Received: 16 November 2018 Revised: 5 April 2019 Accepted: 7 May 2019

DOI: 10.1111/cid.12809

ORIGINAL ARTICLE

Autogenous interpositional block graft vs onlay graft for

horizontal ridge augmentation in the mandible

Mohammed Atef PhD1 | Ahmed H. Osman MSc2 | Maha Hakam PhD1

1
Faculty of Oral and Dental Medicine,
Department of Oral and Maxillofacial Surgery,
Cairo University, Cairo, Egypt
2
Faculty of Dentistry, Department of Oral and
Maxillofacial Surgery, The British university of
Egypt, Cairo, Egypt
Correspondence
Ahmed H. Osman, Faculty of Dentistry,
Department of Oral and Maxillofacial Surgery,
The British University in Egypt, El Sherouk
City, Suez Desert Road, P.O. Box 43, Cairo
11837, Egypt.
Email: a_othman98@hotmail.com
Abstract
Background: Interpositional block graft revealed promising results in vertical ridge
augmentation in the mandible, while scarce evidence is available regarding the use of
interpositional block graft for horizontal ridge augmentation in the mandible.
Purpose: To compare the efficacy of autogenous block interpositional graft vs onlay
graft in terms of horizontal ridge augmentation in the mandible.
Materials and Methods: Twenty patients were randomly divided in two groups
interpositional and onlay groups, using autogenous blocks harvested from the
mandibular symphysis as the donor site. For the interpositional group, the man-
dibular ridge was split and the harvested block was inserted in the created space
and fixated using titanium screws. For the onlay group, the defect site was
decorticated and the harvested block was firmly fixated buccally using titanium
screws. Immediate and 4 months postoperative cone beam computed tomography
scans were taken for assessment.
Results: In the interpositional group, the mean preoperative bone width was
3.85 ± 0.6 mm, after 4 months, the mean bone width was 8.84 ± 0.54 mm. While in
the onlay group, the mean preoperative bone width was 3.74 ± 0.83 mm while after
4 months the mean bone width was 7.37 ± 1.98 mm. this was statistically significant.
Conclusion: Within the limits of this study, interpositional block graft appears to be a
viable treatment option for horizontal ridge augmentation in the mandible.

KEYWORDS
atrophic mandible, autogenous bone graft, bone augmentation, horizontal ridge augmentation,
interpositional graft, onlay graft

1 | I N T RO D UC T I O N Autogenous bone augmentation has been the golden standard for

For successful implant placement a minimum amount of bone volume
is essential. As a general rule, the implant should be covered circum-
ferentially by 1.5 to 2 mm of bone to ensure long-term success.1 Inade-
quacy in either the bone volume or architecture resulting from
prolonged tooth loss, trauma, or periodontal disease would render the
oral rehabilitation process using dental implants much more challenging
and would require augmentation of the residual alveolar bone prior to
implant placement.
ridge augmentation, due to the offered osteogenic, osteoinductive, and
osteoconductive properties. Autogenous bone grafts could be obtained
from either intraoral donor sites such as mandibular symphesis, ramus.
Maxillary tuberosity or extraoral donor sites such as iliac crest, calvarium,
tibia, and fibula. Intraoral bone grafts offer the advantages of reduced
patient morbidity, lack of cutaneous scarring, and less resorption of the
graft owing to the similarity in embryologic origin and microarchitecture.2-5
Interpositional grafts have been successfully established in restoring
vertical bone height in the mandible.6 However much less evidence is

