Int. J. Oral Maxillofac. Surg.

2015; 44: 1131–1137

http://dx.doi.org/10.1016/j.ijom.2015.04.009, available online at http://www.sciencedirect.com

Clinical Paper
Dental Implants

The effect of conventional N. Altiparmak1, S. S. Soydan1,

S. Uckan2
1
Department of Oral and Maxillofacial

surgery and piezoelectric Surgery, Baskent University, Ankara, Turkey;

2
Department of Oral and Maxillofacial
Surgery, Istanbul Medipol University, Istanbul,
Turkey

surgery bone harvesting

techniques on the donor site
morbidity of the mandibular
ramus and symphysis
N. Altiparmak, S.S. Soydan, S. Uckan: The effect of conventional surgery and
piezoelectric surgery bone harvesting techniques on the donor site morbidity of the
mandibular ramus and symphysis. Int. J. Oral Maxillofac. Surg. 2015; 44: 1131–1137.
# 2015 International Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.

Abstract. The aim of this study was to evaluate the morbidity following bone harvesting
at two different intraoral donor sites, mandibular symphysis and ramus, and to
determine the effects of piezoelectric and conventional surgical graft harvesting
techniques on donor site morbidity. Intraoral block bone grafts were harvested from
the symphysis (n = 44) and ramus (n = 31). The two donor site groups were divided
into two subgroups according to the surgical graft harvesting method used
(conventional or piezoelectric surgery). Intraoperative and postoperative pain was
assessed using a visual analogue scale (VAS). Donor site morbidity and the harvesting
techniques were compared statistically. Of 290 teeth evaluated in the symphysis
group, four needed root canal treatment after surgery. The incidence of transient
paresthesia in the mucosa was significantly higher in the symphysis group than in the
ramus group (P = 0.004). In the symphysis group, the incidence of temporary skin and
mucosa paresthesia was lower in the piezoelectric surgery subgroup than in the
conventional surgery subgroup (P = 0.006 and P = 0.001, respectively). No
permanent anaesthesia of any region of the skin was reported in either donor site
Key words: bone block grafts; bone augmenta-
group. VAS scores did not differ between the ramus and symphysis harvesting groups,
tion; piezoelectric surgery; autologous bone
or between the piezoelectric and conventional surgery subgroups. When the grafts; morbidity.
symphysis was chosen as the donor site, minor sensory disturbances of the mucosa and
teeth were recorded. The use of piezoelectric surgery during intraoral harvesting of Accepted for publication 21 April 2015
bone blocks, especially from the symphysis, can reduce these complications. Available online 5 June 2015

