Quantity and Quality of Intraoral Autogenous Block Graft

Donor Sites with Cone Beam Computed Tomography

Emel Tuğba Ataman-Duruel, DDS, PhD1/Onurcem Duruel, DDS, PhD1/
Salvador Nares, DDS, MS, PhD, MBA2/Clark Stanford, DDS, PhD, MHA3/Tolga Fikret Tözüm, DDS, PhD2

Purpose: The autogenous bone block graft is regarded as the gold standard material due to reported osteoconductive,
osteoinductive, and osteogenic properties. Various intraoral donor sites for autogenous block grafts are presented in the
literature. The aim of this study was to radiographically evaluate the maximum dimensions, volume, and bone quality
values of these sites. Materials and Methods: According to the inclusion criteria, 50 cone beam computed tomography
(CBCT) images from 50 subjects were evaluated. The maximum length, width, height, and volume of autogenous regions
where block grafts could be harvested were measured. Radiographic bone quality was calculated by using Hounsfield
units derived from CBCT (CBCT-HU). Results: The mean age of 50 subjects (19 men and 31 women) was 55.84 ± 15.9
years. In this study, the symphysis was the largest potential donor site (3.14 ± 1.05 cm3), while maxillary tuberosity was
the smallest (0.53 ± 0.34 cm3). These results correlated with bone density values, where the symphysis retained the
highest values (937.31 ± 160.59 CBCT-HU) and the maxillary tuberosity had the lowest values (360.87 ± 141.48 CBCT-HU).
Conclusion: Intraoral bone blocks have restrictions due to surrounding vital anatomical structures. The surgeons should
consider these vital structures using accurate CBCT evaluation. The volume and density of the maximal bone harvest
from the symphysis was statistically higher in comparison with ramus, palatal, and maxillary tuberosity bone blocks. Int J
Oral Maxillofac Implants 2020;35:782–788. doi: 10.11607/jomi.8079

Keywords: augmentation, density, dental implant, imaging, tomography, volume

O ral rehabilitation of edentulous sites using dental

implants is considered to be the preferred treat-
ment to recover oral esthetics and function with pre-
dictable outcomes.1,2 However, bone defects of the
alveolar ridge resulting from periodontal disease, atro-
phy, and trauma may cause inadequate bone volume
or unfavorable vertical, transverse, and/or sagittal in-
terarch relationship(s), resulting in challenging implant
placement.3 Therefore, quantity and quality of bone at
the site of preferred restorative space is a prerequisite
for successful oral rehabilitation with oral implants.4 In
addition to the factors related to surgery, consideration
of prosthetic factors is essential for treatment success.5
Crown-to-implant ratios, numbers, angles, and sites of
oral implants are critical factors for the esthetic outcome
and survival of dental implants.5,6 Moreover, increased
1Department of Periodontology, Faculty of Dentistry, Hacettepe
University, Ankara, Turkey; Department of Periodontics,
College of Dentistry, University of Illinois at Chicago,
Chicago, Illinois, USA.
2Department of Periodontics, College of Dentistry,
University of Illinois at Chicago, Chicago, Illinois, USA.
3Department of Restorative Dentistry, College of Dentistry,
University of Illinois at Chicago, Chicago, Illinois, USA.
Correspondence to: Dr Tolga F. Tözüm, 801 South Paulina St, 469G,
Chicago IL 60612, USA. Email: ttozum@icloud.com
S ubmitted September 19, 2019; accepted February 3, 2020.
©2020 by Quintessence Publishing Co Inc.
crown-to-implant ratio may be associated with a higher
risk of crestal bone loss and prosthetic complications
such as screw loosening, implant or abutment fracture,
and chipping of ceramic.6–8 Numerous surgical proce-
dures have been described to augment deficient bone
volume sites.9,10 For severely atrophic ridges, block
grafting procedures are presented as predictable ap-
proaches.11,12 Autogenous bone, xenografts, allografts,
and alloplastic materials are used during block grafting
procedures.13 For block grafting, the use of autogenous
bone is claimed to be the gold standard, as only autog-
enous bone combines osteoconductive, osteoinduc-
tive, and osteogenic properties.14,15
Various extraoral and intraoral donor sites are avail-
able for harvesting bone grafts.16 Extraoral bone block
grafts (calvarial or iliac crest) provide greater quantities
of bone but have numerous disadvantages, including
increased cost, morbidity at the donor site, and cre-
ation of a second surgical site. While the amount of
available bone for harvest from intraoral sites has lim-
ited volume, its primary advantage is the potential for
harvest with minimal morbidity. In addition, harvesting
bone from the same surgical area may decrease the du-
ration of the procedure, minimize the surgical field, and
limit surgical interventions.17–19 A variety of donor sites
are available intraorally, such as the mandibular ramus,
symphysis, palatal, and maxillary tuberosity.20 Block
grafts can be harvested from these donor sites in differ-
ent sizes and volumes with attention given to distances