Clin Implant Dent Relat Res. 2019;1–8. wileyonlinelibrary.com/journal/cid © 2019 Wiley Periodicals, Inc. 1
2 ATEF ET AL.
present on its use for horizontal augmentation. It is the purpose of this
study to assess the efficacy of autogenous interpositional cortico-
cancellous block graft for horizontal mandibular alveolar ridge augmenta-
tion as compared to onlay block graft.
2 | PATI ENT S AND M ET HODS
Twenty patients suffering from partial edentulism in the mandible
with an inadequate bone width to allow for favorable implant place-
ment were selected from the outpatient clinic of Oral and Maxillofa-
cial Surgery Department, Faculty of Dentistry, Cairo University.
This study was approved by the ethics committee of the Faculty
of Oral and Dental Medicine, Cairo University. A thorough preopera-
tive assessment for all enrolled candidates was carried out including
history taking, clinical, and radiographic examination. A preoperative
digital panoramic radiograph with 1:1 magnification was taken for
each patient as a primary survey to identify the deficient areas and
exclude the presence of any lesion at the area of interest. A cone
beam computed tomography (CBCT) scan (Planmeca ProMax 3D Clas-
sic, Planmeca, Finland) was ordered for the enrolled candidates to
assess the extent of the defect and evaluate the symphesis donor site.
2.1 | Inclusion criteria
1. Adult patient of both sexes presenting with partially edentulous
mandibular ridge with horizontal bone defect.
2. The horizontal ridge dimension measured 2 mm below the alveolar
crest should range from 2 to 5 mm.
3. The minimum alveolar vertical dimension measured <10 mm from
the alveolar crest to the roof of the inferior alveolar canal.
4. No local pathosis that may interfere with bone healing.
2.2 | Exclusion criteria
1. Patient taking any medication that may interfere with normal bone
physiology or impair bone healing.
2. All patients suffering from any systemic disease that may affect
bone healing.
3. All patients that have undergone any horizontal augmentation pro-
cedure at the site of interest.
This study was approved by the ethics committee of the Faculty
of Dentistry, Cairo University (Figure 1).
The patients were randomly divided into two groups, the
interpositional group received an interpositional corticocancellous
block graft while the onlay group received onlay block graft.
3 | S U R GI C A L P RO CE D UR E
All patients were premedicated using midazolam (Dormicum, Roche)
10 mg intramuscular 1 hour before surgery. Patients were asked to
rinse their mouths with Chlorhexidine HCL 1.25% mouthwash (Orovex
mouthwash, Macro group, Egypt) immediately preoperatively. All pro-
cedures were performed under local anesthesia. Bilateral inferior alveo-
lar and lingual nerve block (Articaine 4% 1:100 000 epinephrine;
Artinibsa 40 mg/0.1 mg/mL—epinephrine 1:10 000, Spain) was used.
Additional infiltration anesthesia was injected in the operative sites for
hemostasis.
Initially, the recipient site was adequately exposed using a
mid-crestal and -sulcular incision extending one tooth on each
side of the defect and vertical releasing incisions. Carefully, a full
mucoperiosteal flap was elevated to expose the underlying bone
(Figure 2).
F I G U R E 1 Reformatted cross
sectional CBCT showing
calculation of the horizontal bone
dimensions of the ridge at two
levels. CBCT, cone beam
computed tomography
ATEF ET AL.
F I G U R E 2 Crestal and sulcular incision to expose the posterior
edentulous space
4 | CHIN GRAFT HARVESTING
Two approaches were utilized to expose the symphesis. The suitable
approach was selected in accordance with the clinical indication as
described by Pikos.7
The crestal approach: was chosen in cases where the periodontium
