Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 249e256

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Journal of Cranio-Maxillo-Facial Surgery

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A clinical study of the outcomes and complications associated with

zygomatic buttress block bone graft for limited preimplant
augmentation procedures
Andreas Sakkas a, *, Alexander Schramm a, Winter Karsten b, Nils-Claudius Gellrich c,
Frank Wilde a
a

Department of Oral and Maxillofacial Surgery (Head: Prof. A. Schramm), Facial Plastic Surgery, Military Hospital Ulm and Academic Hospital University
Ulm, Ulm, Germany
Translational Centre of Regenerative Medicine (TRM-Leipzig), Germany
c
Department of Oral and Maxillofacial Surgery (Head: Prof. N.-C. Gellrich), Hannover Medical School, Hannover, Germany
b

a r t i c l e i n f o

a b s t r a c t

Article history:
Paper received 6 September 2015
Accepted 7 December 2015
Available online 17 December 2015

Purpose: The aim of this study was to evaluate the possibility of using the zygomatic buttress as an
intraoral bone harvesting donor site and determine the safety of this harvesting procedure for later
optimal positioning of dental implants in accordance with prosthodontic and functional principles.
Material and methods: A consecutive retrospective study was conducted on patients who had been
treated at the Department of Oral and Maxillofacial Surgery of Ulm military and academic hospital, over a
3-year period (January 2008 to December 2010). Medical history, smoking status, area of surgery, and
complications were recorded. The need for bone grafting was dened by the impossibility of installing
implants of adequate length or diameter to fulll prosthetic requirements, or for esthetic reasons. The
patients were treated using a 2-stage technique. During the rst operation, bone blocks harvested from
the zygomatic buttress region were placed as lateral onlay grafts and xed with titanium osteosynthesis
screws after exposure of the decient alveolar ridge. After 3e6 months of healing, the ap was reopened,
the screws removed and the implants placed.
Results: A total of 113 zygomatic buttress bone block grafts in 112 patients were performed. Graft loss
and graft removal were dened as failure; swelling, wound dehiscence, infection with pus, temporary
paresthesia, and perforations of the maxillary sinus membrane were dened as complications. According
to our criteria, 4 (3.5%) of the patients presented postoperative complications of the donor site and 20
(17.8%) of the recipient site. Throughout, 93 (82.3%) of the bone grafts were successful and 20 (17.6%) had
complications, regardless of the nal success of the implant procedure. Smoking was associated with a
high rate of complications and graft failure. Early graft exposure appeared to compromise the results,
whereas pain and swelling were comparable to usual dentoalveolar procedures. However, in 1.7% of all
cases, concerning 2 patients, the nal rehabilitation with dental implants was not possible.
Conclusions: The zygomatic buttress block bone graft is a safe intraoral donor site for the reconstruction
of small- to medium-sized alveolar defects, providing the greatest surgical access with minimal postoperative complications.
2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

Keywords:
Alveolar ridge augmentation
Autogenous bone grafts
Zygomatic bone
Endosseous dental implants
Intraoral donor sites

1. Introduction
The use of dental implants for the oral reconstruction of partially
or totally edentulous jaws has lately been due to long-term

* Corresponding author.
E-mail address: ansakkas@yahoo.com (A. Sakkas).

experience with a very common practicing method in the oral

surgery (Lang et al., 2004). However, unfavorable local conditions of
the alveolar ridge, due to atrophy, periodontal disease, trauma
sequelae, malformation, or neoplasias, may result in insufcient
bone volume, possibly complicating therapy of the masticatory
function with dental implants (Chiapasco et al., 2006). In the case of
lack of bone volume, the need of the surgical reconstruction of the
alveolar ridge is warranted. Several bone grafting techniques have

http://dx.doi.org/10.1016/j.jcms.2015.12.003
1010-5182/ 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

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A. Sakkas et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 249e256