0901-5027/0901131 + 07 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1132 Altiparmak et al.
Bone grafting techniques for pre-prosthet-
ic alveolar reconstruction, with varying
degrees of success, are well documented
in the literature.1,2 A variety of allografts
and alloplastic grafts have been used,
however the vast majority of authors have
reported the superiority of autogenous
bone for alveolar reconstruction.3 Autog-
enous bone is considered the gold standard
for osseous reconstruction because it does
not produce immunological reactions and
contains osteoinductive components.1–4
Although the iliac crest is most often
used in jaw reconstruction, there is a sig-
nificant risk of resorption with iliac block
bone grafts.5,6 This disadvantage, and
the fact that dental implants do not
require a large amount of bone, has led
to the increasing use of autogenous block
bone grafts from intraoral sources, partic-
ularly from the mandibular symphysis and
ramus.7
In the repair of localized alveolar
defects, bone grafts from the symphysis
and the ramus offer several benefits: (1)
conventional surgical access; (2) the prox-
imity of donor and recipient sites reduces
the length of the operation and the time
spent under anaesthesia, making intraoral
bone grafts ideal for outpatient implant
surgery; and (3) minimal discomfort
reported by patients because of the lack
of a cutaneous scar and less morbidity as
compared with extraoral locations.1,8,9
Despite these advantages, several compli-
cations are mentioned in the literature
related to bone graft harvesting from the
symphysis and the ramus. These include
tooth numbness, neurosensory distur-
bances, alterations of mucosa and skin
sensitivity, postoperative discomfort (lim-
ited mouth opening, bleeding, swelling,
and pain), and aesthetic problems
(changes in the contour of the donor area
or soft tissue recession).10–22
An advantage of the ramus donor site
over the symphysis site is fewer com-
plaints of postoperative discomfort. The
disadvantages of the ramus area include
the limited surgical access, limited graft
volume, and potential hazard of damage to
the mandibular neurovascular bundle.10
Although these features appear to indicate
the mandibular symphysis as the graft
donor site of choice,16,23,24 both mandib-
ular symphysis and ramus bone grafts are
commonly preferred in clinical practice.
The use of ultrasonic vibrations to cut
bone was first introduced two decades ago
to overcome the limitations of traditional
instrumentation in oral bone surgery; this
was done by modifying and improving
conventional ultrasound technology. Pie-
zoelectric surgery is a minimally invasive
technique that reduces the risk of damage
to the surrounding soft tissues and impor-
tant structures, such as nerves, vessels, and
mucosa, and produces less collateral tissue
damage, resulting in better healing.25,26
This surgery also reduces damage to
osteocytes during the bone harvesting pro-
cedure. Furthermore, piezoelectric sur-
gery minimizes patient psychological
stress and fear during osteotomy under
local anaesthesia. It is believed that the
use of piezoelectric surgery for autoge-
nous alveolar bone harvesting may reduce
the risk of sensory disturbance and other
donor site morbidities.11
A few reports in the literature describ-
ing long-term follow-up studies, claim
that the mandibular ramus and the retro-
molar areas are associated with less donor
site morbidity than the parasymphyseal
region.12 However, there is still a lack
of information regarding any differences
in donor site morbidity between the man-
dibular ramus and the symphysis, espe-
cially when early postoperative results are
considered. The aims of this study were as
follows: (1) to evaluate and compare the
morbidity of the mandibular symphysis
and ramus donor sites; and (2) to compare
the effects of different bone harvesting
methods (conventional or piezoelectric
surgery) on donor site morbidity.
Materials and methods
This prospective study was conducted on
patients undergoing an onlay bone grafting
procedure, performed by the same surgeon
in the Department of Oral and Maxillofacial
Surgery of Baskent University, between
January 2011 and January 2013. Intraoral
grafts were harvested consecutively from
the mandibular ramus or symphysis;
harvesting procedures were performed con-
secutively by either conventional or piezo-
electric surgery. Patients who were able to
attend the clinic for follow-up appointments
at 1 and 6 months postoperative were in-
cluded in the study.
The following patients were excluded:
those who smoked, patients on medica-
tion, patients with periodontal disease,
patients with any systemic disorder, such
as hypertension, diabetes, rheumatic dis-
ease, or a neurological disease, and
patients who required revision for an onlay
bone grafting procedure.
Surgical procedures
The recipient area was first prepared. Mid-
crestal and vertical mucosal incisions were
made along the recipient area, depending
on the graft localization. A mucoperiosteal
flap was reflected, and bone defects were
revealed. Next, the donor sites were ex-
posed surgically, and a block bone graft
was obtained by means of a conventional
bone harvesting procedure or using piezo-
electric surgical equipment (VarioSurg
50/60 Hz; NSK, Nakanishi Inc., Kanuma,
Tochigi, Japan).
To harvest the bone graft from the
mandibular ramus, the mucosal incision
was performed medial to the external
oblique ridge and extended anteriorly to
the buccal sulcus of the molar teeth and
posteriorly to the retromolar region. A
mucoperiosteal flap was reflected, expos-
ing the lateral aspect of the ramus and the
third molar area. An anterior vertical bone
cut was performed (the length of the bone
block depended on the size of the bone
graft required), and a posterior vertical
bone cut was made on the lateral aspect
of the ramus. Following the superior hori-
zontal bone cut, an inferior horizontal
bone cut was performed to avoid an unfa-
vourable fracture. Osteotomy lines were
elevated with a thin chisel along the entire
length of the osteotomy, and the bone
block was separated gently to avoid dis-
turbance of the inferior alveolar nerve.
To harvest the bone graft from the
symphysis, a full thickness horizontal mu-
cosal incision was performed in the ves-
tibular area of the lower incisor teeth from
the right canine to the left canine, and a
mucoperiosteal flap was created. The
superior horizontal bone cut was per-
formed at least 5 mm below the apices
of the incisor teeth and the inferior hori-
zontal bone cut was performed at least
5 mm above the lower border of the man-
dible. The size of the bone graft was
determined by considering the size of
the bone defect at the recipient site. The
vertical osseous cuts were made under
copious irrigation with saline. After re-
moving the corticocancellous bone block
with a bone chisel, additional bone was
harvested from the caudal site with gauges
and curettes. Sharp osseous edges and
irregularities were reduced to minimize
postoperative discomfort. A gelatin
sponge was applied as a haemostatic
dressing to the donor area.
The bone blocks were all monocortical
bone grafts. The lingual cortex was left
intact at the donor site. The block bone
graft was adapted and immediately posi-
tioned over the recipient area. This graft
was fixed to the recipient site with two
titanium miniscrews that were 1.5 mm wide
and 10 mm long (Synthes GmbH, Oberdorf,
Switzerland), and were removed during
implant placement. Any sharp angles of
the bone block that could perforate the

