REVIEW
Local Intraoral Autologous Bone Harvestingfor Dental Implant Treatment:
Alternative Sources and Criteria of ChoiceFederico Brugnami,1 Alfonso Caiazzo2 and Cataldo Leone3

Private Practice, Rome, Italy
Private Practice, Salerno, Italy
3
Department of Periodontology and Oral Biology,
Boston University Goldman School of Dental Medicine, MA, USA
12(Received for publication on Mar 11, 2008)(Revised for Publication on July 9, 2008)(Accepted for publication on September 18, 2008)

Abstract
Dental implants are established alternatives for replacing missing teeth. In case of alveolarbone resorption, implant placement may be prevented unless the volume of hard tissues isincreased before or during implantation. Autologous bone graft is still regarded as the “goldstandard” in alveolar reconstruction., but many factors may influence the final outcome.
The success of intraoral bone grafts, in fact, depends, among other factors, on the choice ofdonor graft material as well as on how the material is handled. The evidence supporting theuse of autogenous intramembranous bone with or without the use of barrier membranes isbriefly reviewed. The rational of donor site choice is also presented. Advantages and disadvantages of different harvesting site are discussed. (Keio J Med 58 (1) : 24－28, March 2009)

Keywords: autologous bone graft, guided bone regeneration, ridge augmentation, oral implants
Introduction

by the technical, intraoperative surgical manipulations
employed. It is readily apparent that the quantity of bonerequired is a major factor in donor site selection. An extraoral donor site is often required for ridge augmentation in totally edentulous patients, for example, whereridge resorption may be extreme and extensive. A popular and reasonably safe extraoral site is the posterior iliac
crest, which can yield relatively large bone volumes
ranging 70-140cc.5 Of course, the surgical convenienceof iliac grafts is negated, in part, by the additional procedural requirements and attendant patient morbidity; suchprocedures are longer, often require the use of generalanesthesia, increase the likelihood of intra- and postoperative complications, and can result in considerable
postoperative pain. In contrast, ridge defects in partiallyedentulous patients often are less severe and more localized, necessitating a smaller quantity of bone. This allows greater flexibility in autogenous donor site selection
and, in particular, makes highly feasible the use of intraoral donor sites. In such cases relatively modest bone

An adequate volume of bone is one of the factors critical to successful osseointegration and long-term retention of endosseous dental implants. 1, 2 In situations
where inadequate bone volumes exist, osseous ridge
augmentation procedures often are necessary for predictable implant therapy. Although a number of different
materials have been used for hard-tissue ridge augmentation during the past several decades, autogenous bone
grafts are generally considered one of the more ideal
augmentation materials.3,4Clinical and Scientific BackgroundThe choice of autogenous donor site is markedly influenced by two important considerations; namely, thequantity of bone required at the recipient site and the biologic qualities of the donor bone. Additionally, successful augmentation of the recipient site is influenced

Reprint request to: Federico Brugnami, DDS, Piazza Prati degli Strozzi, 21, Rome Italy
24

Keio J Med 2009; 58 (1):24－28

25Fig. 1 Mandibular symphysis block harvesting: a- Outline ofthe graft. b- Mobilization of the block with a chisel. c- Area ofsymphysis after harvesting .d- Block grafting in place in theanterior maxilla in a 43-year old female.

Fig. 2 a- Buccal dehiscence. b- SPI implant (Waldenburg,Switzerland) placed. c- Bone harvested from retromolar area. dBone graft covering the implant before membrane placement.

volumes ranging 5-10cc from the mandibular symphysis,for example, may be adequate for ridge augmentation(Fig. 1).5 Intraoral sites generally allow for shorter procedures, avoid the need for general anesthesia, and are associated with few complications and less postoperativediscomfort. Somewhat less apparent than the bone quantity required, but no less important, are the biologic qualities of the transplanted bone. These include the bone’s
embryologic origin, morphology, cytological constituents, and biochemical composition of the extracellularmatrix.6 Although detailed review of each of these properties is beyond the scope of this report, further discussion of the embryologic origin of donor bone is warranted. The development of any given bone proceeds along
one of the two general pathways, either endochondral orintramembranous ossification. In endochondral ossification, bone replaces a hyaline cartilage precursor. Longbones such as the tibia, fibula and femur as well as theiliac crest are formed in this way. Intramembranous ossification proceeds by direct mineralization of the organic matrix, without a cartilaginous intermediate. The
bones of the craniofacial complex, with limited exceptions, form via intramembranous ossification. The calvaria, maxillary bones and mandibular body and ramus,
in particular, are intramembranous; the mandibular condyles are exceptions because they are of endochondral
origin.7 The particular embryologic origin of donor bone
is recognized as one factor in the success of bone transplantation procedures. From comparative studies of craniofacial reconstruction in animals and man, it appears
that intramembranous grafts tend to maintain their volume whereas endochondral grafts undergo variable degrees of resorption over variable periods of time.8, 9, 1 0Thus, all other factors being equal, intramembranous