was healthy and no crowns were present that could present esthetic
problems with associated gingival recession, or when the anterior
region itself the defect site.
The incision begins in the gingival sulcus from second bicuspid of
one side to second bicuspid of the other side. An oblique releasing
incision was made at the distal buccal line angle of these teeth and
continues into the depth of the buccal vestibule.
A full-thickness mucoperiosteal flap was reflected down to the
inferior border of the mandible). The mental neurovascular bundles
were identified bilaterally (Figure 3).
The vestibular approach: was indicated in cases with compromised
periodontium in the lower anterior region, when crown margins were
within the esthetic or speaking zones.
The flap design begins with a beveled partial- to full-thickness
mucoperiosteal incision. The incision is placed 5 to 10 mm below the
mucogingival junction, extending just distal to the mandibular canines
to allow for adequate access and easier adaptation of the flap for
tension-free closure. The flap was carefully elevated to expose the
symphesis region (Figure 4A,B).
The graft osteotomy was performed using saw disk. The graft size
should be 2 mm larger than the defect size to allow for graft contouring.
The osteotomies were connected together and the graft was
elevated using bibeveled chisels and mallet. In case of unilateral block
harvest or two separate bilateral block harvest, elevation started from
the medial cut (toward the midline). This is to prevent any unneces-
sary trauma to the mental neurovascular bundle.
The block was contoured under copious irrigation using a round
fissure bur to remove any sharp margins. Then, the block was stored in
cold sterile saline solution till preparation of the recipient site (Figure 5A-C).
3
FIGURE 3 Crestal approach to expose the mandibular symphesis
5 | P R E P A R A T I O N OF TH E R E C I P I E N T SI T E
5.1 | Interpositional graft group
A saw disk was used to perform the crestal and buccal vertical
corticotomies under copious saline irrigation.
The vertical extent of the buccal corticotomies should be equiva-
lent to the desired implant length. A shallow apical horizontal cut
within the buccal cortex was performed to allow for greenstick fracture
of the corticocancellous buccal segment. Following the corticotomies,
the vertical and superior horizontal cuts were connected together using
sharp straight chisels.
The buccal trap door was then mobilized laterally carefully to cre-
ate a space for the graft as follows; a spatula chisel was inserted into
the crestal corticotomy, a straight bibeveled chisel was wedged lingual
to the spatula chisel in the corticotomy and malleted to mobilize the
buccal segment (Figure 6).
The block graft was checked for accurate adaptation and adjust-
ments were made whenever necessary. The adjusted block was gently
malleted in place and adequately fixed using 2.0 mm bicortical tita-
nium screws (Figure 7).
5.2 | Onlay group
The recipient site was prepared using a round bur under copious
saline irrigation to create multiple penetrations through the buccal
cortical bone in order to form communication with the marrow space
and facilitate angiogenesis to the graft (Figure 8).
The harvested bone block was then fixed using bicortical titanium
screws (Figure 9A,B).
Any residual spaces were filled with a particulate bovine xeno-
graft material (Tutogen bone; Tutogen Medical GmbH, Neunkirchen
am Brand, Germany).
The donor site was closed in two layers, the deep muscular
layer was first closed using 5 to 0 resorbable interrupted sutures
(Polyglactin 910 suture material, Assut, Switzerland). The mucosal
4 ATEF ET AL.