overlying mucosa were removed with a
round bur. The periosteum of the buccal
flap at the recipient site was incised to allow
the adaptation of the wound margins to be as
tension-free as possible. Both the donor and
the recipient sites were sutured with resorb-
able sutures, and the sutures were removed
1 week later.
Assessments
Clinical symptoms such as excessive in-
traoperative bleeding and a prolonged pe-
riod of healing at the donor site were
recorded for all graft harvesting proce-
dures. A visual analogue scale (VAS)
was used to assess both intraoperative
and postoperative pain.
Parameters of sensory disturbance were
evaluated by the same clinician (NA) on
both the oral mucosa and adjacent skin
(Fig. 1) at 1 and 6 months postoperative.
The superficial sensory function of the oral
mucosa and adjacent skin was assessed by
means of the pointed–blunt test (cotton
pellets were used to lightly touch the
mucosa and skin for the evaluation of
tactile sensitivity). The superficial sensory
function of the oral mucosa and adjacent
Fig. 1. (A) The region of oral mucosa evaluated for the symphysis group; (B) the region of oral
mucosa evaluated for the ramus group; (C) the region of skin evaluated for the symphysis group;
(D) the region of skin evaluated for the ramus group.
Donor site morbidity of symphysis and ramus
skin was also assessed by two-point dis-
crimination test. Patients were asked to
differentiate the number of contacts on the
mucosa and skin with their eyes closed.
The results were classified into three
groups: distance <7 mm indicating no
alteration, distance 7–11 mm indicating
a slight alteration, and distance >11 mm
indicating impaired sensitivity.
The vitality of the teeth adjacent to the
harvesting sites was evaluated using an
electric pulp test (Pulp Vitality Tester 9V;
Parkell Inc., Edgewood, NY, USA) and
the necessity for root canal treatment was
evaluated at 6 months postoperative.
The symphysis (n = 44) and ramus
(n = 31) groups were divided into sub-
groups according to the surgical graft
harvesting method used: conventional sur-
gery or piezoelectric surgery. First, the
parameters for donor site morbidity of
the ramus and symphysis groups were
compared, and then the subgroups of each
group were compared.
Statistical analysis
The data analysis was performed using
SPSS for Windows version 11.5 (SPSS
1133
Inc., Chicago, IL, USA). Ordinal data
were recorded as the median (mini-
mum–maximum); the number of cases
and percentage were recorded for nominal
data. The Wilcoxon signed rank test was
used to determine whether differences in
median VAS scores between groups were
statistically significant. Nominal data
were analyzed using Pearson’s x2, conti-
nuity corrected x2, or Fisher’s exact test,
as applicable. A P-value of less than 0.05
was considered statistically significant.
For all possible multiple comparisons,
the Bonferroni correction was applied to
control type I error.
Results
Out of 105 consecutive patients, 64 (16
males and 48 females) were included in
this study after applying the inclusion and
exclusion criteria. These 64 patients un-
derwent 75 bone grafting operations. They
ranged in age from 17 to 71 years (mean
age 44.8 years).
Forty-four bone harvests were from the
mandibular symphysis (symphysis group)
and 31 were from the mandibular ramus
(ramus group). In the symphysis group, 13
bone harvests were done by conventional
surgery and 31 by piezoelectric surgery. In
the ramus group, 15 bone harvests were
done by conventional surgery and 16 by
piezoelectric surgery.
No sign of major sensory disturbance,
permanent paresthesia (anaesthesia), hy-
peresthesia, or hypoesthesia of the oral
mucosa or the adjacent skin was detected
in either the symphysis group or the ramus
group at 6 months postoperative. Howev-
er, different incidences of minor sensory
disturbance (temporary paresthesia) were
observed in the symphysis and ramus
groups at 1 month postoperative.
There was no statistical difference be-
tween the symphysis and ramus groups
with respect to the incidences of excessive
intraoperative bleeding and a prolonged
healing period. Excessive intraoperative
bleeding was seen in three cases in the
ramus group (9.7%), whereas it was not
seen in any case in the symphysis group. A
prolonged healing period was detected in
five cases in the ramus group (16.1%) and
in four cases in the symphysis group
(9.1%).
When temporary paresthesia of the skin
was assessed in the patients in the ramus
and symphysis groups by pointed–blunt
test, no statistically significant difference
was found between the two groups. How-
ever, temporary paresthesia of the oral mu-
cosa, as assessed by the pointed–blunt test,
was significantly higher in the symphysis
1134 Altiparmak et al.

