Mandibular Bone Block Harvesting from the

Retromolar Region: A 10-Year Prospective Clinical Study

Fouad Khoury, PhD, DMD1/Thomas Hanser, DMD2

Purpose: The aim of this prospective study was to evaluate the outcome of bone block harvesting from the
external oblique ridge with the MicroSaw, assess the volume of the harvested block, and identify possible
morbidity and complications related to the procedure. Materials and Methods: Bone blocks were harvested
from the external oblique line of the mandible according to the MicroSaw protocol. The bone blocks were split
into two thinner blocks with a diamond disk according to the split bone block (SBB) technique for biologic
grafting procedures. Results: In all, 3,874 bone blocks were harvested from the external oblique line of
the mandible in 3,328 patients. Four hundred nineteen patients (12.59%) underwent bilateral bone block
harvesting, and 127 patients (3.82%) had more than one block harvested from the same area during the study
period. In 431 cases (11.12%), only one block was required, so the second was repositioned to reconstruct
its donor site. The average harvesting time was 6.5 ± 2.5 minutes, and a mean volume of 1.9 ± 0.9 cm3
was obtained (maximum 4.4 cm3). In 168 (4.33%) cases, the alveolar nerve was exposed, leading to sensory
problems lasting up to 6 months. In 20 cases (0.5%), minor nerve injury resulted in hypesthesia or paresthesia
that lasted for up to 1 year in most patients. No major nerve lesions with permanent anesthesia were observed.
Sixty-one (1.58%) donor sites showed primary healing complications, most in smokers (80.4%). Reentry of 16
reimplanted harvested areas was performed between 6 and 40 months later, showing a well-regenerated
and healed external oblique ridge. Conclusion: This study demonstrated that relatively large volumes of bone
block graft can be retrieved in the mandible with a low complication rate. Reimplantation of half of the bone
block offers the possibility for complete regeneration of the donor site. Int J Oral Maxillofac Implants 2015;30:
688–697. doi: 10.11607/jomi.4117

Key words: autogenous bone block, diamond disk, external oblique line, mandibular bone graft, mandibular
bone harvesting, MicroSaw, split bone block

T he reconstruction of alveolar defects after tooth

loss is one of the biggest challenges in implant
dentistry. To augment existing bone defects, grafts of
originating from the native bone. However, autog-
enous bone grafts are osteoinductive, osteogenic, and
osteoconductive, with significant regenerative capac-
various origins have been used, eg, alloplastic grafts, ity in comparison to all other grafts. This is why au-
xenografts, allografts, and autografts. The mode of togenous bone, especially for larger lateral or vertical
graft integration with respect to regeneration de- defects, remains the gold standard for augmentation.1
pends primarily on its origin and composition. Xeno- Extraoral donor sites for autogenous bone include
grafts and allografts, as well as alloplastic material of the skull, the fibula, the ribs, and the iliac crest, all of
natural or synthetic origin, with their osteoconductive which inevitably lead to additional patient morbid-
properties, serve as scaffolds for new bone growth ity.2,3 Intraoral sources have the advantages of prox-
imity of the donor and recipient sites, convenient
surgical access, low morbidity, and elimination of a
1Professor, Department of Oral and Maxillofacial Surgery, hospital stay.1,3–5 The maxilla offers only small amounts
University of Münster, Germany; Chairman, Private Clinic of mainly cancellous autografts. However, corticocan-
Schloss Schellenstein, International Dental Implant Center, cellous bone block grafts, suitable for two- or three-
Olsberg, Germany.
2Senior Surgeon, Private Clinic Schloss Schellenstein,
dimensional reconstructions of alveolar ridge defects,
International Dental Implant Center, Olsberg, Germany. can be harvested only from the mandibular symphysis
(chin area), the retromolar and paramolar areas (exter-
Correspondence to: Prof Dr Fouad Khoury, Am Schellenstein nal oblique ridge), or edentulous areas.1,6–9
1, 59939 Olsberg, Germany. Fax: +49-2962-9719-22. The removal of large bone block grafts with drills or
Email: prof.khoury@t-online.de
engraving or oscillating saws may be particularly dan-
©2015 by Quintessence Publishing Co Inc. gerous in the anterior mandibular ramus. The MicroSaw

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 Khoury et al

Fig 1  Visualization of the external

oblique line on a panoramic radiograph.