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Fig 1   (a) Cross-sectional and (b) panoramic
view of maximum harvesting of bone from
the ramus. (1) Maximum width, (2) maximum
height, and (3) maximum length.
a b
from critical anatomical structures.21,22 Dimensions
and volumes of intraoral donor sites, and their adjunct
anatomical structures, can be evaluated using CBCT.18
CBCT images provide the surgeons with detailed infor-
mation about anatomical structures, bone morphology,
anatomical variations, and pathologies.23–25 Although
numerous studies have been published on block grafts,
to the best of the authors’ knowledge, there is no ra-
diologic study published in English comparing the po-
tential dimensions and volumes of intraoral donor sites.
The aim of this study was to evaluate the maximum di-
mensions and volume of various intraoral autogenous
block graft donor sites and to evaluate the bone quality
of these donor sites.
MATERIALS AND METHODS
Study Design
Ninety CBCT images from 90 subjects were evaluated.
All CBCT images acquired from the patients visited the
College of Dentistry between January 1, 2004 and Au-
gust 31, 2017. The study was approved by the Institu-
tional Review Board of University of Illinois at Chicago
(Protocol no: 2017-0968).
In this retrospective study, the age of the subjects
ranged from 18 to 99 years. CBCT images fulfilling the
following criteria were included: (1) no previous bone
grafting or sinus surgery; (2) no jaw fracture; (3) good
visibility in the CBCT scan; and (4) no artifacts resulting
from movement during image acquisition.
CBCT Image Analysis
The CBCT scans were made using a single CBCT ma-
chine (i-CAT Model 17-19, Imaging Science Interna-
tional) operating at 1.4 mA and 120 kV, providing a
field of view of 11 cm with a resolution of 0.2 voxels.
The images of the scans were saved in a Digital Imag-
ing and Communications in Medicine (DICOM) format.
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Ataman-Duruel et al
2 3
The high-resolution, limited-volume CBCT images were
viewed on a monitor with a resolution of 1.6 MP (Dell)
and calibrated for medical imaging using software
(SIMPLANT Pro 17.01, Dentsply Implants) on a com-
puter running the Windows 7 (Microsoft) system. The
software acquires images in the axial plane and recon-
structs in coronal and sagittal views. It also provides a
3D reconstructed model of the area of interest. Stan-
dardization of software utilization and interpretation
of CBCT scans were provided over several sessions. All
images were reviewed and measurements performed
separately for the right and left sites by one examiner
(E.T.A.D).
Assessment of Mandibular Ramus Donor Site
Quantity19
The maximum height of the mandibular ramus donor
site was measured between the inferior alveolar crest
and 2 mm above the inferior alveolar canal (Fig 1). The
maximum width of the donor site was measured (mm)
between the buccal surface of the mandible and 2 mm
buccal to the lingual plate. The maximum length of
bone graft harvest from the ramus was measured be-
tween 2 mm distal to the most distal tooth and the area
perpendicular to the inferior alveolar canal crossing
through the intersection between the cranial surface of
the mandible and the first bucco-oral CBCT reconstruc-
tion with a consistently visible ascending ramus. The
volume of maximum bone graft potentially harvested
from the ramus was calculated in cm3 by marking the
bone block in each scan.
Assessment of Mandibular Symphysis Donor
Site Quantity19
The maximum height of the mandibular symphysis
donor site was measured between 5 mm apical to the
apex of incisor teeth and 2 mm caudal to the mandibu-
lar basis (Fig 2). The maximum width of the donor site
was measured between the buccal surface and 2 mm
The International Journal of Oral & Maxillofacial Implants  783
Ataman-Duruel et al

Fig 2   (a) Cross-sectional and

(b) axial view of maximum har-
vesting of bone from the sym-
physis. (1) Maximum width, (2)
maximum height, and (3) maxi-
3 mum length.