FIGURE 4 (A) Vestibular split thickness incision. (B) Complete exposure of the symphesis

FIGURE 5 Block elevation using bibeveled chisel. (A) Bilateral single block. (B) Bilateral two blocks. (C) unilateral block

FIGURE 6 Buccal trap door mobilized to receive the graft

F I G U R E 7 Block graft inserted in place. Note that the graft is

layer was then closed using apical horizontal mattress and simple
below the level of the native alveolar crest
interrupted sutures with 5 to 0 synthetic monofilament suture
(Prolene, Assut, Switzerland).
For the grafted sites in both groups, scoring of the buccal flap was Two-line Closure was performed compromising of apical horizon-
performed to release the periosteal tissue and allow for tension-free clo- tal mattress and simple interrupted sutures using 5 to0 synthetic
sure of the flap. monofilament sutures.
ATEF ET AL.
F I G U R E 8 Multiple
penetrations through the buccal
cortical bone
F I G U R E 9 The harvested
onlay graft are adequately fixed
using osteosynthesis screws
• All patients received postoperative antibiotic (amoxicillin/clavulanic
acid; Augmentin 1 gram tab., Pfizer) 1 g every 12 hours orally for
5 days, and nonsteroidal anti-inflammatory analgesic (Ibuprofen;
Brufen 400 MG 30 tab. Abbott/Cairo, Egypt) 600 mg every 8 hours
orally for 5 days. Patients were instructed to follow oral hygiene mea-
sures and to use chlorhexidine 1.25% (Orovex mouthwash, Macro
group, Egypt) mouthwash for 2 weeks. Sutures were removed 2 weeks
postoperative. Immediate postoperative CBCT scans were ordered
for all patients and at 4 months interval, to assess the amount of hori-
zontal bone gain and calculate the percentage of graft resorption.
6 | RESULTS
A total of 20 patients (9 males and 11 females) ranging from 29 to
54 years old with a mean of 42.1 years were included in this study. All
block grafts were harvested from the mandibular symphesis either unilat-
erally or bilaterally according to the mesiodistal dimension of the defect.
7 | CLINICAL RESULTS
7.1 | Interpositional group
• All patients showed uneventful soft-tissue healing with no signs of
infection, sequestration of the mobilized buccal plate, or neurosensory
deficits except for a single case who reported immediate postopera-
tive paresthesia that resolved at 1 month follow-up appointment.
5
• At 4 months during re-entry, all cases revealed sufficient bone
width that allowed conventional implant placement in all cases,
without any further augmentation procedures (Figure 10).
7.2 | Onlay group
• All patients healed uneventfully, no signs of infection or wound
dehiscence were noted (Figure 11). Postoperative swelling was still
noted at suture removal 2 weeks postoperatively.
• One subject (case no. 20) developed postoperative edema,
swelling, and pus formation at the grafted site 3 weeks postop-
eratively. Broad spectrum antibiotics (amoxicillin/clavulanic
acid) 1 g every 12 hours orally was prescribed for 7 days, until
resolution of the infection. At re-entry fibrointegration of the
graft was observed and the graft was removed.
• One subject (case no. 4) showed wound dehiscence 1 month post-
operative and the graft was removed (Figure 12).
8 | RADIOGRAPHIC RESULTS
8.1 | Radiographic observations
• In all cases in both groups, the graft fixing screws were seen exten-
ding bicortically and 1 to 2 mm beyond the lingual cortex.
• In all cases, in both groups, the vertical level of the graft was below
that of the native alveolar bone except for a single case in the
6 ATEF ET AL.
F I G U R E 1 0 Clinical view at 4 months postoperative showing
alveolar width in interpositional group
F I G U R E 1 1 Alveolar bone width at re-entry 4 months
postoperatively in onlay group
interpositional group, where part of the graft was extending about
2 to 3 mm beyond the alveolar ridge height.
• In all cases, in both groups, the graft appeared well adapted to the
native bone except for a single case in the onlay group where a fine
radiolucent demarcating line was present between the graft and the
buccal cortex in the immediate CBCT scan. At 4 months, the CBCT scan
showed radiolucent area between the graft and the buccal cortex.
• In the interpositional group, 4 months CBCT scan, cortex of the
block graft could still be easily demarcated within the bone.
9 | S T A T I S T I C A L A N A L Y S I S OF
R A D I O G RA P H I C M E A S U R E M E N T S
Numerical data were explored for normality using Kolmogrov-Smirnov
test. Comparisons between the two groups and over time were done
by two way repeated measure ANOVA, while comparisons between
F I G U R E 1 2 Wound dehiscence and exposure of the graft at
patient no. 4 in the onlay group
the two groups at each time interval were done using independent
t test. Overtime comparisons in each group were done repeated mea-
sure ANOVA followed by post hoc paired t test. P values ≤.05 were
considered significant.
9.1 | I-Bone width at different intervals in each group
• Preoperatively, the mean bone width of interpositional group was
3.85 ± 0.6 mm and increased to a mean of 9.22 ± 0.64 mm imme-
diately postoperative. At 4 months postoperative, it decreased
slightly to reach a mean of 8.84 ± 0.54 mm (P < .001; Table 1).
• For the onlay group, preoperatively the mean bone width was
3.74 ± 0.83 mm and increased to 7.82 ± 2.19 mm immediately post-
operative. Four months postoperative, it decreased slightly to reach
7.37 ± 1.98 mm. This was statistically significant (P < .001; Table 2).
9.2 | II-Comparisons between two groups in
bone width
• Preoperative: the mean bone width of interpositional group was
3.85 ± 0.6 mm compared to 3.74 ± 0.83 mm in onlay group. This
was statistically not significant (P = .756).
• Immediate postoperative: the mean bone width of interpositional
group was 9.22 ± 0.64 mm compared to 7.82 ± 2.19 mm in onlay
group. This was statistically not significant (P = .068).
• Four months postoperative: the mean bone width of interpositional
group was 8.84 ± 0.54 mm compared to 7.37 ± 1.98 mm in onlay
group. This was statistically significant (P = .046; Table 3).
9.3 | III-Comparisons between two groups in
bone gain
Bone gain: The mean bone gain of interpositional group was 5.02 ± 0.8 mm
compared to 3.6 ± 2.2 mm in onlay group. This was statistically not
significant (P = .086).
ATEF ET AL. 7