rather than endochondral bone autografts may be preferred in head and neck/intraoral applications. From thepreceding discussion we can appreciate the relative attractiveness of intraoral sites for the harvesting of donorbone. Such local harvesting is advantageous when bonevolume demands are not prohibitively high because intraoral sites can serve as excellent, readily accessible
sources of intramembranous bone. Within the mouth,
the mandible tends to present more sources than themaxilla. As mentioned above, the mandibular symphysis
is a very good donor site. The mandibular symphysis isalmost invariably, however, not contiguous with the area
to be augmented. This requires the involvement of asecond surgical site. Clearly, an alternative mandibular
donor site that is contiguous with the recipient area
would obviate the need for an extra surgical site. Suchalternative sources for local harvesting in the mandible
can be evaluated by careful clinical and radiographic examinations of the patient. Tori and exostoses, which arecommon intraoral exophitic findings,11 are suitable alternative bone sources. Retromolar and edentulous areas
also can be accessed (Fig. 2). It is important to emphasize, albeit obvious, that the anatomical factor limitingbone harvesting in the posterior mandible is the mandibular canal and associated neurovascular elements. Presurgical treatment planning therefore should include appropriate anatomical determinations when such alternative harvesting is considered. Once harvested, the donorbone must be adapted to the recipient site. Several investigators have examined the various technical considerations in this regard.12, 13, 14 These intraoperative considerations include the adequacy of donor bone volume,use of block grafts vs. ground bone, method of fixation,
concomitant use of barrier membranes, and degree of26

Brugnami F, et al: Local Intraoral Bone Harvesting for Dental Inplants

Fig. 3 a- Ridge defect with loss of buccal and lingual plate. bImplant placement. c- Radiograph also showing sinus proximity.
d- Post-operative radiograph showing sinus lift and ridge
augmentation with bone graft harvested from retromolar area.

Fig. 4 Mandibular ramus block harvesting and horizontal ridge
augmentation in the same quadrant in a 56-year old male. aOutline of the block to be harvested from the ramus. b- Blockgraft in place.

flap coaption. In 1993, Buser and co-workers presented
a technique for localized ridge augmentation using stainless steel pins to maintain space underneath a barrier
membrane.1 2 Subsequently, this group modified theirtechnique by adding corticocancellous bone grafts harvested from the retromolar area.13 Bone chips harvested
from contiguous areas were also packed into the augmentation site. The rationale for using autologous bonewith barrier membranes was that the bone had both
space-maintaining and bone growth promoting properties. The benefit of the combined use of bone grafts andmembranes was confirmed by Jensen et al. who found,using a canine model, less resorption of autologous blockgrafts when membranes were used (Fig. 3).14

ated implant success rates range 25-86%.1 0, 2 3 -2 5 As aconsequence, intramembranous bone tends to be more
preferred in craniofacial reconstructions, again with orwithout implant placement.26-37 Intramembranous, mandibular symphysis grafts have shown less delayed resorption and less morbidity than extraoral endochondral
grafts.3 6, 3 7 The placement of implants in areas graftedwith chin bone has been documented.32-35 In particular,
Jensen and Sindet-Pedersen3 2 reported a 94% successrate of 107 implant fixtures in 26 patients grafted withchin bone, following up to 32 months. Other locations in
the mandible also have been used to obtain intramembranous bone; these include the retromolar region (Fig. 2),13
the ramus20, 38 (Fig. 4) and tori.39-40 Tori mandibularis11
when present may represent an alternative or additionalsource of grafting tissue. Postoperative morbidity, mainly temporary paresthesia, differs among the sites used for
harvesting: the chin ranged from 10% to 50%, 4 1, 4 2
whereas the mandibular ramus ranged from 0% to5%.4 1, 4 2 Thus, the mandibular ramus has some advantages when compared to the mental symphisis as a possible donor site: the quality of bone is similar, the quantity
may be higher, and the risk of neural damage is lower.43
Survival and success rates of implants placed in reconstructed jaws are, on average, lower than those of implants placed in native bone. This appears to be particularly true in cases where extensive reconstructions wereperformed, although it has to be considered that many of
the implants failures occurred in relatively few patients.43 The success rates of implant therapy using thesealternative sources for local harvesting in the mandible
have been less well documented. Nevertheless, a hierarchy of clinical preferences can therefore be establishedfor ridge augmentation in the partially edentulous patient

Discussion and Criteria of Choice
Successful treatment of localized ridge defects can beachieved with autologous intraoral bone transplant withand without combined guided bone regeneration.1 5 -1 9
The volume of bone required can be small enough to allow harvesting from intraoral sites. Intraoral bone donorsites provide convenient surgical access, decreased procedure time, and lower morbidity.20 In addition, the donor and recipient sites are comprised of bone having thesame embryologic origin (i.e., intramembranous). Thereseems to be some difference in treatment outcomes, intraorally, between endochondral and intraoral donorbone. Endochondral grafts have been widely used inoral and maxillofacial reconstructions, with and without
osseointegrated implants. Typical donor sites are the anterior and posterior iliac crest, the rib,5 and the tibia.21, 22
However, endochondral bone grafts are associated withdelayed, sometimes dramatic resorption10 and the associ-Keio J Med 2009; 58 (1):24－28

using autogenous bone. First, intraoral intramembranous
donor bone is often preferred over extraoral bone of either intramembranous (ex. calvaria) or endochondral (ex.
iliac crest) origin. Second, mandibular donor bone tends
to be preferred over maxillary bone. Third, when feasible, donor bone that is contiguous with the recipient site
is preferred over intraoral bone from a second distinct
location. Fourth, when the transplanted bone is insufficient, additional chips of bone can be collected andpacked to achieve a ridge with the desired size andshape. Fifth, the concomitant use of a barrier membrane,in accordance with the principles of Guided Tissue Regeneration, is more preferred than bone transplants without membranes.
Conclusion
The use of appropriate surgical techniques, backed bysound knowledge of bone biology and knowledge ofpossible alternatives for intra-oral bone harvesting optimizes ridge augmentation procedures.
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