An Additional Donor Site for Alveolar Bone Reconstruction. Technical Note

Home , Mandibular symphysis

723 whereas a / 3 3,4 11 1 2 The morbidity of 5 The disadvantage of intraoral donor 4 6–8 Possible complications with intraoral /Kyösti S. Oikarinen, DDS, PhD S. Oikarinen, /Kyösti 2 7,9,10 A variety of intraoral donor sites have been The most commonly used donor sites for bone The most commonly used donor sites be accom- Intraoral bone harvesting can usually The International Journal of Oral & Maxillofacial Implants of Oral & Maxillofacial Journal The International sites is a limitation in the amount of available bone. intraoral donor sites is usually relatively low, and intraoral donor sites is usually relatively low, the use of a transoral approach does not result in a visible scar. 6- to 9-month healing period is needed for bone grafts of endochondral origin. introduced in oral and maxillofacial surgery. The introduced in oral and maxillofacial surgery. bone has osteoinductive and osteoconductive prop- bone has osteoinductive and osteoconductive erties and it is immunologically safe. area are the reconstruction in the maxillofacial and maxilla. ilium, rib, calvarium, tibia, mandible, general anes- Extraoral harvesting usually requires morbidity thesia and hospitalization. Postoperative crest donor and ambulatory disturbances from iliac sites are well-known complications. routine dental plished under local anesthesia in a office setting or on a hospital outpatient basis. The advantages of intraoral donor sites are their conve- nient surgical access and close proximity of donor and recipient sites, which reduce operative time. It has also been shown that a 4-month healing period is sufficient for mandibular bone grafts, donor sites include altered sensation of teeth, neu- rosensory disturbances, and infections. 2002;17:723–728) MPLANTS I Cameron M. L. Clokie, DDS, PhD M. L. Clokie, Cameron /George K. B. Sàndor, DDS, MD B. Sàndor, K. /George 1 AXILLOFAC M RAL J O alveolar ridge augmentation, autogenous bone graft, bone harvesting, endosseous dental bone graft, bone harvesting, autogenous augmentation, ridge alveolar NT (I rds: Dr Vesa Kainulainen, Institute of Dentistry, Institute Kainulainen, Dr Vesa ygomatic Bone: An Additional Donor Site for for Site Donor An Additional Bone: ygomatic esa T. Kainulainen, DDS Kainulainen, esa T. cover exposed implant threads and expand a narrow alveolar ridge. It also could be used as an addi- ridge. alveolar and expand a narrow threads exposed implant cover

V Z Key wo bone zygomatic sites, intraoral donor implants, This article describes a procedure to harvest bone from the zygoma for alveolar bone reconstruction. A bone reconstruction. alveolar zygoma for the from bone harvest This article to describes a procedure and a preliminary report procedure undergo- of 3 patients bone harvesting of the detailed description maxillary in the placement implant and simultaneous dental anterior reconstruction bone ing alveolar example, is needed, for amount of bone when a modest is indicated technique The is presented. area to and can simple zygoma is the to access Surgical intraoral donor sites. other of bone with tional source are after zygomatic bone harvest complications Postoperative be performedanesthesia. using local minimal. Alveolar Bone Reconstruction. Technical Note Technical Reconstruction. Bone Alveolar

ait University, Kuwait; Professor of Oral and Maxillofacial Professor Kuwait; ait University, one grafts in the maxillomandibular region are one grafts in the maxillomandibular of needed mostly to facilitate the placement onto, Canada. onto, w r ersity of Oulu and Oulu University Hospital, Oulu, Finland. ersity of Oulu and Oulu University eprint requests: ersity of Oulu, 90014 Oulun Ylioposito, Finland. Fax: +358-8- Fax: Finland. Oulun Ylioposito, ersity of Oulu, 90014 Professor, Oral and Maxillofacial Surgery, Faculty of Dentistry, Faculty Surgery, Oral and Maxillofacial Professor, Ku of Oulu, Oulu, Finland. University (on leave), Surgery Oral and Maxillofacial Professor, and Associate Chairman Network, Health and University of Toronto University Surgery, To Associate Professor and Director of Graduate Residency Pro- Residency of Graduate and Director Professor Associate The of Toronto; University Surgery, gram in Oral and Maxillofacial MacMillan Children’s The Bloorview Children, Sick Hospital for Canada. Toronto, Centre, Clinical and Research Fellow, Department of Oral and Maxillofa- Fellow, Clinical and Research Children, Sick The Hospital for of Toronto; University cial Surgery, and University Centre MacMillan Children’s The Bloorview Depart- Associate, Canada; Research Toronto, Network, Health Uni- of Dentistry, Institute Surgery, ment of Oral and Maxillofacial v Department of Oral and Maxillofacial Surgery, PO Box 5281, Uni- 5281, PO Box Department Surgery, of Oral and Maxillofacial v 537-5560. E-mail: [email protected] 3 4 2 1 R