(Dentsply Implants), a diamond-tipped disk described and extent of the external oblique ridge (linea obliqua
in 1984 for the preparation of a bone lid as part of the externa). This clinical examination provided informa-
root resection of mandibular molars, is well suited for tion on the shape of the available bone at the donor
safe and quick removal of bone blocks from different site. Panoramic radiographs were used to gather ad-
areas of the mandible.1 Bone block grafts harvested ditional information on the donor site and its relation-
with the MicroSaw can be used as onlay, inlay, or lat- ship to important neighboring anatomical structures
eral bone block grafts, as well as filler in sinus floor el- (Fig 1). In the years 2009 and 2010, cone beam com-
evation and guided bone regeneration procedures.1,6 puted tomographic (CBCT) scans (Galileos, Siemens)
This prospective clinical study details the 10-year were also performed to obtain a three-dimensional
clinical experience in a private clinic with harvesting view of the anatomical structures and to allow better
of mandibular bone blocks from the external oblique evaluations of bone thickness and exact mandibular
ridge in the retromolar area. Diagnostic methods, in- nerve position (Figs 2 and 3).
struments, and harvesting technique are presented,
and indications, advantages, and complications are dis- Surgical Procedure
cussed. The aim of this prospective study was to evalu- Preoperative antibiotic administration was performed,
ate the outcome of bone block harvesting from the either intravenously (penicillin G, 1 million IU)11 im-
external oblique ridge with the MicroSaw. This study mediately before local anesthetic was injected (before
was performed following the STROBE (Strengthening vasoconstriction occurred) or by mouth (penicillin V,
the Reporting of Observational Studies in Epidemiol- 1 million IU) at least 1 hour prior to surgery. Antibiot-
ogy, http://www.strobe-statement.org) guidelines.10 ics were to be continued for 7 days postoperatively
(1 million IU three times per day). In case of a penicil-
lin allergy, clindamycin 300/600 mg1 was administered
MATERIALS AND METHODS (1.2 g/day). Amoxicillin12 (2 g per day) was prescribed
in patients who were also undergoing a sinus floor
Between 2000 and 2010, patients who underwent elevation.
bone block harvesting from the retromolar area in the Harvesting of intraoral bone for block grafting was
mandible for the reconstruction of large bony defects generally performed under local anesthesia in con-
or severe bone atrophy of the maxilla or/and the man- junction with intravenous sedation. General anesthe-
dible prior or simultaneous with implant placement sia was indicated for large reconstructions involving
were included in this study. Patients with general con- multiple donor sites and for surgery exceeding 3 hours.
traindications to implant surgery, poor oral hygiene An inferior alveolar nerve block was avoided in almost
(full mouth plaque and bleeding score ≥ 20%), active all patients; instead, only local vestibular and lingual in-
periodontal lesions, and lack of motivation were ex- filtration with 4% articaine and 1:100,000 epinephrine
cluded from the study. (Ultracain DS forte, Sanofi Aventis) was performed. This
was important so that minimal sensation was retained
Preoperative Clinical and Radiographic to warn the surgeon when approaching the mandibular
Examinations nerve. The only exception to this rule was a situation in
Visual examination and digital palpation allowed for a which bone block harvesting was combined with the
preliminary estimation of the morphologic contours removal of an impacted third molar; in this situation, an
and dimensions of the donor site, such as the thickness inferior alveolar nerve block was performed.

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Khoury et al

Fig 2   CBCT scan of the retromolar area showing the shape of Fig 3   CBCT view at the junction of the vertical/horizontal part
the external oblique line and the thick cortical bone plate. The of the mandible (ramus mesial border). In this area, the nerve is
distance between the bone surface and the mandibular nerve in more superficial because the bone is thinner.
this area is usually more than 3 mm.

Fig 4 (left)  Exposure of the

retromolar area with the exter-
nal oblique line.

Fig 5 (right)  MicroSaw Kit

(Dentsply Implants).

