**5. Complications of autogenous bone grafting**

The use of autogenous bone graft with dental implants was originally discussed by Branemark.

### **5.1. Maxillary tuberosity bone graft**

The major complication with maxillary tuberosity graft harvesting is oroantral communica‐ tion. Grafts may be harvested with a chisel or rongeurs. The chisel edge should be kept slightly superficial to the maxilla to shave off pieces of tuberosity bone and prevent inadvertent sinus communication.

### **5.2. Mandibular symphysis bone graft**

A CT scan or panoramic radiograph is used to evaluate the available bone at this donor site. Lateral cephalometric radiograph can be useful to determine the anteroposterior dimension of the anterior mandible. A vestibular incision is made in the mucosa between the cuspid teeth. Limiting the distal extent of the incision will reduce the risk of mental nerve injury. The mandibular symphysis is associated with a higher incidence of postoperative complications. Incidence of temporary mental nerve paresthesia for symphysis graft patients is usually low. Ptosis of the chin has not occurred and can be prevented by avoiding complete degloving of the mandible.

#### **5.3. Mandibular ramus**

The limits of the ramus area are dictated by clinical access. After graft preparation, the donor site is not augmented with bone substitutes because the inferior alveolar nerve may be exposed and irritated by the graft particles. The potential for damage to the IAN, as opposed to its peripheral mental branches is of greater concern with the ramus graft technique. Patients may experience trismus following surgery and should be placed on postoperative glucocorticoids and NSAIDs medications to help reduce dysfunction.

#### **5.4. Tibia**

There has been a low reported incidence of significant complications with this procedure. Complications may include hematoma formation, wound dehiscence, infection and fracture. The patient should avoid strenuous exercise for 4 to 6 weeks. Although quite rare most cases of tibia fracture are due to a bony access too low on the leg.

#### **5.5. Ilium**

The grafting of larger areas of bone deficiency often requires bone harvesting from the ilium. The crestal incision is made about 2cm below the anterior superior iliac spine and extending caudally 4 to 5 cm. Care is taken not to cut through the external oblique or gluteal muscles during this incision because this increases postoperative discomfort and slows ambulation. All bleeding from the marrow is controlled with small amounts of bone wax or collagen hemostatic. The patient is advised to avoid any lifting or twisting for the next 6 weeks to preclude hip fracture. The use of a pain pump with long acting local anesthetics has dramat‐ ically reduced the level of postoperative pain from the hip area.

#### **5.6. Rib graft**

The preferred donor ribs are the fourth and fifth ribs. The fifth rib is superior to the fourth in growing female patients. A major complication in rib harvesting is pleural perforation. In this case a chest tube catheter is inserted in to the area of pleural compromise to a length of approximately 1 to 2 cm; with the red rubber catheter in position, a purse string suture is placed to fix the tube which should be attached to a chest tube bottle. For small perforations the anesthesiologist provides positive pressure and maintains this position while a surgical knot is tightened. All patients having costochondral or rib harvests require a postoperative chest radiograph performed and clinical inspection for pneumothorax. If a pneumothorax is noted a chest tube may be placed.

#### **5.7. Cranial bone**

**5.2. Mandibular symphysis bone graft**

576 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

and NSAIDs medications to help reduce dysfunction.

of tibia fracture are due to a bony access too low on the leg.

ically reduced the level of postoperative pain from the hip area.

the mandible.

**5.4. Tibia**

**5.5. Ilium**

**5.6. Rib graft**

**5.3. Mandibular ramus**

A CT scan or panoramic radiograph is used to evaluate the available bone at this donor site. Lateral cephalometric radiograph can be useful to determine the anteroposterior dimension of the anterior mandible. A vestibular incision is made in the mucosa between the cuspid teeth. Limiting the distal extent of the incision will reduce the risk of mental nerve injury. The mandibular symphysis is associated with a higher incidence of postoperative complications. Incidence of temporary mental nerve paresthesia for symphysis graft patients is usually low. Ptosis of the chin has not occurred and can be prevented by avoiding complete degloving of

The limits of the ramus area are dictated by clinical access. After graft preparation, the donor site is not augmented with bone substitutes because the inferior alveolar nerve may be exposed and irritated by the graft particles. The potential for damage to the IAN, as opposed to its peripheral mental branches is of greater concern with the ramus graft technique. Patients may experience trismus following surgery and should be placed on postoperative glucocorticoids

There has been a low reported incidence of significant complications with this procedure. Complications may include hematoma formation, wound dehiscence, infection and fracture. The patient should avoid strenuous exercise for 4 to 6 weeks. Although quite rare most cases

The grafting of larger areas of bone deficiency often requires bone harvesting from the ilium. The crestal incision is made about 2cm below the anterior superior iliac spine and extending caudally 4 to 5 cm. Care is taken not to cut through the external oblique or gluteal muscles during this incision because this increases postoperative discomfort and slows ambulation. All bleeding from the marrow is controlled with small amounts of bone wax or collagen hemostatic. The patient is advised to avoid any lifting or twisting for the next 6 weeks to preclude hip fracture. The use of a pain pump with long acting local anesthetics has dramat‐

The preferred donor ribs are the fourth and fifth ribs. The fifth rib is superior to the fourth in growing female patients. A major complication in rib harvesting is pleural perforation. In this case a chest tube catheter is inserted in to the area of pleural compromise to a length of approximately 1 to 2 cm; with the red rubber catheter in position, a purse string suture is placed to fix the tube which should be attached to a chest tube bottle. For small perforations the anesthesiologist provides positive pressure and maintains this position while a surgical knot

Cranial bone just superior and posterior to the temporal crest is generally quite thick and accidental full thickness harvest and or dural perforation is minimized. An incision is made beginning 1cm inferior to superior temporal line to avoid main arterial trunks of the superficial temporal and posterior auricular arteries thus reducing bleeding; the parietal bone, which is flat and also quite thick as compared with other areas of the cranium.

#### **5.8. Grafting recipient sites**

The bone graft should have intimate contact with underlying host bone. Following harvest, the bone graft may be stored in sterile saline. The graft is mortised into position and fixated to the ridge with screws. Complete flap coverage and tension free closure is essential to the successful incorporation of the bone graft. After the periosteal releasing incision is made, the flap is gently stretched to assess closure without tension. Although it is important that the flap margins are well approximated, the sutures should not be pulled too tightly or ischemia will occur. It is imperative that the graft is immobilized during healing postoperatively. The patient should continue antibiotic therapy for at least 1 week. Smoking has been associated with a high rate of wound dehiscence and graft failure. Cholorhexidine rinsing is used for oral hygiene until the sutures are removed.