a b

Fig 3   (a) Cross-sectional and

(b) axial view of maximum har-
vesting of bone from the hard
1 palate. (1) Maximum width, (2)
maximum height, and (3) maxi-
mum length.
3
2

a b

Fig 4   (a) Cross-sectional and

(b) panoramic view of maxi-
mum harvesting of bone from
the maxillary tuberosity. (1) The
maximum width,   (2) the maxi-
3 mum height, and (3) the maxi-
mum length.
2
1

a b

buccal to the lingual plate. The maximum length of the
donor site was measured between 5 mm mesial to the
right and left mental foramen. The volume of maximum
bone graft harvested from symphysis was calculated in
cm3 by marking the bone block in each scan. A mono-
block measurement including the right and left sides
was made.
Assessment of Palatal Donor Site Quantity
The maximum length of the palatal donor site was
measured between the distal border of the second
premolar and 2 mm to the incisive foramen (Fig 3).
The maximum height of the donor site was measured
between the palatal surface and 2 mm to the sinus or
nasal cavity. The maximum width of the donor site was
measured between the palatal surface and 2 mm to the
buccal plate or 2 mm to the root surface.26 The volume
of maximum bone graft harvesting from the palatal re-
gion was calculated in cm3 by marking the bone block
in each scan.19
Assessment of Maxillary Tuberosity Donor Site
Quantity
To measure the maximum width of the maxillary tu-
berosity donor site, the buccolingual distance of the
alveolar crest of the maxillary tuberosity was measured
(Fig 4).27 The maximum potential length of a donor site
was measured 2 mm distal to the most distal tooth to

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 Ataman-Duruel et al

the distal border of the tuberosity.27 The maxi- Table 1   Maximum Dimensions and Volumes of
mum height of a donor site was measured Autogenous Grafts According to Harvesting Sites
from the crestal surface to 2 mm from the
sinus cavity.26 The potential volume of maxi- Right side Left side P value Overall
mum bone graft harvesting from the tuberos- Ramus
ity was calculated in cm3 by marking the bone   Length (mm) 9.82 ± 4.29 10.02 ± 4.28 .021* 9.94 ± 4.29
  Width (mm) 8.15 ± 3.02 8.04 ± 2.93 .026* 8.09 ± 2.97
block in each scan.19   Height (mm) 10.55 ± 3.77 10.38 ± 3.61 .023* 10.46 ± 3.70
  Volume (cm3) 0.91 ± 0.45 0.89 ± 0.40 .004* 0.90 ± 0.42
Evaluating Bone Quality of Intraoral Symphysisa
Block Graft Donor Sites28   Length (mm) N/A N/A N/A 29.76 ± 7.17
Radiographic bone quality was calculated   Width (mm) N/A N/A N/A 8.38 ± 2.66
with a tool incorporated in the software with   Height (mm) N/A N/A N/A 13.36 ± 3.71
a 1-mm edged square. The bone density mea-   Volume (cm3) N/A N/A N/A 3.14 ± 1.05
surements were obtained in Hounsfield units Palatal
from post-processed CBCT DICOM data using   Length (mm) 14.51 ± 4.93 14.42 ± 5.01 .298 14.47 ± 4.81
  Width (mm) 5.82 ± 1.79 5.74 ± 1.77 .202 5.76 ± 1.69
software (Simplant) (CBCT-HU). A high CBCT-   Height (mm) 9.91 ± 2.94 9.76 ± 2.91 .182 9.81 ± 2.69
HU indicated high bone density. Conversely, a   Volume (cm3) 0.61 ± 0.32 0.58 ± 0.33 .343 0.60 ± 0.30
low CBCT-HU pointed to low bone density. Tuberosity
  Length (mm) 7.96 ± 4.20 7.95 ± 3.97 .001* 7.95 ± 4.10
Statistical Analysis   Width (mm) 7.79 ± 3.71 7.66 ± 3.44 .001* 7.80 ± 3.87
All statistical data were processed using IBM   Height (mm) 7.27 ± 4.63 7.12 ± 4.26 .001* 7.23 ± 4.09
SPSS Statistics for Windows, Version 24.0.   Volume (cm3) 0.54 ± 0.37 0.52 ± 0.33 .002* 0.53 ± 0.34
Means and SD values were used for descrip- *Statistically significant differences (P < .05). N/A = not available.
aMonoblock measurements including right and left sides were made.
tion-based statistics for intermittent and con-
tinuous numeric variables. Student t test was
used for the average of independent pairs.
Correlations between continuous and inter- Table 2   Bone Quality (CBCT-HU) Values of the Autogenous
mittent numeric variables were investigated Graft Donor Sites
using Pearson’s correlation test. Comments Right side Left side P value Overall
and assessments were based on comparisons Ramus 887.22 ± 164.35 877.63 ± 142.00 .248 880.74 ± 151.37
with a statistical significance of .05. Data from
Symphysisa N/A N/A N/A 937.31 ± 160.59
10 patients were reevaluated by the same
examiner (E.T.A.D.), while intraclass and inter- Palatal 556.60 ± 153.56 563.41 ± 149.11 .243 558.46 ± 148.22
class correlation coefficients (ICC) for numeric Tuberosity 364.12 ± 139.35 358.98 ± 147.72 .238 360.87 ± 141.48
measurements were calculated to assess the N/A = Not available.
intraexaminer reliabilities. aA monoblock measurement including right and left sides was made.