been described in the literature to ensure sufcient bone volume

for implantation (Williamson, 1996; Sant'Ana, 1997).
The use of autologous bone grafts with dental implants was
nemark et al. (1975), and is now a welloriginally described by Bra
accepted procedure in oral and maxillofacial rehabilitation
(Brnemark et al., 1975). Autologous bone graft material is osteogenic and contains bone-reforming cells, which make it osteoductive and osteoconductive for bone regeneration. Because of
these physiological characteristics, autogenous bone grafts remain
the gold standard in reconstructive surgery, providing higher bone
quality and implant osseointegration, despite recent advances in
bone substitutes (Lynch et al., 1999; Misch et al., 2001).
Performing ridge augmentation and implant placement as a 2stage surgical procedure is still said to be more successful than
the single-stage procedure (Listrom and Symington, 1988; SchulzeMosgau et al., 2001). Barrier membranes, either resorbable or
nonabsorbable, are used when the buccal wall is decient in protecting the bone graft, to reduce the tendency of absorption after
placement during the healing period (Esposito et al., 2006;
Topazian, 1992). Autogenous bone grafts can be harvested from
intraoral or extraoral donor sites. Each of these techniques has its
own advantages and disadvantages. To avoid the hospitalization or
general anesthesia associated with 2 major surgeries from extraoral
donor sites, surgeons have been led to the growing use of bone
block grafts from intraoral sources (Keller et al., 1987; Collins, 1991;
Kwast et al., 1992; McGrath et al., 1996; Raghoebar et al., 1996;
Lekholm et al., 1999).
Harvesting bone grafts from the zygomatic buttress region has
been previously reported (Wolford and Cooper, 1985; Kainulainen
et al., 2002, 2004; Gellrich et al., 2007). In 1985, Wolford and
Cooper described a technique to harvest cortical bone block from
the zygomatic eminence and arch during Le Fort I osteotomies.
They found it easy to harvest a 1
1.5-cm graft from this area
without untoward esthetic or functional decits in the donor site
(Wolford and Cooper, 1985). Harvested zygomatic bone in this case
series included both cancellous and cortical bone, as well as particulated bone, which was retrieved using a connected bone collector. In the authors' opinion, the use of zygomatic bone as donor
tissue for alveolar bone grafting has been better described by
Kailunainen et al. (2002). They mentioned that it is possible to
harvest approximately 0.5e1 mL of bone without causing damage
to surrounding tissues, and that this can be used as an onlay graft to
ll alveolar defects in 1 or 2 implant sites (Kainulainen et al., 2002).
The zygoma consists of frontal and temporal processes and an
orbital surface. The infraorbital nerve is on the medial side of the
zygomatic bone and dorsal of the zygoma is the infratemporal
fossa, where the maxillary artery, maxillary veins, pterygopalatine
nerve ganglion, maxillary nerve, zygomatic nerve, and temporalis
muscle are located (Kainulainen et al., 2002). The use of the zygomatic buttress as a donor site is said to be less invasive and to save
surgical and anesthetic time, and can be carried out in the outpatient operating theater (Wolford and Cooper, 1985; Kainulainen
et al., 2002, 2004; Gellrich et al., 2007). According to these authors, bone grafts from the zygomatic buttress offer several advantages in the repair of localized alveolar defects: a) the proximity
of donor and recipient sites reduces operating and anesthesia time;
b) conventional surgical access is possible; and c) the combination
of these factors makes this an ideal procedure for outpatient
implant surgery. Minimal discomfort and decreased morbidity are
characteristics also reported (Wolford and Cooper, 1985;
Kainulainen et al., 2002, 2004; Gellrich et al., 2007).
The purpose of the present retrospective study was to evaluate
the surgical success, to assess the rate of complications, and to
demonstrate the advantages of zygomatic buttress bone harvesting
in a group of partially edentulous patients prior to implant

placement. There is no retrospective or prospective study in the

current literature describing the success and rate of complications
using bone grafts from the zygomatic buttress area in oral
implantology.

1.1. Ethics considerations

This research has been conducted in full accordance with ethical
principles, including the World Medical Association Declaration of
Helsinki. The patient's data was undertaken with the understanding and written consent of each patient and data was also anonymized and de-identied prior to analysis. This study has been
independently reviewed and approved by an ethical board. The
study followed the STROBE guidelines for observational studies
(Strobe Statement, 2014).

2. Material and methods

A consecutive retrospective study was conducted in patients
who underwent a bone grafting procedure using zygomatic
buttress from January 2008 until December 2010. Files of 112 patients reporting bone graft operations were reviewed. Patients
were excluded if they needed the following: a) grafting of bone
defects caused by tumor resections, osteoradionecrosis, or
bisphosphonate-associated osteonecrosis; or b) grafting of extraction sockets or intraalveolar defects simultaneously with immediate implant placements.
Medical history, cause of tooth loss, and smoking status at the
time of operation were recorded. All patients underwent primary
clinical and radiographic examination and were diagnosed as
having an inadequate quantity of bone for implant placement. The
etiology causing tooth loss was caries/periodontitis in 98 of the
cases and trauma in 15 cases.
The need to augment the defective alveolar ridge was preoperatively evaluated after a careful clinical examination and use of
panoramic radiographs to observe the vertical resorption of the
ridge. All patients were informed in advance that bone reconstruction would be necessary prior to implant placement.
We used a standardized 2-stage surgical technique. In the rst
intervention, a bone block harvested from the zygomatic buttress
were xed with osteosynthesis titanium screws to the recipient site
as onlay grafts, to achieve a horizontal augmentation of the ridge
volume. In the second procedure, 4e6 months later, the screws
were removed and implants were placed. The results regarding
bone augmentation obtained, donor and recipient site morbidity,
bone graft stability, and resorption prior to implant placement were
recorded during the postoperative period and healing phase.
Complications associated with this procedure involved mostly
infection, incision-line opening, wound dehiscence, sinus membrane perforation, nerve dysfunction, or graft mobilization.
A total of 113 alveolar segments were treated, and all procedures
involved the maxilla. Two patients included in the study were
treated in separate procedures for augmentation of different alveolar sites. Each augmented site was studied. All surgical procedures
were carried out under local anesthesia, and all sites were treated
in a similar fashion. The number of bone blocks, donor sites, and
number of implants inserted in each augmented site were also
recorded. The choice of donor site, left or right, was determined
preoperatively based on defect morphology and recipient site
location. When the augmentation was planned in the posterior
maxilla, a single surgical eld was needed, thus reducing patient
discomfort. The recipient site was allowed to heal completely prior
to graft surgery.