A trapeze-like incision (starting distal to the second following a clear protocol. The MicroSaw consists of an
molar with a 2-cm vestibular incision over the ramus 8-mm-diameter, 0.25-mm-wide diamond disk mount-
bone, continuing parallel and lateral to the second mo- ed on a contra-angle or MicroSaw handpiece with a
lar, and then going back in the vestibular direction on soft tissue protector (Fig 5). In the harvesting protocol,
the distal border of the first molar) was followed by the three osteotomies are performed with the diamond
elevation of a mucoperiosteal flap (similar to that used disk: two proximovertical osteotomies are made with
for the removal of impacted third molars). This exposed the MicroSaw handpiece, and one is made apicohori-
the bone at the level of the external oblique ridge to a zontally with the contra-angle handpiece (Figs 6 to
length of 3 to 4 cm and a depth of 2 cm (Fig 4). 8). The apicohorizontal osteotomy was made slightly
The volume of bone to be harvested depended on overlapping both vertical osteotomies basally. Once
the size and extent of the external oblique ridge and the osteotomy lines were positioned apical to the al-
the quantity of bone needed for grafting. The har- veolar nerve level, the MicroSaw’s maximum cutting
vesting osteotomy was performed with the MicroSaw capacity of 3.2 mm was avoided in the distal section

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 Khoury et al

Fig 6 (left)  A distal vertical

osteotomy is made with the
MicroSaw handpiece on the
mesial border of the ramus.

Fig 7 (center)  A mesial ver-

tical incision is performed on
the mesial border of the exter-
nal oblique line.

Fig 8 (right)  Apical connec-

tion of both vertical incisions
is carried out using the Micro-
Saw contra-angle handpiece.
The disk protector reduces
the risk of damage to the soft
tissues.

Fig 9 (left)  Crestal connection of both vertical incisions is per-

formed with a drill bur.

Fig 10 (right)  Connection of the perforations with a fine 4-mm

chisel and dislocation of the block.

Fig 11 (left)  The block is split

longitudinally.

Fig 12 (right)  The resulting two

thin blocks.

of the donor site, starting directly behind the second creating a kind of “explosive effect” in the area of the
molar. In this area, the maximal depth of the incision crestal perforations, leading to easy lateral dislocation
with the diamond disk was 2 mm (the diamond layer of the bone block (Fig 10). The donor site was typically
is 1 mm wide). The final osteotomy, on the occlusal sealed with collagen fleece.
crestal site parallel to the external oblique ridge, was The harvested bone blocks were split into two thin
achieved with a thin 1-mm drill bur. Small perforations bone blocks with the diamond disk according to the
of 3 to 4 mm in depth, parallel to the buccal bone wall, split bone block (SBB) technique of the biologic con-
were made with the drill bur at the level of the crestal cept of grafting procedures (Figs 11 and 12). This graft-
platform of the external oblique ridge approximately ing technique, which uses pure autogenous bone in
4 to 5 mm from the external border of the external the form of a thin bone block in combination with au-
oblique line and between the two vertical incisions togenous bone chips without any biomaterial or mem-
(Fig 9). These perforations were connected with a fine branes, has shown clinical volume stability as well as a
chisel, producing tension in the cortical bone and success rate above 95%.1

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Khoury et al

Fig 13 (below)  Vertical three-dimensional reconstruction is

performed with one-half of the split block, in combination with
autogenous particulate bone. No other augmentation material
or membranes were used.

Fig 14 (above)  The second half of the

bone block is replanted at its origin and
secured with a MicroScrew to reconstruct
the external oblique line.

Fig 15 (left)    Postoperative radiograph

showing the reconstructed area in the
maxilla and the replanted bone, secured
with a screw to reconstruct the donor
site.

