Bone Graft Harvesting From Distant Sites Concepts and Techniques
Bone Graft Harvesting From Distant Sites Concepts and Techniques
Bone Graft Harvesting From Distant Sites Concepts and Techniques
F ro m D i s t a n t Si t e s :
Concepts and
Tec h n i q u e s
Kenneth J. Zouhary, DDS, MDa,b,*
KEYWORDS
BACKGROUND
Reconstruction of the moderately to severely resorbed maxillary and mandibular alveolar bone in
preparation for endosseous dental implant placement can be one of the most challenging tasks
presenting to the oral and maxillofacial surgeon.
Bell1 summarized the aim of bone grafting over
40 years ago to place a readily vascularizable
osteogenic organic structure in intimate contact
with a vascular osteogenic cancellous host bed
while adhering to sound orthopedic principles.
A number of autogenous, allogeneic, xenogeneic,
and alloplastic grafts have been employed alone
or in various combinations to meet this challenge.
The ideal bone graft material for implant reconstruction should have the following characteristics.
The graft material should have the structural integrity to maintain space during bone ingrowth, graft
consolidation and maturation, and implant
osseointegration. It should be able to promote cells
at the recipient site to form bone within the graft.
The graft material should be able to be resorbed,
remodeled, and replaced as the viable native
bone. The resultant augmented alveolus should
be stable over time after implant restoration and
functional loading. The material should have ease
of harvest (if autogenous) and placement to minimize procedure length, thus maximizing potential
for graft success while minimizing patient
a
Department of Oral and Maxillofacial Surgery, Birmingham VA Medical Center, 700 19th Street South,
Birmingham, AL 35233, USA
b
Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, 2000 6th Avenue
South, Birmingham, AL 35233,USA
* Department of Oral and Maxillofacial Surgery, Birmingham VA Medical Center, 700 19th Street South,
Birmingham, AL 35233.
E-mail address: kzouhary@uab.edu
oralmaxsurgery.theclinics.com
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Zouhary
When selecting the appropriate bone graft
source, there are multiple factors that one must
consider with regards to the recipient site, the
donor site, and the patient. One must first consider
the size of the defect to be restored to help determine the quantity of bone graft required. One must
also decide what type of defect is to be restored to
determine the quality of graft required: cortical
versus cancellous. Operative time and donor site
morbidity are major factors to be considered and
help to guide the choice of graft material. Only
after careful consideration of these factors in light
of the patients comorbidities and expectations
will one be able to select the appropriate harvest
site for each particular patient and application.
Much of what is known about the behavior of
various autogenous bone grafts to the dental alveolus comes from past experience with congenital
alveolar cleft defects. Early animal studies showed
that membranous bone grafts maintained volume
better than endochondral bone grafts when used
as a corticocancellous onlay graft. This led to
a consensus that membranous bone grafts were
superior to endochondral grafts based on their
embryologic origin. Thus cranial bone and
mandibular bone were often preferred for onlay
grafting in craniofacial applications. Ozaki and
Buchman3 hypothesized that membranous bone
resorbed less over time compared with endochondral bone because of its microarchitectural
features (relative cortical and cancellous composition) rather than its embryologic superiority. They
found no statistical difference in rate of resorption
between two cortical onlay grafts of different embryologic origin when the cortical and cancellous
components were separated. Rosenthal and
Buchman4 proceeded to examine the behavior of
embryologically diverse bone grafts in inlay grafts
as opposed to onlay grafts. They created four critical size defects in rabbit crania and grafted each
with either membranous cortical, endochondral
cortical, endochondral cancellous, or a control
consisting of no bone graft at all. They found that
all three grafted sites increased in bone volume
compared with the control. Interestingly, they
found that the endochondral cancellous bone
volume increased the most. They concluded that
the ratio of cortical to cancellous graft was far
more influential in graft performance than embryologic origin. They also concluded that inlay grafts
behave differently than onlay grafts, thus the
selection of donor site must fit the type of defect
to be corrected.
Autogenous bone can be harvested from either
intraoral or extraoral (distant) sites. Intraoral
harvest sites include, but are not limited to, the
mandibular symphysis, external oblique ridge,
Table 1
Typical noncompressed graft volumes available
for harvest
Tibia
Anterior Ilium
Posterior Ilium
Calvarium
Noncompressed
CorticoCancellous
Cortical
Block
2540 cc
50 cc
100125 cc
variable, minimal
1 2 cm
3 5 cm
5 5 cm
abundant
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Fig. 1. Nerves vulnerable to injury with incision in the region of the iliac crest as depicted by two different
authors. (A) The lateral branch of the subcostal nerve is shown to be especially vulnerable to injury where the
grafts are harvested from the anterior crest. M, muscle; n, nerve. (From Chou D, Storm PB, Campbell JN. Vulnerability of the subcostal nerve to injury during bone graft harvesting from the iliac crest. J Neurosurg 2004;1:879;
with permission.) (B) Relationship of the iliohypogastric nerve to the iliac tubercle, placing it at considerable risk
during bone harvest from the iliac crest. (From Kademani D, Keller E. Iliac crest grafting for mandibular reconstruction. Atlas Oral Maxillofac Surg Clin North Am 2006;14:16170; with permission.)