dental implants in adequate bone. Several materials dental implants in adequate bone. Several bone graft sub- have been introduced and tested as for auto- stitutes that can function as replacements standard” for genous bone, which remains the “gold Autogenous maxillomandibular reconstruction. B

COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 26 Preparation of the recipient site should be done Preparation of the the inferior Bone harvesting is started just above Once the cortical bone has been removed, can- SURGICAL PROCEDURE FOR HARVESTING FOR PROCEDURE SURGICAL BONE ZYGOMATIC pre- bone is performed of the zygomatic Palpation to harvest zygoma is easier A prominent operatively. a flat of bone than a greater quantity and will give projection and Townes axial, one. Anteroposterior, skull could be used to evaluate radiographs of the bone. An axial or coronal the form of the zygomatic scan of the head is helpful computed tomographic of zygomatic bone and pro- to estimate the volume Three-dimen- of the anatomy. vides a good view also be used to visualize the sional imaging can bone. shape of the zygomatic of the bone graft. This allows for before harvesting of bone graft the determination of the amount appropriate needed and the final selection of the local anesthesia donor site. Following application of middle supe- to the infraorbital nerve, posterior and nerve rior alveolar nerves, and zygomaticofacial through a area, the zygomatic bone is exposed made through vestibular incision. The incision is above the the alveolar mucosa about 5 mm the first mucogingival junction, starting between to the and second molars, and proceeds anteriorly are used to first premolar area. Periosteal elevators dissection elevate a mucoperiosteal flap. The infraorbital extends to the inferior aspect of the of the body of nerve and around the inferior half of the max- the zygoma (Fig 1a). The lateral border border of illary sinus is visualized and the inferior the orbital rim is palpated. from the border of the zygomatic rim and lateral or thin round bur, maxillary sinus. A trephine bur, can be used to fissure bur on a straight handpiece of the zygo- harvest bone from the anterior aspect matic bone (Fig 1b). All drilling of the bone must be done under copious saline irrigation, and a suction trap should be used to collect bone chips. The drill is kept at an angle of approximately 45 degrees to the occlusal plane and should not be drilled deeper than 12 to 14 mm. The drill should be kept parallel to the lateral sinus wall and lateral surface of the zygomatic bone. The anterolateral corner of the zygomatic bone should be left intact. Care should be taken to avoid entering the orbital floor or infratemporal fossa with the drill. A 4.6-mm trephine drill or 2.3- to 3-mm round burs have been used to create a window in the anterior zygoma. Between 2 and 5 corticocancellous bone plugs can be harvested with a trephine bur (Fig 1c). cellous bone, if present, can be curetted. A suction 11,12 3,11,14,15 21 maxillary 6,7 The coronoid and in conjunc- 18 Both cortical and 16 The principle of 17 22–24 alveolar defect reconstruction alveolar and reconstruction of the orbital and reconstruction 13 19 25 Bone from the zygomatic eminence and Bone from the zygomatic olume 17, Number 5, 2002 Number olume 17, V 20 Zygomatic bone has not been previously Zygomatic bone has not been This article describes a method for harvesting Alveolar bone augmentation can also be accom- Alveolar bone augmentation can also KAINULAINEN AL ET 724 cancellous bone can be obtained from the mandibu- cancellous bone can harvested from the maxillary lar symphysis. Bone used to fill alveolar defects tuberosity has been placement. before dental implant guided bone regeneration using barrier membranes guided bone regeneration using barrier for alveolar is also a predictable surgical technique been used to ridge augmentation. Autografts have augmentation support a membrane for lateral ridge procedures. sinus grafting, reported as a donor site for reconstruction of alveo- reported as a donor site for reconstruction and tem- lar bone. The zygoma consists of frontal It is sur- poral processes and an orbital surface. sphenoid, rounded by the maxilla and the frontal, arch is partly and temporal bones. The zygomatic In the middle zygomatic and partly temporal bone. mm caudal to section of zygomatic bone, about 5 rim, are the the inferolateral corner of the orbital zygomaticofacial foramen and nerve. The zygomati- cotemporal nerve is superior to the zygomaticofacial nerve and is on the posterior surface of the temporal process of the zygomatic bone. The infraorbital nerve is on the medial side of the zygomatic On the dorsal bone and close to the orbital floor. side of the zygoma is the infratemporal fossa, where the maxillary artery (which divides into the infraorbital artery and superior alveolar arteries), maxillary veins, pterygopalatine nerve ganglion, maxillary nerve, zygomatic nerve, and temporalis muscle are located. bone from the zygoma for alveolar bone reconstruction. A description of the surgical procedure and a preliminary report of 3 patients are presented. plished by using alloplastic materials, which work plished by using alloplastic materials, surround- as a scaffold for bone regeneration from as hydroxy- ing host bone. Bone substitutes, such bone, and apatite, demineralized freeze-dried for alveo- bovine bone, have been used successfully lar bone reconstruction. reconstruction of the orbital floor, reconstruction of the Mandibular symphyseal bone has been used in sec- has been used in symphyseal bone Mandibular grafting, cleft bone ondary alveolar lateral aspect of the mandibular ramus and retromo- of the mandibular lateral aspect cortical bone. is a source of mostly lar area arch area has been used to graft the maxillary step arch area has been gaps. osteotomy and interdental osteotomy tion with Le Fort I osteotomy. tion with Le Fort floor. process of the mandible has been used for paranasal process of the mandible augmentation before the placement of dental implants, placement of dental before the

COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 725 KAINULAINEN AL ET o trephine holes (4.6 mm outer holes o trephine Tw 1c diameter) are drilled lateral to the maxillary the to drilled lateral are diameter) sinus. Fig On the first postoperative day the patient experi- On the first postoperative day the patient atient 2 The International Journal of Oral & Maxillofacial Implants of Oral & Maxillofacial Journal The International in the right lateral incisor area. On the palatal in the right lateral incisor area. On were exposed, aspect, 5 mm of the implant threads buccal cortex. and an implant tip perforated the the technique Bone was harvested according to trephine bur described above using a 4.6-mm Three cortico- (Nobel Biocare, Göteborg, Sweden). with the cancellous bone plugs were harvested and cancellous bone was obtained trephine bur, A small from the zygomatic bone by dental curettes. noted after perforation of the maxillary sinus was with a bone harvesting (Fig 2a). Bone was minced and bone chips mill (Osteodisc, GenSci, Irvine, CA) sides of the were placed on the buccal and palatal to be suffi- implant. The amount of bone was found of bone was cient to treat this site and the quality clinically good (Figs 2b and 2c). weeks postoper- enced mild swelling and pain. Two the intraoral wound had healed and the atively, No sensory majority of the swelling had resolved. disturbances were noted along the distribution of the infraorbital or zygomaticofacial nerves. The patient described mild “tenderness” in the area during the first 2 postoperative weeks, and it was noted that the donor site was not palpable extraorally. P Bone grafting from the right zygomatic bone was man. The 21-year-old performed on a healthy, patient had an implant placed in the maxillary right which central incisor area 5 months previously, appeared to be failing. The implant was removed and the area was thoroughly curetted. The residual alveolar crest was found to be narrow and, at this stage, a bone graft harvested from the mandibular symphysis was used to treat the defect. Five months later the area was exposed under local anesthesia ygomatic bone harvesting with the with ygomatic bone harvesting Z ig 1b F handpiece. bur on a straight trephine The zygomatic bone is exposed The zygomatic bone ough a vestibular incision. A periosteal ough a vestibular r ASE REPORTS retract the soft the tissues. retract atient 1 ig 1a F th elevator is placed under the zygomatic bone is placed under the elevator to A healthy 51-year-old woman with a previously A healthy 51-year-old repaired cleft lip and palate required revision of her maxillary alveolar bone graft. The operation was done under general anesthesia. The implant site was exposed and the alveolar crest was noted to be too narrow buccolingually for implant placement without a bone graft. A SLA solid-screw dental implant Switzerland) was placed (Straumann, Waldenburg, P C dental Three patients who underwent simultaneous of zygo- implant placement and bone harvesting matic bone are presented. All patients had had pre- vious bone grafts and 2 patients had failed dental implants in the grafted areas. Patients gave consent for intraoral bone grafting from the mandibular symphysis or zygomatic bone. The decision to pro- ceed with zygomatic bone harvest was made during the surgical intervention. trap should also be used during curetting to prevent trap should also be used during curetting to curette, a any loss of bone. If the bone is too hard for further round bur and suction trap can be used blocks can be bone harvesting. Cortical bone When har- minced in a bone mill or with rongeurs. is rinsed with vesting has been completed, the area agent may be saline, and a resorbable hemostatic is closed applied to the donor site. The incision sutures, and with running or interrupted resorbable for 1 week. antibiotic treatment is recommended drugs, or Usually nonsteroidal anti-inflammatory are satisfac- acetaminophen combined with codeine, chlorhexidine tory for postoperative pain relief. A postoperatively. mouth rinse should be administered

COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. Mucosal wounds closed. Note the closed. Note Mucosal wounds A solid-screw Straumann implant was Straumann implant A solid-screw Particulated bone bone graft the from ig 2c ig 3a ig 3b F donor and recipient of the close proximity site. F right central incisor. of the site placed at the surface exposed on the The implant was labial and palatal aspects (patient 2). F collector was placed and packed over the over placed and packed was collector (patient 2). defects atient 3 P was performed Grafting from the zygomatic bone woman who 8 months previously for a 19 year-old using an iliac had had alveolar crest reconstruction in the ante- crest graft to repair a traumatic defect been lost in rior maxilla. All maxillary incisors had had an accident. The alveolar crest reconstruction placement been accompanied by the simultaneous of four 13-mm-long dental implants (Nobel Bio- care). Eight months following the initial surgery, during the second-stage procedure, the right lateral incisor implant was found to be loose and was removed. The procedure was performed under local anesthesia and nitrous oxide sedation. The site was curetted and a 12-mm SLA implant (Straumann) was placed in the same location. Primary stability 8 mm of the implant was excellent; however, threads were exposed on the labial surface. This surface was covered with bone harvested from the right zygomatic bone. The zygomatic bone area was exposed, a round bur was used to create a window to the zygoma, and a suction trap was used to collect the bone chips. A dental curette was used to harvest the cancellous bone. No maxillary sinus perforations were noted and the bone quantity was A small Particulated bone graft placed to was 27,28 ig 2b he palatal and labial aspects of the implant. implant. of the he palatal and labial aspects F t ygomatic harvesting procedure in procedure ygomatic harvesting olume 17, Number 5, 2002 Number olume 17, Z V ig 2a KAINULAINEN AL ET 726 patient 1. Bone graft was harvested from the from Bone graftpatient 1. harvested was bur trephine the right zygomatic bone with maxillary the A perforation to and curette. cor- anteromedial at the present sinus was donor site. ner of the F combined with nitrous oxide sedation, and it was combined with nitrous oxide sedation, been resorbed. noted that some of the bone had 14 mm in a narrow solid-screw implant, However, stability length (Straumann), was placed. Primary on both was achieved, but threads were exposed the labial and 5 sides of the implant (6 to 7 mm on graft from the mm on the palatal) (Fig 3a). A bone using a right zygomatic bone was harvested trephine, round burs, and curettage. Bone chips from drilling were collected by a suction trap as described previously by the authors. perforation of the maxillary sinus was noted after bone harvesting. Cortical bone blocks were particulated with the bone mill. Particulated bone and harvest from a suction trap were used to cover the implant surface on both the labial and palatal aspects (Fig 3b). The amount of bone harvested was sufficient for this application. The patient was also able to compare the zygomatic bone harvest to that of the symphysis and found the zygomatic bone operation more comfortable and recovery signifi- cantly less morbid. At the follow-up visits, the zygomatic donor site was not palpable extraorally and No sensory disturbances were was not tender. noted.

COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. 727 29,30 KAINULAINEN AL ET Perforation to the orbit can be avoided with Perforation to the harvesting Contraindications for zygomatic bone CKNOWLEDGMENTS The International Journal of Oral & Maxillofacial Implants of Oral & Maxillofacial Journal The International This study was financially supported by the Finnish Dental Association, the Research Support Foundation of the University of Oulu, and the Ontario Research and Development Challenge Fund. CONCLUSION site for treat- Zygomatic bone is a suitable donor implant sites, ment of bone defects at 1 or 2 dental and as an addi- covering exposed implant surfaces, tional source of bone together with other intraoral donor sites. Surgical access to the zygoma is fairly simple and can be performed using local anesthesia. In the limited experience presented here, postoperative complications after zygomatic bone harvesting appear to be minimal. A implant sites. Because the amount of bone harvested Because the amount implant sites. from than that zygoma is smaller from the suited technique is best donor sites, this mandibular only moderate amounts situations where for those when implant surgery needed, especially of bone are zygo- Furthermore, in the maxilla. is undertaken to harvest than either the matic bone is easier or retromolar sites. The gain mandibular symphysis bone is too small to be used from the zygomatic of the maxillary sinus. alone for augmentation additional source of it can be used as an However, example, the harvest from the bone graft when, for is found to be inadequate. mandibular symphysis but opening to the maxillary sinus careful surgery, of the 3 patients. During maxil- occurred here in 2 the maxillary lary osteotomies, large perforations to without prob- sinus can occur; usually these heal during lems. Perforation of the sinus membrane does not cause sinus floor augmentation generally is used. infection if proper antibiotic coverage related to a include atrophy of the zygomatic area as well as pre- syndrome or congenital abnormality, Osteosynthesis vious surgery or trauma to the area. ability materials can also interfere with a surgeon’s when mini- to harvest zygomatic bone, especially One of the plates have been used previously. Le Fort I described patients had undergone wire was used; osteotomy in which stainless steel did not preclude bone procurement. this however, 25 1.5-cm graft from this area Harvested zygomatic bone in this 21 described a technique to harvest cortical 21 ith the described technique, it is possible to the authors’ knowledge, the use of zygomatic the authors’ knowledge, the use of The first patient described was treated using gen- W

bone block from the zygomatic eminence and arch bone block from the zygomatic eminence found it to be during Le Fort I osteotomies. They easy to harvest a 1 deficits in without untoward esthetic or functional the donor site. eral anesthesia, but the second and third patients underwent the harvest under local anesthesia. Both patients reported the procedure to be painless and easy to tolerate under local anesthesia. Postoperative complications were not severe, but included swelling and mild pain or tenderness. No postoperative pares- thesia was noticed in the maxillary nerve area. harvest approximately 0.5 to 1 mL of bone without causing damage to surrounding tissues. This amount of bone is sufficient to cover exposed implant threads, for example, and it can be used as an onlay graft to fill alveolar defects at 1 or 2 bone as donor tissue for alveolar bone grafting has bone as donor tissue for alveolar bone and Wolford not been previously reported. In 1985, Cooper To DISCUSSION more than adequate for the intended procedure. adequate for the more than and on both labial bone was placed The harvested The patient tolerated of the implant. palatal aspects bone that zygomatic well and found the procedure At without pain. could be accomplished harvesting had the wound follow-up appointment, her 4-week donor site was not palpable. healed well and the that she had had moderate The patient reported of her right maxilla on the swelling in the region which was resolved by the day, first postoperative She also had minor bruising day. third postoperative but her discomfort and pain under her right eye, controllable with oral analgesics were minimal and and 30 mg of codeine). (500 mg of acetaminophen case series included both cancellous and cortical case series included both cancellous which was bone, as well as particulated bone, to the retrieved using a bone collector connected using a suction tubing. Bone plugs obtained a bone mill trephine drill can be particulated using as such into a or rongeurs, or they can be placed can be com- defect. Bone chips from a suction trap bone to bined with particulated corticocancellous material. This create an easily moldable paste-like guided bone kind of material is also suitable for regeneration using barrier membranes.

COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. KAINULAINEN ET AL REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. PRINTING OF THIS DOCUMENT IS RESTRICTED TO 2002 BY QUINTESSENCE PERSONAL USE ONLY. PUBLISHING CO, INC. NO PART OF THIS COPYRIGHT © REFERENCES 16. Bagatin M. Reconstruction of orbital defects with autogenous bone from mandibular symphysis. J Craniomaxillofac 1. Block MS, Kent JN, Kallukaran FU, Thunthy K, Weinberg Surg 1987;15:103–105. R. Bone maintenance 5 to 10 years after sinus grafting. J 17. Waite PD, Tejera TJ, Anucul B. The stability of maxillary Oral Maxillofac Surg 1998;56:706–714. advancement using Le Fort I osteotomy with and without 2. Marx RE, Morales MJ. Morbidity from bone harvest in genial bone grafting. 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