TABLE 1 Mean, standard deviation, and repeated measure ANOVA test of bone width in inlay and onlay group

Preoperative Immediate postoperative Four months postoperative

Mean SD Mean SD Mean SD P value

Inlay group 3.85 0.6 9.22 0.64 8.84 0.54 <.001
Onlay group 3.74 0.83 7.82 2.19 7.37 1.98 <.001

Note: P ≤ .05 is considered statistically significant.

TABLE 2 Mean, standard deviation, and independent t test of bone gain in Inlay and Onlay groups

Inlay group Onlay group

Mean SD Mean SD P value

Preoperative 3.85 0.60 3.74 0.83 .737
Immediate postoperative 9.22 0.64 7.82 2.19 .068
Four months postoperative 8.44 0.54 7.37 1.98 .046

Note: P ≤ .05 is considered statistically significant.

Bone gain%: The mean bone width gain% of interpositional group T A B L E 3 Mean and independent t test of bone graft resorption in
was 137 ± 50% compared to 112.7 ± 82.4% in onlay group. This was inlay and onlay groups
statistically not significant (P = .863). Graft resorption

Mean SD P value
9.4 | IV-Comparison between two groups in graft Inlay 0.357 0.29 .08
resorption Onlay 0.448 0.27 .0006

• The mean graft resorption of the interpositional group was
0.357 ± 0.58 mm. This was statistically nonsignificant (P = .08).
• The mean graft resorption for the onlay group was 0.448 ± 0.274 mm.
This was statistically significant (P = .0006).
1 0 | DI SCU SSION
Case selection was of crucial importance prior to determining the appro-
priate technique of augmentation. Several authors have recommended a
minimum thickness of 3 mm to attempt ridge splitting. This allows for a
minimum of 1 mm of buccal and lingual cortices and 1 mm of cancellous
8
bone in between to facilitate splitting and buccal plate mobilization. In
this study, the selected candidates for the interpositional group pres-
ented with mean horizontal width of 3.85 ± 0.6 mm, with a single case
being less than 3.0 mm. The selected candidates for the onlay group had
a mean horizontal width of 3.74 ± 0.8 mm. Regarding the base line
width, there was no statistically significant difference between the two
groups indicating a random homogenous sample.
The antero-posterior extent of the defect is also an important factor
in selection of the augmentation technique. Longer defects (three-teeth
spaces or more) were more difficult to split due to the inherent stiffness
of the mandibular bone. In such cases dividing the long segment by a ver-
tical cut into two smaller ones facilitated splitting and mobilization.
As for the donor site, although chin harvest offers a relative ease of
access, relatively fewer vital structures, however chin harvest has con-
siderable morbidity regarding teeth vitality and neurosensory deficits of
the mental nerve.9 This risk is owed to the fact that the operator has
very little reference points when it comes to translating the position of
Note: P ≤ .05 is considered statistically significant.
these anatomical structures from the CBCT images to the patients
intraoperatively.
The use of onlay bone grafts for horizontal ridge augmentation has
been well documented in the literature. In a systematic review published
by Milinkovic and Cordaro10 in 2014 to assess the efficacy of onlay block
grafts, they reported that in 171 patients, the mean horizontal bone gain
at re-entry ranged from 2.7 to 5.0 mm, with an average bone gain of
4.3 mm. These results were comparable to those obtained in this study
where the onlay bone group obtained mean bone gain of 3.6 ± 2.2 mm.
The hypothesis behind the use of interpositional graft is that the base
and sides of the graft are in intimate contact with the recipient bed. This
results in more than doubled graft-to-host contact area. This increased
contact results in greater graft-host interaction. Interpositional grafting
converts the single wall defect to a four-wall defect.11 Cortellini et al,12
demonstrated that bone fill clearly improved proportionally as the num-
ber of residual defect walls increased.
The graft also remains shielded from any harmful stresses that fall
on the alveolar ridge. Also, placing the graft between two pedicled bone