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251

2.1. Surgical protocol

2.1.1. Stage 1 surgery
Local anesthesia of all patients was carried out with Ultracain DS (Hoechst Marion Roussel Deutschland, Frankfurt, Germany)
containing 1:200,000 epinephrine at the donor and recipient sites.
A single shot of 2.2 g penicillin (Augmentan, GlaxoSmithKline
Consumer Healthcare GmbH & Co. KG) or, if a patient is penicillin
allergic, 600 mg clindamycin (Clinda-saar, MIP Pharma GmbH) as
well as 250 mg prednisolone (Solu-Decortin, Merck Pharma GmbH)
was administered intravenous to patients a few minutes prior to
surgery.
A panoramic view of 1 of our study patients shows a singletooth space in the right anterior maxilla. The proposed recipient
site for the graft was exposed prior to graft harvest in all cases. In
this manner, the dimensions and morphology of the bony defect
were measured, and minimal time elapsed between graft harvest
and placement (Fig. 1).
The recipient site was prepared and reconnoitered with the
Safescraper (C.G.M. S.p.A., Divisione Medicale META, Italy) by
pushing the end of the device toward the bone surface and
simultaneously pulling the device backward. Collection of 2e3 mL
of bone was feasible with a mean surgical time of 5 min for harvesting. The collected bone was preserved in a sterile environment
until grafting. Following application of a local anesthetic to the
infraorbital nerve and the posterior and middle superior alveolar
nerves, a marginally detached mucoperiosteal ap reaching from
the upper left second bicuspid was raised through a vestibular
incision similar to Le Fort I osteotomy. The preoperative coronal and
sagittal CT scans were used to measure the size of the zygomatic
bone at different levels and to estimate the volume of the zygomatic buttress. Both the thickness and length were measured at the
level of the infraorbital foramen. The osteotomy was carried out
with an osteotomy kit for Piezosurgery (Mectron, Deutschland
Vertriebs GmbH). A 1.5e2 cm2 cortical bone transplantation was
harvested from the ipsilateral caudal end of the zygomatic buttress
(Fig. 2).
A thin chisel was gently tapped along the entire length of the
osteotomy line, and care was taken to maintain this parallel to the
lateral surface of the zygomatic bone, so that a fracture would occur
at a particular level without perforation of the maxillary sinus
mucous membrane. This level could be adjusted to predetermine
the size of the bone graft. If a local sinus membrane perforation

Fig. 1. Alveolar ridge atrophy in this maxilla posterior quadrant.

Fig. 2. The bone graft is harvested from the left zygomatic buttress.

occurred, then the donor area was lled with a collagen membrane
as protection for the soft tissues.
The zygomatic buttress bone block graft was then xed with
small-diameter titanium osteosynthesis screws (Matrix Midface,
Synthes 2011 NHS Supply Chain). Corticocancellous bone,
collected with the Safescraper (C.G.M. S.P.A., Divisione Medicale
META, Italy), was then used to ll the small gaps between the bone
graft and the alveolar crest (Fig. 3).
In all cases, a collagen membrane (Bio-Gide, Geistlich Biomaterials, Wolhusen, Switzerland) was cut appropriately and
adapted to cover the defect and extended 2e3 mm sideways, being
laid over the graft in a saddle conguration. It was tucked underneath the palatal ap to cover the ridge and buccal defect, moistened, and pressed gently to adapt to the underlying bone (Fig. 4)
Periosteal releasing incisions were made where necessary to
achieve easy closure without tension to the mucosal aps on top of

Fig. 3. The bone graft is placed in a bone defect in the maxillary left frontal area and
xed with titanium osteosynthesis screws.