If only one block was required, the second block • Osteotomy time. This was measured from the
was replaced to reconstruct its donor site (Figs 13 to moment the osteotomy incision began with the
15). When needed, they were additionally stabilized MicroSaw until the bone block was completely
with a small screw (Microscrew, Stoma Instruments). removed.
The remaining half-blocks were placed back over the • Volume of block graft. This was measured by
collagen fleece, without any screw stabilization, within Archimedes’ law while maintaining aseptic
the contour of the external oblique line. conditions. The harvested graft was placed inside
Finally, the donor wound was closed with 5-0 a graduated tube filled with a 0.9% saline solution
monofilament sutures, and grafting procedures were physiologic serum. Graft volume was determined
performed. by subtracting the volume of saline solution serum
remaining after the graft was removed from the
Postoperative Management total volume (graft plus saline solution physiologic
In addition to antibiotics, analgesics (ibuprofen 400) serum).1,12,13
and chlorhexidine 0.02% mouth rinse were prescribed • Intraoperative complications. These included
for patients after surgery. Patients were advised to con- fracture of the diamond disk, difficulties in luxation
sume a soft diet during the first 6 postoperative weeks of the bone block (more than 10 minutes after
to avoid a potential postoperative mandible fracture. the last osteotomy), heavy bleeding (ie, required
Sutures were removed 10 days postoperative. separate measures to control it), nerve exposure,
and nerve injury (determined clinically).
Outcome Measures • Postoperative pain. The amount of pain was
This study evaluated the outcome of bone block har- classified into three categories: heavy pain, with
vesting from the retromolar area with the MicroSaw. the patient taking more than eight painkillers
The outcome measures were as follows: (ibuprofen 400); moderate pain, when the patient

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 Khoury et al

took four to eight painkillers; or little pain, when treated under intravenous sedation, and 469 (14.1%)
the patient needed fewer than four painkillers. patients underwent surgery under general anesthesia
• Healing of the surgical site. This was determined because they required multiple grafting procedures.
clinically by primary healing of the soft tissue One hundred nine patients (3.28%) received an infe-
over the harvested area; any tissue necrosis, rior alveolar nerve block. A total of 3,874 bone blocks
suppuration, or bone exposure was noted. The soft were harvested from the external oblique line at the
tissue was supposed to show normal color without retromolar area of the mandible. Some patients (419,
any inflammation by 2 weeks after the surgery 12.59%) underwent bilateral bone block harvesting. In
(removal of the sutures) as well as at later recall 127 patients (3.82%), more than one block was harvest-
appointments. ed from the same area during the 10-year study period.
• Presence or absence of complications caused by A total of 431 (11.12%) half-blocks were reposi-
injury to adjacent teeth or the mandibular nerve tioned, and about 228 (52.9%) of them required addi-
with the diamond disk. This was determined tional stabilization with a small screw. The remaining
clinically by the absence of any pain or pathologic 203 (47.1%) half-blocks were placed back over the col-
symptoms on the neighboring teeth. In addition, lagen fleece, without any screw stabilization within the
pulp sensitivity in neighboring teeth was recorded contour of the external oblique line.
by testing with carbon dioxide snow (cold vitality The average time required to harvest a bone block
test). Patients were asked whether they sensed any from the mandibular retromolar area (time between
paresthesia, hypesthesia, anesthesia, or any other starting the osteotomy and total luxation of the block)
subjective difference versus the contralateral site. was 6.5 ± 2.5 minutes. In eight (0.2%) cases, the oste-
Sensation in the lower lip and chin areas on the otomy time was more than 15 minutes because the
right and left was compared using a probe with donor site bone was of dense cortical quality.
an extra-fine sharp point (EX8, Stoma Instruments) Of the 3,874 bone grafts harvested from the exter-
while patients’ eyes were closed. nal oblique ridge, a mean volume of 1.9 ± 0.9 cm3 was
• Regeneration of the harvested area. The presence measured (maximum 4.4 cm3) with a thickness up to
or absence of the external oblique ridge was 6.5 mm. In this area, bone quality was normally corti-
determined clinically by palpation of the donor cal, with little cancellous bone. The cortical bone in the
site with the second finger and radiologically on area of the distal osteotomy had a thickness of 1.5 to
the control panoramic radiograph by detection of 3.5 mm (average thickness, 2.2 ± 0.5 mm). The cortical
the presence or absence of the lamina dura in the bone in the area of the mesial osteotomy was thicker,
retromolar area. with a range of 2.5 to 5.5 mm (average, 3.3 ± 0.8 mm).
• In patients who underwent CBCT scans, the level All blocks were successfully split; no fractures were
of the external oblique ridge was compared before seen.
and up to 36 months after the bone harvesting In 2,285 donor sites, osteotomy lines were posi-
procedure with or without reimplantation of the tioned apical to the alveolar nerve. In 168 (7.35%) of
half bone block if another CBCT scan was made those cases, the mandibular alveolar nerve was ex-
for other presurgical diagnostic reasons. The posed, generally in the distal area of the donor site,
CBCT scan was used to evaluate the level of bone leading to transient sensory problems that lasted for a
regeneration after the healing of the donor site. maximum of 6 months. In 20 cases, minor nerve injury
occurred (0.5%): 8 patients (0.2%) demonstrated hyp-
Outcomes were assessed by the surgeon and there- esthesia, and 12 patients (0.31%) suffered paresthesia
fore were not blinded or independent. that lasted for up to 1 year. In 4 patients (0.1%) the par-
esthesia was present for more than 1 year. No major
nerve lesion of the mandibular nerve with permanent
RESULTS anesthesia was observed in any case.
Heavy bleeding at the donor site that required ad-
During this 10-year study, 3,328 patients (2,007 [60.3%] ditional procedures to control it, such as electrocoagu-
women and 1,321 [39.7%] men) underwent bone block lation or compression with bone chips, occurred in 56
harvesting. The youngest patient was 17 years old, patients (1.44%). Postoperatively, minimal pain was
and the oldest was 84 years old, and the average age observed in 1,624 patients (48.8%). Another 1,589 pa-
was 57.8 years. There were 912 (27.4%) smokers and tients (47.74%) reported moderate pain, and only 115
2,416 (72.6%) nonsmokers or previous smokers (had patients (3.45%) reported severe pain.
stopped smoking at least 4 weeks before the surgery); A total of 61 (1.58%) donor sites showed com-
most of the smokers (81.7%) consumed more than 10 plications related to primary healing. Most of these
cigarettes per day. Most patients (2,859, 85.9%) were (46, 1.19%) were minor complications, eg, wound