Table 1. Results of the pointed–blunt test for the ramus and symphysis groups. pointed–blunt test results, there was a
Parameters Ramus group (n = 31) Symphysis group (n = 44) P-valuea statistically significant difference in the
incidence of temporary paresthesia
Skin 1.000b
Normal 27 (87.1%) 38 (86.4%) between the two bone graft harvesting
Temporary paresthesia 4 (12.9%) 6 (13.6%) subgroups (conventional surgery and pie-
Mucosa 0.004c zoelectric surgery) of the symphysis group
Normal 28 (90.3%) 25 (56.8%) when the results of the two-point discrim-
Temporary paresthesia 3 (9.7%) 19 (43.2%) ination test of the oral mucosa and the skin
a
According to the Bonferroni correction, P < 0.025 was considered statistically significant. were evaluated: temporary paresthesia of
b
Fisher’s exact test. both the skin and the oral mucosa was
c
Continuity corrected x2 test. significantly lower in those patients in the
symphysis group who underwent piezo-
electric surgery (Table 5).
Table 2. Results of the two-point discrimination test for the ramus and symphysis groups. There was no statistically significant
Parameters Ramus group (n = 31) Symphysis group (n = 44) P-valuea difference between the two bone graft
harvesting techniques (conventional sur-
Skin 0.039b
<7 mm 31 (100.0%) 38 (86.4%) gery and piezoelectric surgery) used in the
7–11 mm 0 (0.0%) 6 (13.6%) ramus group when intraoperative and
Mucosa 0.142c postoperative median VAS pain scores
<7 mm 26 (83.9%) 29 (65.9%) were considered (1.8 vs. 1.9). However,
7–11 mm 5 (16.1%) 15 (34.1%) the median intraoperative VAS score of
a
According to the Bonferroni correction, P < 0.025 was considered statistically significant. the symphysis group was higher with con-
b
Fisher’s exact test. ventional surgery (3.1) than with piezo-
c
Continuity corrected x2 test. electric surgery (1.6) (P < 0.001). There
was no statistically significant difference
between the two bone graft harvesting
group (P = 0.004) (Table 1). When tempo- There was no statistically significant techniques in the symphysis group when
rary paresthesia of the skin and mucosa difference in the incidence of temporary the postoperative median VAS pain scores
was assessed in patients in the ramus and paresthesia in the ramus group according were considered (Table 6).
symphysis groups by two-point discrimina- to the two bone graft harvesting techni- In the ramus group, 32 teeth were eval-
tion test, there was no statistically signifi- ques used (conventional surgery and pie- uated in the conventional surgery sub-
cant difference between the two groups zoelectric surgery), when the results of the group and 28 teeth in the piezoelectric
(Table 2). pointed–blunt test of the oral mucosa and surgery subgroup. In the symphysis group,
There was no statistically significant the skin were evaluated. However, there 113 teeth were evaluated in the conven-
difference between the symphysis and was a statistically significant difference in tional surgery subgroup and 177 in the
ramus groups for intraoperative and post- the incidence of temporary paresthesia in piezoelectric surgery subgroup. There
operative VAS scores, the necessity for the symphysis group according to the two was no statistically significant difference
root canal treatment to the adjacent tooth, bone graft harvesting techniques used between the two bone graft harvesting
or for a negative vitality test result. The (conventional surgery and piezoelectric techniques in the ramus group when the
intraoperative and postoperative median surgery), when the results of the point- necessity for root canal treatment and the
VAS pain scores were similar in the ramus ed–blunt test of the oral mucosa and the loss of vitality of adjacent teeth were
and symphysis groups (Table 3). Sixty skin were evaluated: temporary paresthe- considered. In the symphysis group, the
teeth related to the bone graft harvesting sia of both the skin and the oral mucosa loss of vitality of adjacent teeth was sig-
site were evaluated in the ramus group and was significantly lower in those who un- nificantly lower in the piezoelectric sur-
290 teeth were evaluated in the symphysis derwent piezoelectric surgery (Table 4). gery group than in the conventional
group. Root canal treatment was not re- The results of the two-point discrimina- surgery group. The necessity for root canal
quired in the ramus group; in the symphy- tion test of the oral mucosa and the skin treatment (n = 4) was observed only in the
sis group, however, four root canal were similar for the conventional surgery conventional surgery subgroup of the sym-
treatments of an adjacent tooth were need- and piezoelectric surgery subgroups in the physis group. The loss of vitality of adja-
ed (Table 3). ramus group. In concordance with the cent teeth was higher with conventional