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A. Sakkas et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 249e256

Fig. 4. Adaption of a collagen membrane underneath the palatal ap to cover the

defect.
Fig. 5. View of the operation area after removement the osteosynthesis screws.

the grafts. An orthopantomographic control was always performed

postoperatively to evaluate the outcome of the surgical procedure.
Postoperatively, patients were instructed to rinse their mouth
twice daily with chlorhexidine 0.2% for 2e3 weeks, after which the
sutures were removed. Removable provisional prostheses were
generously adjusted. Patients were instructed to use their prostheses for cosmetic appearance and eating only, rather than wearing them continuously for the whole period of healing. Antibiotic
therapy was not continued after surgery, and patients were
instructed to use nonsteroidal anti-inammatory drugs (ibuprofen,
Docpharm Arzneimittelvertrieb GmbH & Co. KGaA) only if pain was
present.
2.1.2. Stage 2 surgery
The healing period varied after the grafting procedure. Nevertheless, a minimum of 4 months elapsed for all patients between
grafting and implant placement. Preoperatively, clinical and
radiographic evaluations were performed and implants were
placed in a standard manner using the special program for guided
implant surgery CoDiagnostiX (IVS Solutions AG). Computed
tomographic scans were performed in all patients prior to implant
placement to enable the optimal position for the implant to be
planned on the computer, and the result transferred to the mouth.
Bone-level type titanium implants were used, the majority of which
were Straumann Bone Level implants (Institut Straumann AG,
Switzerland), followed by Astra (Astra Tech Inc.) and Camlog
(CAMLOG Vertriebs GmbH, Germany). In total, 134 implants were
placed. After an osseointegration period of 4e6 months, the implants were exposed, and the procedures for the suprastructure
were started. A crestal incision and subperiosteal dissection of the
alveolus were performed, and the xing screws were removed
(Fig. 5). Implant site preparation was performed with guidance
from the laboratory made splint and the implant was positioned.
The removal of healing screws took place 3e4 months after
implant placement, and a few weeks later the prosthesis was
completed. Clinical follow up appointments after surgery were
made to evaluate any complication at the donor and recipient sites,
such as dehiscence, infection, swelling, sensory disturbances, or
hemorrhage. Graft loss and graft removal were dened as failure.
Swelling, wound dehiscence, incision-line opening, infection with
pus, or temporary paresthesia were dened as complications.
Statistical analysis included descriptive statistics using SAS
Software Version 9.3. For the statistical evaluation, c2 tests were
used, and the level of signicance for all tests was set at p  0.05.

The departmental staff followed up all patients. The results were

analyzed in percentage terms and presented in tables and
diagrams.

3. Results
A total of 113 (n 113) zygomatic bone graft procedures were
performed in 112 patients, 108 men and 4 women. Patients ranged
in age from 20 to 61.5 years (average 34.3 years). For the results to
be better presented, the sample of patients was divided into 2
groups, according to the age, 1 group < 35 years and the other group
35 years. Of the 112 patients receiving grafts, 74 were smokers
(Table 1). Seven patients were prediagnosed with general advanced
periodontitis, which was successfully treated before bone grafting.
All procedures involved the maxilla. Two of 112 patients were
treated in 2 different alveolar sites, whereas the rest of the patients
were treated in only 1 atrophied area. Regarding the alveolar crest,
the situation in 89 cases was recorded as single-tooth space, 18 as
multiple tooth gap, and 6 as free-end.
Of the 113 onlay bone grafts, 93 (82.3%) were dened as
completely successful, whereas 20 (17.7%) had adverse effects such
as incision-line dehiscence, swelling or wound infection with pus
exit, or graft exposure. Of the total areas with complications, 4 were
dened in the donor site and 20 in the recipient area. Only 2 grafts
(1.7%) in 2 patients were dened as failures (i.e., graft exposure and
screw mobilization).
Swelling on the operated site was expected to be a normal
complication after surgery. Regarding postoperative swelling
following the bone grafting procedure, 2 weeks postoperatively
most of the patients reported only light facial deformity lasting not
longer than 3 days. At 2 weeks after the operation, none of the 112
patients reported persisting pain.
No major complications were observed regarding donor sites
apart from 2 patients who developed postoperative symptoms of
sinusitis in combination with persistent stula. In these 2 patients,
a perforation of the maxillary sinus membrane was noted intraoperatively. No incision-line dehiscence occurred in the donor site
areas. The incidence of temporary infraorbital nerve paresthesia
was 1.7%, reported by 2 of 113 cases at the time of suture removal
after harvesting. At the time of implant insertion, there were no
reports of persistence of altered sensation by these 2 patients.

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253

Table 1
Study patients according to gender and smoking habit.