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Khoury et al

Fig 16 (above)  Two implants are inserted into the well-vascular-

ized and healed graft.

Fig 17 (right)  Exposure of the replanted bone block half (to

harvest a second block) 7 months postoperative. Total regen-
eration of the external oblique line is confirmed clinically.

dehiscence related to superficial infection of the donor Comparison of preoperative and postoperative
site, and 37 of these patients (80.4%) were smokers. All CBCT scans (in 341 patients) showed that, after at
wounds healed by secondary intention after local rins- least 18 months, a certain amount of bone regenera-
ing for up to 1 week. Major infection occurred in 15 tion had taken place, but the external oblique line had
patients (0.39%), all of whom were smokers. Treatment not been re-formed, compared to the original external
included intensive local rinsing and drainage for up to oblique ridge, which was more pronounced with the
3 weeks. No infection occurred in the 431 donor areas typical step and the thick cortical bone. In the 19 cases
in which half of the bone block was reimplanted. No in which half of the bone block had been reimplanted,
complications caused by injury to the adjacent teeth excellent regeneration of the donor site with re-forma-
with the diamond disk were observed. tion of external oblique ridge was observed. This was
The mandibular donor sites with the osteotomy bor- confirmed in the 7 patients who underwent bilateral
ders were well visualized on postoperative panoramic harvesting with and without reimplantation of the half
radiographs (Fig 15). These surgical scars disappeared bone block.
radiographically within 6 to 12 months, but the lamina
dura of the external oblique line had not regenerated.
Exceptions were patients in whom reimplantation of DISCUSSION
half of the bone block was performed; in these cases,
a lamina dura was already radiographically visible after To obtain large mandibular bone block grafts, the ex-
3 months. ternal oblique ridge is favorable. The proximity of the
In 16 patients, reentry of the harvested area was donor and grafted sites reduces the time needed for
performed between 6 and 40 months after reimplanta- surgery and anesthesia, leading to ideal conditions for
tion of half the block to harvest another block for an- implant surgery using autogenous bone grafts.1–3,7–9
other augmentation procedure. In all the cases, a well Special attention should be given to the presence of
regenerated and healed external oblique ridge was contraindications, either local or systemic, to intraoral
observed. bone harvesting. All patients must be well informed of
In 52 patients an additional CBCT was made for other both the advantages and disadvantages of autologous
presurgical diagnostic reasons within 18 to 36 months bone grafts.1,14
(average, 29 months). In 33 patients, the donor site had Anatomical variations in donor sites result in grafts
been treated with collagen fleece, and in 19 patients with morphologic differences. Clinical evaluation
half of the bone block had been reimplanted to regen- and comparison of donor sites are essential.3,4 Visual
erate the donor site. In addition, 7 patients underwent examination and digital palpation1 allow for prelimi-
bilateral harvesting from the retromolar area, but one nary assessments of the morphologic contours and
site had been reimplanted and the other site had not. dimensions of the donor site, such as the thickness