layers accelerates angiogenesis within the graft leading to increased
potential for osteoinductive and osteoconductive and greater biologic
activity.13-15 This could be considered superior to onlay block graft
where angiogenesis occurs mainly from one direction only and also the
contact between the graft and the host is reduced. Furthermore, onlay
bone grafts stretch and deform the overlying soft-tissue envelope, gen-
erating recoil forces that act directly on the block graft.15 This could
explain why the amount of graft resorption in the interpositional group
8 ATEF ET AL.
was 0.357 mm which was statistically nonsignificant, while the amount
of graft resorption in the onlay group was 0.448 mm which was statisti-
cally significant and also the higher mean bone width at 4 months in
the interpositional group 8.84 ± 0.54 mm as compared to the onlay
group 7.37 ± 1.98 mm, despite the statistically insignificant difference
immediately postoperative.
It should be noted here that although full-thickness periosteal flaps
have been used and greenstick fractures were performed in the buccal
cortical plate, however the mobilized segment remained attached through
the underlying cancellous spongy bone and no loss of the buccal plate
was noted.
Several criteria should be followed when attempting to augment
the mandible using interpositional technique due to the inherent
toughness of the mandibular bone. The vertical corticotomies should
be relatively parallel or slightly converging crestally. Care should be
taken not to impinge on the adjacent roots. All three cuts should
extend into the cancellous bone and should be connected together
to allow mobilization of the buccal segment. A shallow inferior cut
should be made to facilitate the creation of greenstick fracture on
the buccal plate to facilitate its mobilization and creation of graft
space.
Recipient site osteotomy in the interpositional group was per-
formed successfully in all cases without malsplits. Applying the double
chisel technique using spatula osteotome and bibeveled chisel during
the ridge splitting is thought to help preventing fracture of the buccal
segment during its mobilization. This technique distributes the force
on a wider surface area along the buccal segment and thus allowed
for gradual and gentle mobilization of the segment and reduced the
risk of the buccal plate fracture or malsplit.
To conclude, both the interpositional block graft and onlay graft
proved to be viable options for horizontal mandibular ridge augmenta-
tions. Interpositional block graft showed promising results and
deserves further investigations.
AUTHOR CONTRIBUTIONS
M.A. is a principle investigator and contributed to the conception of
the work and interpretation of data for the work, drafted the paper,
approved of the version to be published, and agreed to be account-
able for all aspects of the work in ensuring that questions related to
the accuracy or integrity of any parts of the work are appropriately
investigated and resolved. A.H.O. is a second investigator and con-
tributed to the conception of the work and interpretation of data for
the work, drafted the paper, approved of the version to be publi-
shed, and agreed to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity of any
parts of the work are appropriately investigated and resolved.
M.H. contributed to the conception and design of the work, interpre-
tation of data for the work, revised the paper critically, approved of
the version to be published, and agreed to be accountable for all
aspects of the work in ensuring that questions related to the accu-
racy or integrity of any parts of the work are appropriately investi-
gated and resolved.
CONFLIC T OF INT ER E ST
All authors express no conflict of interest.
OR CID
Mohammed Atef https://orcid.org/0000-0003-4849-6626
Ahmed H. Osman https://orcid.org/0000-0002-1967-3251
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How to cite this article: Atef M, Osman AH, Hakam M.
Autogenous interpositional block graft vs onlay graft for
horizontal ridge augmentation in the mandible. Clin Implant
Dent Relat Res. 2019;1–8. https://doi.org/10.1111/cid.12809