The frequency of complications was higher in recipient sites

than in donor sites. Except for minor complications such as
incision-line opening in 8 cases, with or without membrane
exposure, there also wound infection with pus excreted by
augmented areas in 5 cases and bone graft exposures in 7 cases. The
distribution of frequency of the postoperative complications in
recipients is presented in Table 2. According to the age, there were
no signicant association between patient age and complications
observed postoperatively (p > 0.05).
In 22 cases of postoperative complications on either the donor
or recipient site, 17 were observed in smokers and 5 by nonsmokers, from a total of 20 bone grafts. The 2 patients with temporary paresthesia of the infraorbital nerve were excluded from the
statistical analysis, in this case, because smoking and nerve injury
after harvesting do not appear to be associated.
In 17 smoker patients of a total of 74 patients (22.9%), complications were noted. In the nonsmokers, complications were documented for 5 of 38 patients (13.1%). A statistically signicant
difference between smoking and complications was found
(p 0.009). Table 3 lists the postoperative complications for both
donor and recipient sites in relation to smoking habit.
Great importance was placed on the management of the postoperative complications. Minor effects were treated conservatively
with chlorexamide mouth rinse and antibiotics, either orally or
intravenously. Patients with persistent sinus maxillaris perforation
and symptoms of sinusitis were being treated surgically in
conjunction with an antibiotic cover. By exposed grafts, the bone
sequesters were removed, the bone block was refreshed, and plastic
was recovered under the antibiotic cover. In 2 cases (1.7%), the bone
graft was totally exposed in combination with wound infection and

Table 2
Postoperative complications at the recipient site, according to patient age.

seepage of pus. The surgical removal of the graft was then inevitable, presenting a failure rate of 0.01%. The subsequent wound
healing was uneventful, but there was insufcient bone for the
insertion of implants. These 2 patients did not wish to have further
bone grafting operation and were nally treated with a normal
ridge-reconstruction. Patients with temporary paresthesia after
suture removal were given follow-up appointments in our clinic,
until their nerve dysfunktion had disappeared. In these 2 patients
with paresthesia, the nerve function was completely recovered 6
weeks after the surgical operation.
Bone resorption was easily visible on removal of the osteosynthesis screws, since the heads of the screws were always 1e2 mm
above the grafted bone. On reopening, the shape of the grafted
block was not visible in most cases. Of the 113 bone reconstructions,
2 (1.7%) required simultaneous augmentation at the time of dental
implant placement.
The average healing period after bone harvesting was 136.1 days
or 4.53 months, with a range of 83e225 43.15 days. The number
of dental implants placed in the maxilla was 134. All implants,
without exception, were placed using the CoDiagnostiX (IVS Solutions AG) program for guided surgery. All implants were integrated
at the abutment connection. To date (i.e., the time point directly
after prosthetic loading), all implantations have been successful,
according to the Kerschbaum and Haastert criteria (Kerschbaum
and Haastert, 1995). In 2 of the 134 cases (1.7%), implant placement proved impossible due to insufcient bone after the
augmentation procedures. The nal rehabilitation with dental implants was possible in 110 of 112 patients, yielding a success rate of
98.2%. After the prosthetic rehabilitation, all aspects of oral function
were completely reestablished in all patients.

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A. Sakkas et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 249e256

Table 3
Incidence of complications in donor and recipient sites according to smoking habit.

4. Discussion
The aim of this study was to report the clinical results, rate of
complications, and bone graft failure after alveolar ridge augmentation in partially edentulous patients prior to implant placement,
using bone blocks from the zygomatic buttress region to be
implanted into small- to medium-sized alveolar defects. The evaluation of survival rate of the inserted implants after 1 year or more
was not the aim of this study. There is no other similar study in the
current literature that describes the morbidity and bone graft
success after augmentation with zygomatic buttress bone block
graft.
In this study, the data were collected by the authors retrospectively after the postoperative phase. The augmented sites differed
in location and type of defect. In the absence of a control group with
bone grafts from a different donor site, the statistical signicance of
the means calculated was not tested. In this study, the suggested
healing time after harvesting was a minimum of 4 months to avoid
extreme bone graft resorptions. In cases of delays of more than 6
months, the lack of stimulation sometimes led to severe graft
resorption so that the osteosynthesis screws were transmucosally
visible.
A total of 113 zygomatic buttress bone block grafts in 112 patients were performed from January 2008 to December 2010 in our
clinic department. All patients were treated using a 2-stage technique; after 4e6 months of healing, the osteosynthesis screws were
removed and the dental implants placed.
Graft loss and graft removal were dened as failure. Swelling,
wound dehiscence, infection with pus, temporary paresthesia, and
perforations of the maxillary sinus membrane were dened as
complications. According to our criteria, 4 patients (3.5%) had
postoperative complications at the donor site and 20 (17.8%) at the
recipient site. Throughout, 93 (82.3%) of the bone grafts were
successful and 20 (17.6%) had complications such as incision-line
dehiscence, swelling from wound infection, or graft exposure. No
major complications were observed regarding donor sites apart
from 2 patients who developed postoperative symptoms of sinusitis in combination with persistent stula. The incidence of temporary infraorbital nerve paresthesia was 1.7%. The nerve function
in these patients at the time of implant insertion was completely
recovered. In the recipient sites, except for minor complications
such as incision-line opening, with or without membrane exposure, wound infection with pus excreted by 5 augmented areas and
bone graft exposures in 7 of the cases was also observed.
We documented only 2 cases of complete failure (graft exposure
and screw mobilization) among 113 onlay bone grafts, which had to
be removed. These 2 patients did not wish no further bone grafting
operations and were nally treated with a normal ridge