Table 3. Comparison of the intraoperative and postoperative VAS pain scores, the necessity for root canal treatment, and the incidence of loss of
vitality of the tooth adjacent to the bone harvest site in the ramus and symphysis groups.
Parameters Ramus group (n = 31) Symphysis group (n = 44) P-valuea
Intraoperative VAS score, median (range) 1.9 (0.0–6.1) 1.9 (0.0–5.0) 0.500b
Postoperative VAS score, median (range) 1.3 (0.0–4.0) 1.5 (0.0–5.8) 0.862b
Necessity for root canal treatment 0 (0.0%) 4 (1.4%) 1.000c
Negative vitality test result 8 (13.3%) 40 (13.8%) 1.000d
VAS, visual analogue scale.
a
According to the Bonferroni correction, P < 0.025 was considered statistically significant.
b
Mann–Whitney U-test.
c
Fisher’s exact test.
d
Continuity corrected x2 test.
 Donor site morbidity of symphysis and ramus 1135

Table 4. Results of the pointed–blunt test for the ramus and symphysis groups according to the surgery in both the ramus and the symphy-
bone harvesting technique. sis groups, although this was not significant
Conventional Piezoelectric for the ramus group (Table 6).
Parameters surgery surgery P-valuea
Ramus group Discussion
Skin 0.043b
Normal 11 (73.3%) 16 (100.0%) Many studies on intraoral alveolar bone
Temporary paresthesia 4 (26.7%) 0 (0.0%) harvesting have focused mainly on the
Mucosa 0.600b reconstructive procedure at the recipient
Normal 13 (86.7%) 15 (93.8%) site,9,27–30 or on the complications related
Temporary paresthesia 2 (13.3%) 1 (6.3%) to harvesting. Only a very limited number
Symphysis group
Skin 0.006b
of studies have reported the results of the
Normal 8 (61.5%) 30 (96.8%) harvesting procedure,30 and all have con-
Temporary paresthesia 5 (38.5%) 1 (3.2%) firmed the superiority of the ramus over
Mucosa 0.001c the symphysis as an intraoral donor site,
Normal 2 (15.4%) 23 (74.2%) since it has less associated morbidity. In
Temporary paresthesia 11 (84.6%) 8 (25.8%) contrast to the common use of mandibular
a
According to the Bonferroni correction, P < 0.0125 was considered statistically significant. bone grafts, data related to the comparison
b
Fisher’s exact test. of mandibular ramus and symphysis donor
c
Continuity corrected x2 test. site morbidity are still sparse. For this
reason, the present study was conducted
to compare the donor site morbidity result-
ing from the harvesting of bone from the
Table 5. Results of the two-point discrimination test for the ramus and symphysis groups mandibular symphysis and the ramus.
according to the bone harvesting technique. Cordaro et al.12 reported significantly
Conventional Piezoelectric higher paresthesia of the oral mucosa ad-
Parameters surgery surgery P-valuea jacent to the mandibular symphysis bone
Ramus group harvesting site than the mandibular ramus
Skin – site as assessed with the pointed–blunt
< 7 mm 15 (100.0%) 16 (100.0%) test, similar to the present results. Howev-
7–11 mm 0 (0.0%) 0 (0.0%) er, a markedly lower percentage of tem-
Mucosa 1.000 porary paresthesia of the oral mucosa
< 7 mm 13 (86.7%) 13 (81.3%) adjacent to the mandibular symphysis
7–11 mm 2 (13.3%) 3 (18.7%) bone harvesting site was reported in the
Symphysis group
Skin 0.006
study of Cordaro et al.,12 compared with
< 7 mm 8 (61.5%) 30 (96.8%) the first month result in the present study
7–11 mm 5 (38.5%) 1 (3.2%) (5.4% vs. 43.2%). A possible reason for
Mucosa <0.001 this difference may be the long-term fol-
< 7 mm 2 (15.4%) 27 (87.1%) low-up (mean 29 months) of the study by
7–11 mm 11 (84.6%) 4 (12.9%) Cordaro et al.12
a
According to the Bonferroni correction, P < 0.0125 was considered statistically significant; Recent studies have reported that
Fisher’s exact test. both ramus and symphysis harvesting
procedures are well accepted by patients,
but that the ramus procedure is generally
preferred.30 The harvesting and grafting

