|Year : 2018 | Volume
| Issue : 2 | Page : 59-62
Clinical Complications in Procedures for Horizontal Bone Augmentation Through Autologous Onlay Grafts Obtained From the Mandibular Ramus: An Observational Study
Daniel R.B de Resende1, Aline Siqueira1, Eduardo Rosas2, Eduardo Borie Echevarrķa2
1 Sociedade de Promoção Social do Fissurado lábio-palatal (PROFIS), Bauru, SP, Brazil
2 Research Centre in Dental Sciences (CICO), Dental School, Universidad de La Frontera, Temuco, Chile
|Date of Web Publication||2-Jan-2019|
Dr. Eduardo Borie Echevarrķa
Universidad de La Frontera, Av. Francisco Salazar 01145, Temuco 4811230
Source of Support: None, Conflict of Interest: None
Aim and Objective : The aim of this study was to describe clinically the prevalence of postsurgical complications in a group of patients treated with autologous bone grafts obtained from the mandibular ramus. Materials and Methods: Data were obtained from a sample of 76 adults, who were subjected to a surgical procedure of horizontal bone augmentation through autologous onlay bone grafts obtained from the oblique line of mandible. A total of 113 onlay grafts were removed and placed in 152 recipients’ area, previously fitted to the receptor site and stabilized through two fixation screws. All complications were recorded in relation to the recipient and donor sites, and the follow-up time of the sample was of 2 years. Results: Of the entire sample studied, 69.7% did not show any type of postsurgical complication; however, 30.3% of them exhibited a type of complication, with temporary paresthesia being the most prevalent (7.9%). Conclusion: More than 30% of the patients that received horizontal bone augmentation through autologous onlay bone grafts obtained from the oblique line according to the conventional technique showed some type of postsurgical complication.
Keywords: Autografts, mandible, onlay grafts, postoperative complication
|How to cite this article:|
de Resende DR, Siqueira A, Rosas E, Echevarrķa EB. Clinical Complications in Procedures for Horizontal Bone Augmentation Through Autologous Onlay Grafts Obtained From the Mandibular Ramus: An Observational Study. J Orofac Sci 2018;10:59-62
|How to cite this URL:|
de Resende DR, Siqueira A, Rosas E, Echevarrķa EB. Clinical Complications in Procedures for Horizontal Bone Augmentation Through Autologous Onlay Grafts Obtained From the Mandibular Ramus: An Observational Study. J Orofac Sci [serial online] 2018 [cited 2019 Apr 25];10:59-62. Available from: http://www.jofs.in/text.asp?2018/10/2/59/249084
| Introduction|| |
An atrophic region or a region with an important bone resorption, either in the maxilla or mandible, is usually a clinical problem when it is desired to achieve a correct rehabilitation, wherein in most cases, additional efforts will be necessary to achieve bone augmentation. In the literature, different techniques for achieving bone augmentation are described; specifically, bone augmentation throughout autologous grafts is considered the gold standard for bone reconstruction and presents numerous advantages such as a short healing period when compared with other bone substitutes. The autologous graft can be obtained from different donor sites, being common in the mandibular ramus, iliac crest, tibia, and calvaria., If the most used donor sites are compared, the mandibular ramus is described as an excellent donor site, offering more advantages than, for example, the mandibular symphysis.,,
The use of a mandibular ramus as a donor site is indicated in cases of moderate-to-severe atrophy and in bone defects that include the edentulous space of one to four teeth.
The use of autologous onlay grafts obtained from the mandibular ramus is described as a predictable and reliable surgery, with a high success rate in the long term, which allows to achieve a favorable site for dental implant placement., However, complications associated with the donor site have been described, such as mandibular fracture, hemorrhage, postsurgical pain, inflammation, and damage of the inferior alveolar nerve. In relation to the receptor site, the commonly described complications include dehiscence, infection, graft exposure, and mobility, among others.
The aim of this study was to clinically describe the prevalence of postsurgical complications in a group of patients treated with autologous bone grafts obtained from the mandibular ramus.
| Materials and Methods|| |
Data were obtained between March 2013 and April 2015 from a sample of 76 adults, with 49 females and 27 males, who required bone augmentation through bone grafts before the placement of dental implants. In this sense, all the patients that needed to be subjected to a surgical procedure of horizontal bone augmentation through autologous onlay bone grafts obtained from the oblique line of the mandible were included in the study. All grafts were obtained according to the Misch technique using local anesthesia. Thereafter, the region was sutured with Vycril 4.0 without the application of any other type of biomaterial. The size of the blocks removed from the donor site was according to the three-dimensional need for the bone augmentation of the recipient area. A total of 113 onlay grafts were removed and placed in 152 recipients’ area, previously fitted to the receptor site and stabilized through two fixation screws. Of all the sites, 135 were in the maxilla and 17 were in the mandible, and 122 were in the anterior region and only 30 were at the posterior region. A total thickness flap was performed on each surgery that received the graft to achieve a complete junction of the edges. In addition, all prostheses were polished and adjusted, and the patients were instructed to reduce, as much as possible, the use of their prostheses to avoid damage to the grafted area. All complications reported by the patients were recorded in relation to the recipient and donor sites, and the follow-up of the sample was for 2 years.