reconstruction. Final rehabilitation with dental implants was

possible in 110 of 112 patients, yielding a success rate of 98.2%.
Regarding the number of bone grafts, only 2 of 113 bone blocks
were lost, yielding a failure rate of 0.01%. A comparison of the
success and failure rates with the literature was not possible
because of the lack of similar studies.
The number of dental implants placed in the maxilla was 134. In
2 of the 134 cases (1.7%), implant placement proved impossible due
to insufcient bone after the augmentation procedures, and the
patients were not again surgically treated. The rest implants were
successfully integrated at the abutment connection according to
the Kerschbaum and Haastert criteria (Kerschbaum and Haastert,
1995). According to Kerschbaum and Haastert (1995), the inserted
implants with no peri-implantitis, no mobility and any other clinical pathology at the time of prothetical rehabilitation were dened
as successful. Higher implant failure rates have been reported when
implants are placed into grafted sites (Von Arx et al., 1996). However, in this study, despite the number of complications, rehabilitation with oral implants was not possible in only 1.7% of all bone
grafting procedures. Aghaloo and Moy have already indicated
similar success rates between implants placed in grafted sites
compared with implants placed in native bone (Aghaloo and Moy,
2007). It is noteworthy that the failure rate was, in reality, lower,
because graft exposure was considered as a failure, even though
part of the graft remained intact in most of these cases. Leaving part
of the exposed graft in place usually was adequate to allow sufcient bone for implantation.
According to our experience, the comparative advantages of the
zygomatic buttress region as a donor site are as follows. This donor
site offers easy access with excellent visibility, and yields goodquality bone of the correct morphology. The zygomatic buttress is
a strong bony pillar providing pressure absorption and transduction in the facial skeleton. This donor site has the great
advantage that no muscles have to be detached, and the bony
structure in this area is especially strong (Gellrich et al., 2007). In
the case of an otherwise nontraumatized facial skeleton, a bone
graft of 1.5e2 cm2 taken from the caudal zygomatic buttress zone
will not compromise the strength of the lateral midface frame. With
the described technique, it is possible to harvest approximately
0.5e1 mL of bone without causing damage to surrounding tissues.
This amount of bone is sufcient to cover exposed implant threads
and is adequate to reconstruct alveolar defects in the maxilla of a
width of between 1 and 2 teeth. The convex cross-section of the
bone graft is ideal for the reconstruction of alveolar projection loss
in the anterior and posterior maxillary zone. The zygomatic
buttress bone block graft patients appeared to have fewer difculties in managing postoperative edema and pain. This clinical
experience was also reported by Gellrich et al (Gellrich et al., 2007).

A. Sakkas et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 249e256

Limiting factors are the mucous membrane of the adjacent

maxillary sinus (Langer and Calagna, 1980; Verdugo et al., 2009). Of
all our patients undergoing this type of bone harvesting, a maxillary
sinus perforation were observed in 20 of the incidents. Complications in form of sinusitis in the donor site were postoperatively
noted in 3 of these cases. However, the incidence of membrane
perforation to the maxillary sinus does not signicantly inuence
the success of this method of bone grafting, which makes bone
harvesting with zygomatic buttress bone block graft a safe method
prior to implant placement. Another limiting factor is the close
relationship to the infraorbital foramen (Langer and Calagna, 1980;
Verdugo et al., 2009). However, direct visualization of the infraorbital region allows nerve identication and preservation during
bone graft harvesting. Ideally, preoperatively, the patient should
have a negative history of any sinus diseases. Piezoelectric ultrasonic surgery (Mectron, Deutschland Vertriebs GmbH) provides
good tactile sense in osteotomy, reducing the danger of sinus
membrane perforation (Langer and Calagna, 1980). It must be
pointed out that less experienced surgeons tend not to reach the
zygomatic buttress and therefore remove the graft from the laterally facial sinus wall, resulting in a thinner bone graft, almost always causing membrane perforation. Finally, atrophy of the
zygomatic area related to a syndrome or congenital abnormality, as
well as previous surgery or trauma to the area, could be considered
as contraindications to zygomatic buttress bone harvesting.
However, a comparison with other intraoral donor sites must be
taken into consideration. Intraoral bone grafts from the mandibular
symphysis, retromolar area, mandibular ramus, and maxillary tuberosity provide a good treatment modality for ridge augmentation, and the amount of bone available for harvesting is sufcient
for defects up to the width of 3 teeth (Sant'Ana, 1997). However, the
position of the inferior alveolar nerve must be considered as a
limiting factor. Harvesting of retromolar and symphysis bone grafts
is especially recommended in cases involving multiple tooth
reconstruction in the mandible. In the maxilla, the bone quantity of
the maxillary tubercle is rather limited, restricting its use to small
bony defects (Sant'Ana, 1997; Lye et al., 2008). That makes the
zygomatic buttress 1 of the most valuable donor sites in the
maxilla, considering the low morbidity of donor and recipient sites.
Because the amount of bone harvested from the zygoma is smaller
than that from mandibular donor sites, this technique is best suited
for situations in which only moderate amounts of bone are needed,
especially when implant surgery is undertaken in the maxilla. The
amount of bone that we harvested from this donor site was
adequate to reconstruct alveolar defects of a width of between 1
and 2 teeth. Furthermore, a zygomatic buttress bone block graft is,
in to our experience, easier to harvest than at either the mandibular
symphysis or retromolar site.
However, we must emphasize that every surgical technique for
obtaining intraoral grafts is much related to the skill of the surgeon,
and especially to the characteristics of the graft that the case demands. With surgeon skill and favorable graft characteristics,
complications and surgical risks are minimized.
An association between zygomatic buttress bone block grafting
complications and smoking habits was also found in this study.
Smokers experienced a high failure rate and more postoperative
complications than nonsmokers (Scabbia et al., 2001; Levin et al.,
2004). This statement is applicable to other studies in the literature according to the effect of smoking in intraoral bone harvesting
(Scabbia et al., 2001; Levin et al., 2004). There was a high incidence
of smoking among the patients in our study (74 of 112 patients). It
was our study (Sakkas, Schramm etc.) meaned. A lower rate would
probably reduce complication rates and optimize grafting outcomes. Nevertheless, for this high smoking rate, the augmentation
outcome was more than satisfactory, and led to functional and