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 Khoury et al

and extent of the external oblique ridge. This provides in the area of the mesial osteotomy was much thick-
information on the shape of the available bone at the er, ranging from 2.5 to 5.5 mm (average, 3.3 mm). In
donor site. Radiography should be used to provide 168 (7.35%) of those cases, mandibular alveolar nerve
additional information on the donor site and its rela- exposure occurred, generally in the distal area of the
tionship to vital neighboring anatomical structures. donor site, leading to transient sensory problems that
The locations of the mandibular canals and the men- lasted, in almost all cases, for a maximum of 12 months.
tal foramina can be traced on a panoramic radiograph, Although no major lesion of the mandibular nerve
while the density of the external oblique ridge is evi- with permanent anesthesia was observed in any case
dent. An estimate of bone quality can sometimes be and only 4 patients (0.1%) felt paresthesia for more
obtained.1 In this paper, during the period 2000 to than 1 year, the distal osteotomy seems to be more
2008, the panoramic radiograph was the only radio- critical and requires special attention to cutting depth.
logic diagnostic method used before harvesting bone The results of the present study demonstrate that
from the external oblique ridge. One study found that relatively large volumes of bone can be successfully
the distance from the mandibular alveolar nerve to harvested from the mandible with a low complica-
the buccal wall in the retromolar area is approximately​​ tion rate using a specific technique with the specified
3.8 to 5.7 mm (mean, 4.7 mm).15 Thus, the maximum instrumentation and protocol. Despite the fact that a
cutting depth of the MicroSaw of 3.2 mm seems to be large part of the external oblique ridge was removed,
anatomically appropriate for safe harvesting of blocks no esthetic or functional deficiencies resulted. No
from the retromolar and paramolar areas. In the area complications caused by injury to the adjacent teeth
of the ascending branch (ramus mandibulae), how- with the diamond disk were observed. In a study of 50
ever, the nerve runs much closer to the surface.15,16 patients, a mean ramus graft of 0.9 cm3 was obtained
Nerve exposure may occur if the external oblique line using fissure burs.4 Another study used a piezoelectric
is weak and the osteotomies made during bone block surgical device and obtained a mean graft volume of
preparation are below the level of the nerve course, 1.15 cm3, with a maximum of 2.4 cm3.13 The difference
and also if the distal vertical osteotomy is positioned in between that study and the current study (mean vol-
the area of the ascending ramus, as the alveolar nerve ume of 1.9 cm3; maximum volume 4.4 cm3; graft thick-
in this area remains close to the buccal cortex before ness up to 6.5 mm) might be explained by the different
it extends lingually into the body of the mandible.16 harvesting technique and different instrumentation. In
In this study, to avoid alveolar nerve injury, an inferior fact, the MicroSaw’s thin diamond disks contributed to
alveolar nerve block was avoided; in most cases, only significantly less bone loss than other techniques.6,12
local vestibular and lingual infiltration was performed. Currently, several types of instruments are used to
This retained minimal sensation to warn the surgeon obtain intraoral grafts; most are piezoelectric instru-
when approaching the mandibular nerve. The authors ments19 or trephine burs20 of different forms and diam-
recommend that the MicroSaw not be used to its full eters. However, a trephine bur can remove only small
cutting depth in the distal retromolar area behind the bone pieces in core form and provides only particulate
second molar when osteotomies are created below the bone, rather than a bone block. The use of such instru-
nerve. A secure 2-mm margin of the osteotomy in this ments along the ramus is risky because of poor access
area is recommended (the diamond layer of the disk is and uncontrolled depth of the horizontal and vertical
1 mm wide). A low complication rate was experienced sections. The MicroSaw allows the surgeon to obtain a
in the present study; thus, the described clinical and large graft in a short time; an average osteotomy time
radiologic protocol seems to be sufficient for safe bone of 6.5 minutes to harvest a bone block from the man-
block harvesting. dibular retromolar area was achieved, with few compli-
Since 2009, CBCT scans17 have been used in this cations. This is documented by the current results with
study. According to the authors’ experience, this ad- bone block preparation.1,6
ditional diagnostic test is not essential for safe bone The postoperative situation after bone harvesting
harvesting using the MicroSaw, but it provides further from the retromolar area is similar to that observed
information, such as the thickness of the cortical wall after the osteotomy of impacted third molars: edema,
and the position of the mandibular nerve.18 Therefore, hematoma, and pain, for example.21–23 Postoperatively,
it gives helpful information prior to surgery. This in- minimal pain was observed in 1,624 patients (48.8%),
formation is important, especially if the osteotomies another 1,589 patients (47.74%) had moderate pain,
are located below the mandibular nerve. In this study, and only 115 patients (3.45%) reported severe pain.
2,285 donor site osteotomy lines were positioned However, primary healing complications in this study
basal to the alveolar nerve. The cortical bone in the (1.58%) were rarer than infections following third mo-
area of the distal osteotomy had a thickness of 1.5 to lar extraction (6% to 8%).1 This could be related to the
3.5 mm (average thickness, 2.2 mm). The cortical bone presence of a lamina dura, pericoronally and around

