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An Additional Donor Site for Alveolar Bone Reconstruction. Technical Note

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An Additional Donor Site for Alveolar Bone Reconstruction. Technical Note REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. WRITTEN PERMISSION FROM WITHOUT TRANSMITTED IN ANY FORM OR REPRODUCED COPYRIGHT ©THIS OF NO PART INC. PUBLISHING CO, 2002 BY QUINTESSENCE PERSONAL USE ONLY. TO THIS DOCUMENT IS RESTRICTED PRINTING OF Zygomatic Bone: An Additional Donor Site for Alveolar Bone Reconstruction. Technical Note Vesa T. Kainulainen, DDS1/George K. B. Sàndor, DDS, MD2/Kyösti S. Oikarinen, DDS, PhD3/ Cameron M. L. Clokie, DDS, PhD4 This article describes a procedure to harvest bone from the zygoma for alveolar bone reconstruction. A detailed description of the bone harvesting procedure and a preliminary report of 3 patients undergo- ing alveolar bone reconstruction and simultaneous dental implant placement in the maxillary anterior area is presented. The technique is indicated when a modest amount of bone is needed, for example, to cover exposed implant threads and expand a narrow alveolar ridge. It also could be used as an addi- tional source of bone with other intraoral donor sites. Surgical access to the zygoma is simple and can be performed using local anesthesia. Postoperative complications after zygomatic bone harvest are minimal. (INT J ORAL MAXILLOFAC IMPLANTS 2002;17:723–728) Key words: alveolar ridge augmentation, autogenous bone graft, bone harvesting, endosseous dental implants, intraoral donor sites, zygomatic bone one grafts in the maxillomandibular region are bone has osteoinductive and osteoconductive prop- Bneeded mostly to facilitate the placement of erties and it is immunologically safe.1 dental implants in adequate bone. Several materials The most commonly used donor sites for bone have been introduced and tested as bone graft sub- reconstruction in the maxillofacial area are the stitutes that can function as replacements for auto- ilium, rib, calvarium, tibia, mandible, and maxilla. genous bone, which remains the “gold standard” for Extraoral harvesting usually requires general anes- maxillomandibular reconstruction. Autogenous thesia and hospitalization. Postoperative morbidity and ambulatory disturbances from iliac crest donor sites are well-known complications.2 Intraoral bone harvesting can usually be accom- plished under local anesthesia in a routine dental 1Clinical and Research Fellow, Department of Oral and Maxillofa- cial Surgery, University of Toronto; The Hospital for Sick Children, office setting or on a hospital outpatient basis. The The Bloorview MacMillan Children’s Centre and University advantages of intraoral donor sites are their conve- Health Network, Toronto, Canada; Research Associate, Depart- nient surgical access and close proximity of donor ment of Oral and Maxillofacial Surgery, Institute of Dentistry, Uni- and recipient sites, which reduce operative time. It versity of Oulu and Oulu University Hospital, Oulu, Finland. has also been shown that a 4-month healing period 2Associate Professor and Director of Graduate Residency Pro- 3,4 gram in Oral and Maxillofacial Surgery, University of Toronto; The is sufficient for mandibular bone grafts, whereas a Hospital for Sick Children, The Bloorview MacMillan Children’s 6- to 9-month healing period is needed for bone Centre, Toronto, Canada. grafts of endochondral origin.5 The morbidity of 3Professor, Oral and Maxillofacial Surgery, Faculty of Dentistry, intraoral donor sites is usually relatively low, and Kuwait University, Kuwait; Professor of Oral and Maxillofacial the use of a transoral approach does not result in a Surgery (on leave), University of Oulu, Oulu, Finland. 6–8 4Chairman and Associate Professor, Oral and Maxillofacial visible scar. The disadvantage of intraoral donor ARTICLE MAY BE MAY ARTICLE Surgery, University of Toronto and University Health Network, sites is a limitation in the amount of available Toronto, Canada. bone.7,9,10 Possible complications with intraoral donor sites include altered sensation of teeth, neu- Reprint requests: Dr Vesa Kainulainen, Institute of Dentistry, 11 Department of Oral and Maxillofacial Surgery, PO Box 5281, Uni- rosensory disturbances, and infections. versity of Oulu, 90014 Oulun Ylioposito, Finland. Fax: +358-8- A variety of intraoral donor sites have been 537-5560. E-mail: [email protected] introduced in oral and maxillofacial surgery. The The International Journal of Oral & Maxillofacial Implants 723 KAINULAINEN ET AL REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. WRITTEN PERMISSION FROM WITHOUT TRANSMITTED IN ANY FORM OR REPRODUCED COPYRIGHT ©THIS OF NO PART INC. PUBLISHING CO, 2002 BY QUINTESSENCE PERSONAL USE ONLY. TO THIS DOCUMENT IS RESTRICTED PRINTING OF lateral aspect of the mandibular ramus and retromo- SURGICAL PROCEDURE FOR HARVESTING lar area is a source of mostly cortical bone.11,12 ZYGOMATIC BONE Mandibular symphyseal bone has been used in sec- ondary alveolar cleft bone grafting,6,7 maxillary Palpation of the zygomatic bone is performed pre- sinus grafting,13 alveolar