Fig. 2. (A) Left anterior iliac crest incision placed lateral to the crest of the ridge and 2 cm posterior to ASIS. Incision carried down through the aponeurosis between the tensor fascia lata laterally and the external oblique
muscle medially. (B) Exposure of the bony crest of the ridge with subperiosteal reflection of the iliacus muscle
using a periosteal elevator followed by a malleable retractor. (C) Bony osteotomies made with reciprocating
saw 3 cm posterior to ASIS and extending 5 cm posteriorly (ASIS marked with horizontal surgical marking
pen). (D) Corticocancellous block graft gently separated from lateral cortex using paired osteotomes. (E) Donor
site after removal of block graft demonstrating remaining cancellous bone available for harvest with bone
curettes. (F) Corticocancellous block graft harvested approximately 5 3 cm.
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Box 1
Complications associated with anterior iliac
crest bone graft harvest
Hematoma
Seroma
Paresthesia
Cosmetic deformity
Pelvic instability
Abdominal hernia
Ileus
Infection
Persistent pain
Fracture
and gluteus maximus followed by the thoracodorsal fascia, subcutaneous tissue, and skin. A drain
is typically placed and left to bulb suction. The
site is then covered with microfoam tape and the
patient is repositioned to the supine position for
oral reconstruction.
Fig. 3. (A) Right-sided posterior iliac crest bone harvest depicting the location of the superior and middle cluneal
nerves to the palpable bony landmarks. (B) Corticotomies along the crest of the ridge and the lateral cortices with
gluteus maximus reflected. (C) Corticocancellous blocks and cancellous bone harvested from the posterior hip. (D)
Closure of the incision with suction bulb drain in place laterally.
Box 2
Complications associated with posterior iliac
crest bone graft harvest
Bleeding
Ureteral injury
Abdominal hernia
Paresthesia
Seroma
Hematoma
Gait disturbance
Infection
Scarring
cm or greater, thus requiring at least 60 cc cancellous bone. They found the posterior approach to
have decreased morbidity in all parameters
measured including pain, ambulation, seroma,
and blood loss (Table 2).
In a prospective nonrandomized study of 118
patients, Kessler and colleagues26 compared the
volume of bone harvested, the operating time,
and the postoperative morbidity between the
AICBG (81 cases) and the PICBG (46 cases). The
mean volume of bone harvested from the anterior
crest was 9 cc (range 52) and from the posterior
crest 25.5 cc (range 1729). The mean operating
time for the anterior approach was 35 minutes
(range 2248). The mean operating time for the
posterior approach was 40 minutes (range 32
55). This did not include the additional time
required for patient repositioning and redraping
with a mean time of 20 minutes (range 1427).
The posterior approach caused less morbidity
particularly with respect to the statistically significant decrease in pain and gait disturbance
(Table 3).
Nkenke and colleagues27 showed gait disturbance and pain scores to be higher in the AICBG
early on as compared with the PICBG, but no
difference at 1 month postoperative. An extensive
review of the literature focusing on anterior and
posterior iliac fractures after graft harvest was reported by Nocini and colleagues28 in 2003. Of
the 35 cases reported in the literature at that
time, 24 fractures were associated with harvesting
from the anterior crest and 12 were due to posterior crest harvest. Four out of 24 anterior fractures
required further surgical treatment (16.6%). Eight
of the 12 posterior fractures required one or
more additional surgical procedures (66.6%).
Although painful, fractures of the anterior iliac crest
remain stable and heal spontaneously in most
cases without further complication. On the
contrary, fractures of the posterior iliac crest due
to graft harvest often require further surgical intervention and functional disability.
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Table 2
Donor site morbidity from anterior and posterior iliac crest graft harvest
Anterior Approach n 5 50
Posterior Approach n 5 50
P Value
3.6 days
12% (6/50)
6% (3/50)
2% (1/50)
7.2/10
4.4/10
42% (21/50)
15% (8/50)
1.7 days
2% (1/50)
0% (0/50)
0% (0.50)
3.1/10
0.3/10
6% (3/50)
0% (0.50)
.005
.005
.050
.010
.005
.005
.005
.005
Data from Marx RE, Morales MJ. Morbidity from bone harvest in major jaw reconstruction: a randomized trial comparing
the lateral anterior and posterior approaches to the ilium. J Oral Maxillofac Surg 1988;48:196203.