| Results|| |
Seventy-six patients were treated with autologous onlay bone grafts. Of the entire sample studied, 69.7% (53 patients) did not show any type of postsurgical complication. However, 30.3% (23 patients) of them exhibited a type of complication, a summary of which is provided in [Figure 1].
|Figure 1 Graph showing the complications observed in the sampled treated with autologous onlay bone grafts obtained from the oblique line of the mandible|
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Regarding the donor site, it was noted that 7.9% (six patients) of the sample reported paresthesia, which was regarded as being temporary, with a recovery time of 30 days. In addition, 5.3% (four patients) of the sample showed mandibular ramus exposure, and 1.3% (one patient) exhibited bone hemorrhage.
In relation to the recipient site, graft exposure was seen in 6.6% of the patients (five patients), 3.9% (three patients) exhibited graft mobility [[Figure 2]], 3.9% (three patients) showed a fracture of a fixation screw, and 1.3% (one patient) had flap hemorrhage.
|Figure 2 Complications observed in this study. (A) Graft mobility after the healing period. (B) Graft exposure at the first month|
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| Discussion|| |
The aim of this study was to describe the prevalence of postsurgical complications in a group of patients treated with autologous onlay bone grafts obtained from the mandibular ramus.
One of the advantages of the use of intraoral donor sites is the proximity of the donor to the receptor site, with less time for surgery and the use of local anesthesia. In this study, the mandibular ramus was used as a donor site because it is better accepted by the patients when compared with the mandibular symphysis. This was so because the use of this site resulted in lesser number of postsurgical complications, less esthetic risk and facial alterations, and less discomfort and postsurgical sensory disturbances, among others.,, However, the surgical approach is more difficult, and an accurate knowledge of the mandibular canal anatomy is needed.
In this study, 30.3% of the patients showed some complication after surgery, which was similar to the prevalence of complications reported by Uckan et al., who treated 18 patients with autologous onlay grafts of the mandibular ramus and reported 38.8% complications. The main difference among them was that one author reported the most prevalent complication to be graft exposure in 16.6% of the patients and the other author reported it as a partial loss of graft due to infection in 16.6% of the patients. In relation to the paresthesia symptom, only one patient was observed, corresponding to 5.5% of the patients.
Restoy-Lozano et al. described the morbidity of donor site, identifying a temporal neurosensory dysfunction in 32% of the patients. However, edema was observed in 6.9% and infection in only 2% of the patients. In a study of 24 patients, Clavero and Lundgren reported neurosensory alterations in 20.8% of the patients. The neural complications were related with the process of obtaining graft site because the mandibular ramus region was directly related with the inferior alveolar nerve. However, other authors, such as Cordaro et al., demonstrated minimal local complications in the donor site and no dehiscence or infection of the donor site.
Greenberg et al. in a retrospective study analyzed 14 patients with onlay grafts obtained from the mandibular ramus (57%) and mandibular symphysis (43%). Seven percent of the patients showed graft exposure and another 7% exhibited hematoma, without any case of paresthesia. All patients with partial graft exposure observed in this study were treated with rinses of chlorhexidine 0.12% twice daily, as recommended in the literature., It is important to mention that when the graft is fully exposed, there is a greater risk of graft loss, requiring its total removal.
Sakkas et al. performed 104 autologous bone grafts obtained from the mandibular ramus of 86 patients, identifying temporary paresthesia as the most prevalent postoperative complication in 10.8% of the patients, which was similar with that observed in our study, although the percentage of the graft loss was 6.7%.
Another complication that was identified was the onlay graft with mobility, which led to fibrosis of the interface with the underlying bone and, consequently, led to fixation failure into the receptor area. This was observed despite stabilizing the graft with two screws, which was reported to be sufficient enough to stabilize a graft.Some authors have reported other complications such as permanent damage to the inferior alveolar nerve, trismus, or mandibular fracture. Fortunately, in this study, no such complications were observed.