defect reconstruction operatively. A prominent zygoma is easier to harvest before the placement of dental implants,3,11,14,15 and will give a greater quantity of bone than a flat reconstruction of the orbital floor,16 and in conjunc- one. Anteroposterior, axial, and Townes projection tion with Le Fort I osteotomy.17 Both cortical and radiographs of the skull could be used to evaluate cancellous bone can be obtained from the mandibu- the form of the zygomatic bone. An axial or coronal lar symphysis. Bone harvested from the maxillary computed tomographic scan of the head is helpful tuberosity has been used to fill alveolar defects to estimate the volume of zygomatic bone and pro- before dental implant placement.18 The coronoid vides a good view of the anatomy. Three-dimen- process of the mandible has been used for paranasal sional imaging can also be used to visualize the augmentation19 and reconstruction of the orbital shape of the zygomatic bone.26 floor.20 Bone from the zygomatic eminence and Preparation of the recipient site should be done arch area has been used to graft the maxillary step before harvesting of the bone graft. This allows for osteotomy and interdental osteotomy gaps.21 the determination of the amount of bone graft Alveolar bone augmentation can also be accom- needed and the final selection of the appropriate plished by using alloplastic materials, which work donor site. Following application of local anesthesia as a scaffold for bone regeneration from surround- to the infraorbital nerve, posterior and middle supe- ing host bone. Bone substitutes, such as hydroxy- rior alveolar nerves, and zygomaticofacial nerve apatite, demineralized freeze-dried bone, and area, the zygomatic bone is exposed through a bovine bone, have been used successfully for alveo- vestibular incision. The incision is made through lar bone reconstruction.22–24 The principle of the alveolar mucosa about 5 mm above the guided bone regeneration using barrier membranes mucogingival junction, starting between the first is also a predictable surgical technique for alveolar and second molars, and proceeds anteriorly to the ridge augmentation. Autografts have been used to first premolar area. Periosteal elevators are used to support a membrane for lateral ridge augmentation elevate a mucoperiosteal flap. The dissection procedures.25 extends to the inferior aspect of the infraorbital Zygomatic bone has not been previously nerve and around the inferior half of the body of reported as a donor site for reconstruction of alveo- the zygoma (Fig 1a). The lateral border of the max- lar bone. The zygoma consists of frontal and tem- illary sinus is visualized and the inferior border of poral processes and an orbital surface. It is sur- the orbital rim is palpated. rounded by the maxilla and the frontal, sphenoid, Bone harvesting is started just above the inferior and temporal bones. The zygomatic arch is partly border of the zygomatic rim and lateral from the zygomatic and partly temporal bone. In the middle maxillary sinus. A trephine bur, round bur, or thin section of zygomatic bone, about 5 mm caudal to fissure bur on a straight handpiece can be used to the inferolateral corner of the orbital rim, are the harvest bone from the anterior aspect of the zygo- zygomaticofacial foramen and nerve. The zygomati- matic bone (Fig 1b). All drilling of the bone must cotemporal nerve is superior to the zygomatico- be done under copious saline irrigation, and a suc- facial nerve and is on the posterior surface of the tion trap should be used to collect bone chips. The temporal process of the zygomatic bone. The infra- drill is kept at an angle of approximately 45 degrees orbital nerve is on the medial side of the zygomatic to the occlusal plane and should not be drilled bone and close to the orbital floor. On the dorsal deeper than 12 to 14 mm. The drill should be kept side of the zygoma is the infratemporal fossa, where parallel to the lateral sinus wall and lateral surface the maxillary artery (which divides into the infraor- of the zygomatic bone. The anterolateral corner of bital artery and superior alveolar arteries), maxillary the zygomatic bone should be left intact. Care veins, pterygopalatine nerve ganglion, maxillary should be taken to avoid entering the orbital floor nerve, zygomatic nerve, and temporalis muscle are or infratemporal fossa with the drill. A 4.6-mm ARTICLE MAY BE MAY ARTICLE located. trephine drill or 2.3- to 3-mm round burs have been This article describes a method for harvesting used to create a window in the anterior zygoma. bone from the zygoma for alveolar bone reconstruc- Between 2 and 5 corticocancellous bone plugs can tion. A description of the surgical procedure and a be harvested with a trephine bur (Fig 1c). preliminary report of 3 patients are presented. Once the cortical bone has been removed, can- cellous bone, if present, can be curetted. A suction 724 Volume 17, Number 5, 2002 KAINULAINEN ET AL REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. WRITTEN PERMISSION FROM WITHOUT TRANSMITTED IN ANY FORM OR REPRODUCED COPYRIGHT ©THIS OF NO PART INC.
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