Table 6. Comparison of the intraoperative and postoperative VAS pain scores, the necessity for root canal treatment, and the incidence of loss of
vitality of the tooth adjacent to the bone harvest site in the ramus and symphysis groups according to the bone graft harvesting technique.
Parameters Conventional surgery Piezoelectric surgery P-valuea
Ramus group
Intraoperative VAS score, median (range) 1.8 (0.0–6.1) 1.9 (0.0–5.8) 0.446b
Postoperative VAS score, median (range) 1.8 (0.0–4.0) 1.1 (0.0–4.0) 0.922b
Necessity for root canal treatment 0 (0.0%) 0 (0.0%) –
Negative vitality test result 7 (21.9%) 1 (3.6%) 0.057c
Symphysis group
Intraoperative VAS score, median (range) 3.1 (1.8–4.3) 1.6 (0.0–5.0) <0.001b
Postoperative VAS score, median (range) 1.8 (1.3–2.5) 1.0 (0.0–5.8) 0.051b
Necessity for root canal treatment 4 (3.5%) 0 (0.0%) 0.022c
Negative vitality test result 28 (24.8%) 12 (6.8%) 0.001d
VAS, visual analogue scale.
a
According to the Bonferroni correction, P < 0.0125 was considered statistically significant.
b
Mann–Whitney U-test.
c
Fisher’s exact test.
d
Pearson’s x2.
1136 Altiparmak et al.
procedures were most often performed in
the same surgical field in the ramus group
in the present study; therefore, it may have
been difficult for the patient to differenti-
ate the discomfort caused by each of these
two separate procedures. This should be
considered as a confounding factor. In this
study, there was no significant difference
between the ramus and the symphysis
groups when intraoperative and postoper-
ative VAS pain scores and intraoperative
bleeding were considered. Excessive in-
traoperative bleeding was observed only
in the ramus group in the present study,
with a percentage of 9.7%, which is almost
the same as the result obtained in the study
of Cordaro et al.12 (9.8% intraoperative
bleeding in the ramus group).
The impact of piezoelectric surgery on
donor site morbidity has not been investi-
gated previously. It could be hypothesized
that the easier and safer alveolar bone
harvesting via piezoelectric surgery may
reduce the morbidity of mandibular donor
sites. In this study, the incidence of the
temporary paresthesia of the skin and the
oral mucosa in the symphysis group was
significantly lower in the piezoelectric
surgery subgroup than in the conventional
subgroup as assessed by the pointed–blunt
test. In addition, intraoperative VAS
scores, the loss of vitality of adjacent
teeth, and the necessity for root canal
treatment were lower in the piezoelectric
surgery subgroup in the symphysis group.
Even though it has been suggested that
the use of a piezoelectric device provides
distinct advantages in the harvesting of
oral bone grafts,31,32 it should not be for-
gotten that piezoelectric surgery has some
critical disadvantages, including a longer
operation time and heat generation during
bone cutting.33
In this study, the mandibular symphysis
donor site showed a higher incidence of
minor sensory disturbance of the mucosa
and the teeth than the mandibular ramus
donor site. Harvesting mandibular symphy-
sis bone grafts by piezoelectric surgery was
found to significantly decrease the inci-
dence of sensory disturbance of both the
skin and the oral mucosa, and to reduce
pulp damage in the adjacent teeth. If the
acceptable morbidity rate and the subjec-
tive moderate complaints are considered,
bone harvesting from the mandibular sym-
physis remains a good option for the recon-
struction of local bone defects. Patients
must, however, be informed of the risk of
sensory disturbance in the donor region.
Funding
None declared.
Competing interests
None declared.
Ethical approval
This study was approved by the Institu-
tional Review Board and Ethics Commit-
tee of Baskent University (Project No. D-
KA 13/13).
Patient consent
All patients included in this study provid-
ed signed informed consent. No clinical
photographs are included in this article.
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Turkey
bone graft. Presentation. Second Balkan Tel: +90 3122151336; Fax: +90 3122152962
Congress of the Balkan Association of Max- E-mail: nuraltiparmak@hotmail.com
illofacial Surgeons (BAMFS) and 5th Oral