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implants - international magazine of oral implantology International Edition

woundhealinghavebeenreported.Sinceourpatients weresenthomeadayaftertheendofthebonegraft- ing procedure, our aim was to reduce swelling as much as possible. Intraoral or intravenous antibiotic therapy postoperative was not given. There is no evi- dence that prolonging antibiotic therapy after the first day gives additional protection if antibiotic pro- phylaxis is correctly prescribed.47 Besides these con- siderations, many surgeons when using bone grafts ormembranesdescribetheuseofintraoralantibiotics for a period varying from three to ten days postoper- atively.6, 53 The potential for damage to the inferior alveolar nerve, as opposed to its peripheral mental branches, is of greater concern with the ramus graft technique. To preventnerveinjury,harvestofbonefromthisareare- quiresknowledgeofthemandibularcanalanatomy.Al- though the position of the canal is variable, anatomic averagesarehelpfulinsurgicalplanning.Themeanan- teroposterior width of the ramus is 30.5 mm, with the mandibular foramen located about two thirds of the distancefromtheanteriorborder.54, 55 The mean vertical distance between the superior edgeofthecanalandthecorticalsurfacealongtheex- ternal oblique ridge is approximately 7 mm in the sec- ondmolarregion,11mminthethirdmolarregion,and 14mmatthebaseofthecoronoidprocess.55 Although the buccolingual position of the mandibular canal is variable, the distance from the canal to the medial as- pectofthebuccalcorticalplate(medullarybonethick- ness) was found to be greatest at the distal half of the first molar (mean= 4.05 mm).55 Therefore, when larger graftsareplanned,theanteriorverticalbonecutshould be made in this area.56 Damage to the neurovascular bundle could also occur during sectioning of the graft. Caremustbetakentoparallelthelateralsurfaceofthe ramus when using the thin chisel along the external obliqueosteotomy.Iftheinferiorramuscutisbelowthe level of the inferior alveolar canal, graft separation shouldnotbecompleteduntilitcanbeascertainedthat theneurovascularbundleisnotentrappedinthegraft. Sometimes, the exposure of the inferior alveolar nerve is accompanied by massive bleeding, because of injury totheinferioralveolarartery.22 Patientswerelessabletodiscernneurosensorydis- turbancesintheposteriorbuccalsofttissuesthaninthe lower lip. Although the incision along the external oblique ridge could possibly damage the buccal nerve, reportsofpostoperativesensorylossinthebuccalmu- cosa are rare, and most go unnoticed by the patient.57 Nospecifictreatmentwasrequired,andallpatientsre- coveredcompletely. It is noteworthy that the failure rate was, in reality, lower because graft exposure was considered as fail- ures, even though part of the graft remained intact in mostofthesecases.Leavingpartoftheexposedgraftin placeusuallywasadequatetoallowsufficientbonefor implantation. Generally, patients who suffer from diabetes show significantlyhigherfailureratesandhavemorepostop- erative complications. Since diabetes increases the risk ofinfectionanddelayswoundhealing,itispossiblethat thiskindofridgeaugmentationisnotsuitableforthese patients. A significant failure of diabetics in this study was, because of lack of fails, not presentable. However, more research should be conducted to determine how to perform a harvesting procedure in diabetic patients withouttheriskofgraftfailure.58 Smokersdemonstrate a high failure rate and more postoperative complica- tions.59 Smokingwasfoundtoimpairtherevasculariza- tionoftheboneinregenerativeproceduressuchasbone grafting,mainlyduetoitseffectonvasoconstrictionof the artery.59 The altered oral flora from smoking in- creasedtheinfectionratebytwotothreetimesinsmok- I research Table 6_Type and number of postsurgical complications in recipient sites. Fig. 4_Incidence of complications noticed in donor and recipient sites according to smoking. 10 I implants4_2013 Type of complication N Incision line opening 4 Swelling/wound infection with pus 6 Swelling/abscess 4 Graft exposure 1 Wound infection with pus und graft expo- sure 5 Graft exposure und screw mobilization 2 Hypoesthesia N.infraorbital 1 Total 23