It is important to consider that, for this study, only autologous onlay bone grafts obtained from the mandibular ramus were used. In most of the researches, complications associated with different donor sites are reported, which is a determinant when comparing the complications. However, the sample size of this research was quite higher than the previously mentioned studies.
Finally, it is possible to identify that a considerable percentage of the patients treated with autologous onlay grafts exhibited a postsurgical complication. However, these complications were not related in horizontal bone augmentation when commercial particulate bone grafts (autografts or allografts) and resorbable membranes were used,, which achieved similar results of bone augmentation in atrophic regions before dental implant placement.
| Conclusion|| |
More than 30% of the patients who received horizontal bone augmentation through autologous onlay bone grafts obtained from the oblique line according to the conventional technique showed some type of postsurgical complication. In this sense, this technique is not recommended for horizontal bone augmentation because of the high prevalence of complications and risks associated with the donor site when compared with more simple procedures such as the use of a resorbable membrane and particulate bone grafts, which achieved similar results.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Chiapasco M, Di Martino G, Anello T, Zaniboni M, Romeo E. Fresh frozen versus autogenous iliac bone for the rehabilitation of the extremely atrophic maxilla with onlay grafts and endosseous implants: Preliminary results of a prospective comparative study. Clin Implant Dent Relat Res 2015;17:251-66.
Misch C. Use of the mandibular ramus as a donor site for onlay bone grafting. J Oral Implantol 2000;26:42-9.
Sjöström M, Sennerby L, Lundgren S. Bone graft healing in reconstruction of maxillary atrophy. Clin Implant Dent Relat Res 2013;15:367-79.
Spin-Neto R, Stavropoulos A, Coletti FL, Faeda RS, Pereira LA, Marcantonio E Jr. Graft incorporation and implant osseointegration following the use of autologous and fresh-frozen allogeneic block bone grafts for lateral ridge augmentation. Clin Oral Implants Res 2014;25:226-33.
Sakkas A, Ioannis K, Winter K, Schramm A, Wilde F. Clinical results of autologous bone augmentation harvested from the mandibular ramus prior to implant placement. An analysis of 104 cases. GMS Interdiscip Plast Reconstr Surg DGPW 2016;5:Doc 21.
Aloy-Prósper A, Peñarrocha-Oltra D, Peñarrocha-Diago MA, Peñarrocha-Diago M. The outcome of intraoral onlay block bone grafts on alveolar ridge augmentations: A systematic review. Med Oral Patol Oral Cir Bucal 2015;20:251-8.
Restoy-Lozano A, Dominguez-Mompell J, Infante-Cossio P, Lara-Chao J, Espin-Galvez F, Lopez Pizarro V. Reconstruction of mandibular vertical defects for dental implants with autogenous bone block grafts using a tunnel approach: Clinical study of 50 cases. Int J Oral Maxillofac Surg 2015;44:1416-22.
Greenberg J, Wiltz M, Kraut R. Augmentation of the anterior maxilla with intraoral onlay grafts for implant placement. Implant Dent 2012;21:21-4.
Misch C. Maxillary autogenous bone grafting. Dent Clin N Am 2011;55:697-713.
Uckan S, Veziroglu F, Dayangac E. Alveolar distraction osteogenesis versus autogenous onlay bone grafting for alveolar ridge augmentation: Technique, complications, and implant survival rates. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;106:511-5.
Clavero J, Lundgren S. Ramus or chin grafts for maxillary sinus inlay and local onlay augmentation: Comparison of donor site morbidity and complications. Clin Implant Dent Relat Res 2003;3:154-60.
Maestre-Ferrín L, Boronat-López A, Peñarrocha-Diago M, Peñarrocha-Diago M. Augmentation procedures for deficient edentulous ridges, using onlay autologous grafts: An update. Med Oral Patol Oral Cir Bucal 2009;14:402-7.
Cordaro L, Sarzi Amadé D, Cordaro M. Clinical results of alveolar ridge augmentation with mandibular block bone grafts in partially edentulous patients prior to implant placement. Clin Oral Implants Res 2002;13:103-11.
Urban IA, Nagursky H, Lozada JL, Nagy K. Horizontal ridge augmentation with a collagen membrane and a combination of particulated autogenous bone and anorganic bovine bone-derived mineral: A prospective case series in 25 patients. Int J Periodontics Restorative Dent 2013;33:299-307.
Lorenzetti M, Vono M, Lorenzetti V. A retrospective tomographic and histologic analysis of horizontal bone augmentation in maxillary atrophic ridges using resorbable membrane with anorganic bovine bone-derived mineral and plasma rich in growth factors. Int J Periodontics Restorative Dent. 2018. doi:10.11607/prd.3082.
[Figure 1], [Figure 2]