Table 3
Complications after harvesting from the anterior and posterior iliac crest
Complication
Anterior (n 5 81)
Seroma
1 (1%)
Hematoma
7 (9%)
Infection
1 (1%)
Hyperesthesia
1 (1%)
Total
10 (12%)
Pain
57 (70%)
Irregularities of gait
After 2 weeks
26 (32%)
After 4 weeks
8 (10%)
Posterior (n 5 46)
Total (n 5 127)
P Value
3 (6%)
2 (4%)
0
0
5 (11%)
15 (33%)
4 (3%)
9 (7%)
1 (1%)
1 (1%)
15 (12%)
72 (57%)
<.001
3 (6%)
1 (2%)
29 (23%)
9 (7%)
.002
Data from Kessler P, Thorwarth M, Bloch-Birkholz A, et al. Harvesting of bone from the iliac crest: comparison of the anterior and posterior sites. Br J Oral Maxillofac Surg 2005;43:516.
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Fig. 4. (A) Bony landmarks for lateral approach to the left tibia highlighting the patella, tibial tuberosity, proximal fibula, and oblique incision overlying Gerdys tubercle. (B) Exposure of Gerdys tubercle. (C) Cortical osteotomy overlying Gerdys tubercle. (D) Corticocancellous block harvest. (E) Cancellous bone harvest. (F) Fat droplets
demonstrating fatty component of tibial bone. (G) Compression of cancellous bone. (H) Compressed tibial cancellous graft.
Fig. 5. (A) Medial approach for a right tibial bone harvest based on vertical and horizontal position of the tibial
tuberosity (circle overlying Gerdys tubercle laterally). (B) Cortical osteotomy demonstrating thickness of tissue
overlying the medial approach as compared with the lateral approach. (C) Corticocancellous block harvested
from tibia. (D) Compressed cancellous tibial bone.
Box 3
Complications associated with tibial bone
graft harvest
Prolonged pain
Gait disturbance
Wound dehiscience
Infection
Scarring
Hematoma
Seroma
Paresthesia
Fracture
Violation of the joint space
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amounts of cortical bone graft are desired. Potential disadvantages of the calvarial bone graft
include risk of dural tear, postoperative contour
deformity, scarring, minimal cancellous bone
Fig. 6. (A) Patient prepped and draped for calvarial bone graft harvest from the right parietal bone. (B) Bone
harvest exposure and surgical marking of proposed osteotomies with medial extent of osteotomy at least 2
cm from the midline to avoid the sagittal sinus. (C) Waste strip designed with round bur clearly showing the thickness of the outer cortical plate. (D) Corticotomies through the outer cortical plate with a reciprocating saw to 3
mm depth or the height of the saw blade tip. (E) Cortical blocks separated from inner table with osteotomes and
mallet. (F) Harvested cortical block grafts and donor site before scalp closure.
Box 4
Complications associated with calvarial
graft harvest
Alopecia
Hematoma
Dural tear
Superior sagital sinus laceration
Epidural hematoma
Infection
Scarring
COMPARATIVE MORBIDITY
In the most extensive comparative donor site
morbidity review to date, Tessier and
colleagues57 reported their combined complication rate of each of the major bone graft donor
sites in their group experience of 20,000 cases.
Iliac crest complications included six hematomas,
one hernia, 10 paresthesias, eight broken figureof-8 wires requiring removal, and two retained
sponges requiring removal. In total, they experienced 27 complications of 5600 cases (0.5
percent). Tibial bone graft complications included
one fracture, one late bleed, and one infection;
thus three complications of 950 cases (0.3
percent). Cranial bone grafts resulted in 12 hematomas or seromas, one retained sponge, two
infections, nine dural lacerations requiring suture,
and three neurologic sequelae, all transient (one
hemiparesis, one leg weakness, and the other
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unspecified). These totaled 27 complications in
10,550 cases (0.3%).
FUTURE INVESTIGATIONS
Boyne and Herford58 suggested an algorithm for
alveolar reconstruction before implant placement
based on the size and geometry of the defect.
Regardless of the source of bone graft, the longterm stability of the graft under function is paramount to a successful treatment. As in-office cone
beam technology becomes more prevalent, clinical
researchers will be able to better quantify and
compare the long-term success of various bone
graft sources and techniques for reconstruction.
One study has shown preprosthetic calvarial bone
inlay and onlay grafts to have a postgrafting volume
reduction of 16.2% and 19.2% at 6 months and 1
year, respectively, without a decrease in bone
density.59
SUMMARY
With adequate training and experience, bone graft
harvest from distant sites has a very low incidence
of complications. A thorough understanding of the
relevant anatomy, various harvest techniques, and
potential morbidity associated with each harvest
site will aid the surgeon in selecting the optimal
bone graft source.
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