thienen CE, Deraemaecker R. The serratus anterior scapular flapa
new osteomuscular unit. Eur J Plast Surg 1988;11:15661.

Author's personal copy

T.T. Snmez et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 344349
19. Beckers A, Schenck C, Klesper B, Koebke J. Comparative densitometric
study of iliac crest and scapula bone in relation to osseous integrated
dental implants in microvascular mandibular reconstruction. J Craniomaxillofac Surg 1998;26:7583.
20. Frodel Jr JL, Funk GF, Capper DT, et al. Osseointegrated implants: a
comparative study of bone thickness in four vascularized bone flaps.
Plast Reconstr Surg 1993;92:44958.
21. Moscoso JF, Keller J, Genden E, et al. Vascularized bone flaps in
oromandibular reconstruction. A comparative anatomic study of bone

349

stock from various donor sites to assess suitability for enosseous dental
implants. Arch Otolaryngol Head Neck Surg 1994;120:3643.
22. Seikaly H, Chau J, Li F, et al. Bone that best matches the properties of
the mandible. J Otolaryngol 2003;32:2625.
23. Shimizu T, Ohno K, Michi K, Segawa K, Takiguchi R. Morphometric examination of the free scapular flap. Plast Reconstr Surg
1997;99:194753.
24. Ariyan S, Finseth FJ. The anterior chest approach for obtaining free
osteocutaneous rib grafts. Plast Reconstr Surg 1978;62:67685.