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Khoury et al

the third molar roots, which can have a negative in- reentry of the harvested area was performed and ra-
fluence on blood supply, bleeding capacity, and the diologically within 18 to 36 months when a CBCT scan
healing process. Concerning disturbances in wound was made. Because the diamond disk in the MicroSaw
healing, smoking24 seems to have a negative impact is thin, it makes a precise osteotomy, and in 47.1%
after block removal; 80.4% of patients with this type of of cases, half bone blocks were placed back into the
complication were smokers. Obviously, repositioning donor site within the contour of the external oblique
of half the block into the donor site seems to reduce line over the collagen fleece, without the need for a
the likelihood of disturbed wound healing, since no in- stabilizing screw. The remaining 52.9% of repositioned
fection occurred in any of the reimplanted 431 donor bone blocks were stabilized with a small screw. In all
sites. cases, a well regenerated and healed external oblique
Osseous regeneration of the mandibular donor site ridge was found. The complete regeneration of the
is similar to that observed for the osteotomy of im- donor site allows for future re-harvesting of a well-
pacted third molars.21,25 When large bone blocks are dimensioned bone block if needed for another bone
harvested, patients should be advised during the first augmentation procedure.
6 postoperative weeks to eat only soft foods to avoid
a potential mandibular fracture. The risk of fracture is
greatest approximately 2 to 3 weeks after bone har- CONCLUSION
vesting, because swelling is usually gone by then and
the patient can eat again without hindrance.1 The data and experience described in this 10-year
Autogenous bone, with its capacity to regener- analysis indicate that the described diagnostic proto-
ate and form new bone through osteoinductive, os- col and surgical procedure allowed efficient and safe
teogenic, and osteoconductive properties, is still the harvesting of bone blocks from the external oblique
gold standard for the treatment of large lateral and ridge. The use of cone beam computed tomograph-
vertical bone defects.4,5 However, mandibular bone ic scans is not essential, but it is recommended, as
blocks, which consist primarily of cortical bone and a these scans provide additional information about the
low percentage of cancellous bone, are more resistant thickness of bone structures and the position of the
to revascularization and consequently may have poor mandibular nerve. Because anatomical variations are
regeneration potential.1 For this reason, the harvested common, this information is important, especially if
thick bone blocks were split into two thin bone blocks bone blocks are harvested from below the mandibu-
with the diamond disk according to the split bone lar nerve. Repositioning of the split bone block after
block technique of the biologic concept of grafting the grafting procedure at the donor site seems to be
procedures.1 Splitting the thick blocks into two thin an adequate means to almost completely rebuild the
blocks not only increases the number of bone blocks, mandibular donor site and to reduce wound healing.
offering the possibility to graft more surfaces in differ-
ent forms, but also improves revascularization and re-
generation (Fig 16).1 The thin blocks were stabilized at ACKNOWLEDGMENTS
the recipient site with microscrews, and any gaps were
filled with autogenous bone chips harvested from the The authors reported no conflicts of interest related to this study.
donor site with a bone scraper. No biomaterials or
membranes were used. This technique with pure au-
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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The International Journal of Oral & Maxillofacial Implants 697

© 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.