255

esthetically successful results. Our study is the rst to examine the

effects of smoking in relation to grafting success with bone blocks
from the zygomatic buttress.
In general, patients with prediagnosed periodontitis, usually
chronic, show signicantly higher failure rates and have more
postoperative complications. Since periodontitis increases the risk
of infection and delays wound healing, this kind of ridge
augmentation may not be suitable for these patients (Langer and
Calagna, 1980; Verdugo et al., 2009). However, the signicance of
periodontitis as a risk factor for failure was not determined in this
study.
The complications documented in this study after autogenous
bone grafting from the zygomatic buttress did not inuence
signicantly the success of the nal dental rehabilitation. The
compliance of our patients during the entire surgical therapy was
excellent, despite the need for 2 surgical treatments. A full appreciation of the clinical dimensions of the alveolar bone effect prior to
graft harvesting and augmentation, together with 3-dimensional
planning, were key factors in every successful case. It was also
important to understand patient expectations of the surgical procedure, in order to achieve the best outcomes.
5. Conclusion
Based on our experience in this study, we conclude that harvesting of intraoral bone blocks from the zygomatic buttress region
is an effective and safe method to treat localized alveolar ridge
atrophy before implant placement, and can lead to long-term
success. The fact that postoperative discomfort after stage 1 surgery is comparable to postsurgical complaints after dentoalveolar
surgery must be taken into consideration. The complication rate
was very low, and the total outcome very good. This method of
bone grafting represents an excellent alternative for augmentation
of atrophied anterior and posterior maxilla regions prior to implantation. A longer follow-up is needed to determinate the longterm efcacy of the grafting technique described, in comparison
to use of other intraoral donor sites. More prospective, welldesigned, long-term trials are needed to evaluate implant stability and bone resorption after this method of augmentation.
Conict of interest
None of the authors had a conict of interest. The authors do not
have any nancial interests, either directly or indirectly, in the
products listed in the study.
Acknowledgments
The authors thank Winter Carsten for assistance in data analyses
and measurements and Professor Schramm for assistance with
study administration.
References
Aghaloo TL, Moy PK: Which hard tissue augmentation techniques are the most
successful in furnishing bony support for implant placement? Int J Oral Maxillofac Implant 22: 49e70, 2007
Brnemark PI, Lindstrom J, Hallen O, Breine U, Jeppson PH, Ohman A: Reconstruction of the defective mandible. Scand J Plast Reconstr Surg 9: 116e128,
1975
Chiapasco M, Zaniboni M, Boisco M: Augmentation procedures for the rehabilitation of decient edentulous ridges with oral implants. Clin Oral Implant Res 17:
136e159, 2006
Collins TA: Onlay bone grafting in combination with Brnemark implants. Oral
Maxillofac Surg Clin North Am 3: 893e902, 1991
Esposito M, Grusovin MG, Coulthard P, Worthington HV: The efcacy of various
bone augmentation procedures for dental implants: a Cochrane systematic
review of randomized controlled clinical trials. Int J Oral Maxillof Implant 21:
696e710, 2006

256

A. Sakkas et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 249e256

Gellrich NC, Held U, Schoen R, Pailing T, Schramm A, Bormann KH: Alveolar zygomatic buttress: a new donor site for limited preimplant augmentation procedures. J Oral Maxillofac Surg 65: 275e280, 2007
ndor GK, Clokie CM, Keller AM, Oikarinen KS: The zygoKainulainen VT, Sa
matic bone as a potential donor site for alveolar reconstructionda
quantitative anatomic cadaver study. Int J Oral Maxillofac Surg 33:
786e791, 2004
ndor GK, Oikarinen KS, Clokie CM: Zygomatic bone: an additional
Kainulainen VT, Sa
donor site for alveolar bone reconstruction. Technical note. Int J Oral Maxillofac
Implant 17: 723e728, 2002
Keller EE, Van Roekel NB, Desjardins RP, Tolman DE: Prosthetic surgical
reconstruction of the severely resorbed maxilla with iliac bone grafting
and tissue integrated prostheses. Int J Oral Maxillofac Implant 2: 155e165,
1987
Kerschbaum T, Haastert B: Statistische Verweildaueranalysen in der Implantologie.
Implantologie 2: 101e111, 1995
Kwast WAM, Krekeler G, Oostenbeek HS: Autogenous maxillary bone grafts in
conjunction with placement of ITI endosseus implants. Int J Oral Maxillofac
Surg 21: 81e84, 1992
Lang NP, Berglundh T, Heitz-Mayeld LJ, Pjetursson BE, Salvi GE, Sanz M: Consensus
statements and recommended clinical procedures regarding implant survival
and complications. Int J Oral Maxillofac Implant 19: 150e154, 2004
Langer B, Calagna L: The subepithelial connective tissue graft. J Prosthet Dent 44:
363e367, 1980
Lekholm U, Wannforms K, Isaksson S, Adielsson B: Oral implants in combination
with bone grafts. A 3-year retrospective multicenter study using the Brnemark
implant system. Int J Oral Maxillofac Surg 28: 181e187, 1999
Levin L, Herzberg R, Dolev E, Schwartz-Arad D: Smoking and complications of
onlay bone grafts and sinus lift operations. Int J Maxillofac Implant 19:
369e373, 2004
Listrom RD, Symington JM: Osseointegrated dental implants in conjuction with
bone grafts. Int J Oral Maxillofac Surg 17: 116e118, 1988
Lye KW, Deatherage JR, Waite PD: The use of demineralized bone matrix for grafting
during Le Fort I and chin osteotomies: techniques and complications. J Oral
Maxillofac Surg 66: 1580e1585, 2008
Lynch SE, Genco RJ, Marx R: Tissue engineering: applications in maxillofavial
surgery and periodontics, 1st edn. Chicago: Quintessence Publishing,
83e98, 1999

McGrath CJ, Schepers SH, Blijdorp PA, Hoppenreijs TJ, Erbe M: Simultaneous
placement of endosteal implants and mandibular onlay grafting for treatment
of the atrophic mandible. A preliminary report. Int J Oral Maxillofac Surg 25:
184e188, 1996
Misch CE, Scoretecci GM, Benner KU: Implants and restorative dentistry. London: M
Duntz, 144e145, 2001
Raghoebar GM, Batenburg RH, Vissink A, Reintsema H: Augmentation of localized
defects of the anterior maxillary ridge with autogenous bone before insertion of
implants. J Oral Maxillofac Surg 54: 1180e1185, 1996
Sant'Ana E: Short-term survival of osseointegrated implants installed in alveolar
~o Paulo
ridge reconstructed with autogenous graft. Bauru School of Dentistry, Sa
University, 1997 (Thesis submitted to obtain PhD)
Scabbia A, Cho KS, Sigurdsson TJ, Kim CK, Trombelli L: Cigarette smoking negatively
affects healing response following ap debridement surgery. J Periodontol 72:
43e49, 2001
Schulze-Mosgau S, Keweloh M, Wiltfang I, Kessler P, Neukam FW: Histomorphometric and densitometric changes in bone volume and structure following
avascular bone grafting in the extremely atrophic maxilla. J Oral Maxillofac Surg
39: 439e447, 2001
Strobe Statement: Strengthening the reporting of observational studies in epidemiology. Available at: http://www.strobe-statement.org/index.php?idstrobehome; [accessed 10.02.14], 2014
Topazian RG: The basis of antibiotic prophylaxis. In: Worthington P, Branemark PI
(eds), Advanced osseointegration surgery. Chicago: Quintessence Publishing,
57e66, 1992
n J: Bone microbial contamination inVerdugo F, Castillo A, Moragues MD, Ponto
uences autogenous grafting in sinus augmentation. J Periodontol 80:
1355e1364, 2009
Von Arx T, Hardt N, Wallkamm B: The TIME technique: a new method for localized
alveolar ridge augmentation prior to placement of dental implants. Int J Oral
Maxillofac Surg 11: 387e394, 1996
Williamson RA: Rehabiliation of the resorbed maxilla and mandible using autogenous bone grafts and osseointegrated implants. Int J Oral Maxillofac Implant
11: 476e488, 1996
Wolford LM, Cooper RL: Alternative donor sites for maxillary bone grafts. J Oral
Maxillofac Surg 43: 471e472, 1985