RESULTS
Ninety scans were identified for this study. Ac-
cording to the exclusion criteria, 18 images
had bone augmentation/sinus procedures,
and 22 CBCT images with artifacts and/or poor
image quality were excluded. In total, 50 sub-
jects were included in the present study. The
ICC values were > 0.90 for the examiner. The
mean age of 50 patients (19 men and 31 wom-
en) was 55.84 ± 15.90 years (men = 61.42 ±
16.19 years; women = 52.41 ± 14.97 years). The
maximum potential dimensions and volumes
of grafts according to harvest area are demon-
strated in Table 1. It was noted that the sym-
physis had the highest graft dimensions and
volume, while the maxillary tuberosity had the
lowest. When evaluating the difference between the left and
right sides, significant differences were noted for all parameters
in the ramus and maxillary tuberosity sites (P < .05). However, no
significant difference was found between the left and right sides
in the palatal site (P > .05). Moreover, sex had no significant ef-
fect on the dimensions or volumes of the potential autogenous
grafts for all donor sites.
Bone quality values of the autogenous potential donor sites
are presented in Table 2. The symphysis had the highest bone
density values, while the maxillary tuberosity had the lowest val-
ues. In general, mandibular donor sites showed higher CBCT-HU
than maxillary donor sites. The differences between the left and
right sides were not significant for any donor site (P > .05). Sex
had no impact on bone density values of donor sites (P > .05).
Quality and quantity of all intraoral autogenous donor sites are
demonstrated in Fig 5.

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Ataman-Duruel et al
1,000
900
937.31
800 880.74
Bone quality (CBCT-HU)
700
600
500 558.46
400
300
200
100
0 0
Ramus Symphysis Palatal
a Donor site
Fig 5   Bone (a) quality and (b) quantity of all intraoral autogenous donor sites.
DISCUSSION
Autogenous bone is regarded as the most predictable
graft material and a gold standard for augmentation
procedures, although various alternatives exist.29 Au-
togenous grafts can be harvested from intraoral donor
sites (eg, ramus, symphysis, palatal, and tuberosity) as
well as extraoral sites (eg, iliac and calvaria).30–32 Qual-
ity and quantity of bone and high predictability of
uneventful healing events are important parameters
when selecting optimal donor sites. Harvesting of au-
togenous bone from extraoral donor sites has been re-
ported to be associated with a hospital stay, increased
costs, and high morbidity in the literature.30 However,
low morbidity risk and outpatient treatment were ad-
vantages of preferring intraoral donor sites.33
Intraoral ramus, symphysis, and tuberosity block
grafts are commonly used for augmentation proce-
dures.29 The advantages of tuberosity block grafts over
mandibular intraoral donor sites are accessibility and
fewer postoperative complications.34,35 Moreover, the
disadvantages of bone harvested from the tuberosity
include a higher volume of cancellous structure, thinner
cortex, and greater susceptibility to resorption.36 How-
ever, ramus and symphysis bone blocks provide denser
and higher bone quality than tuberosity. Successful aug-
mentation procedures utilizing bone derived from vari-
ous sites in the mandible (ramus, symphysis, etc) have
been reported, although consideration of the position
of vital structures, such as teeth, nerves, and arteries,
may restrict its use. In the maxilla, palatal bone blocks
are one of the donor site options for augmentation.37
The palatal block harvest procedure has the potential
to enclose both the donor and the recipient site in the
same surgical field and may limit complications associ-
ated with a second surgical area. The disadvantages of
palatal blocks include difficulty in accessing the donor
site, harvesting limited bone volume due to the incisive
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3.5
Bone quantity (volume) (cm3)
3.0
3.14
2.5
2.0
1.5
360.87 1.0
0.90
0.5
0.60 0.53
Tuberosity Ramus Symphysis Palatal Tuberosity
b Donor site
canal, the nasal floor form, and the maxillary roots of
the teeth.21 Unfortunately, there is a lack of studies
comparing intraoral block site dimensions and volumes
in the literature.22,37,38 Hence, the aim of this study was
to evaluate the maximum intraoral bone block dimen-
sions, volume, and bone quality of donor sites.
Radiographic imaging allows for measurement of the
potential volume and bone density. In the present study,
the maximum length, width, and height measured were:
9.94 ± 4.29 mm, 8.09 ± 2.97 mm, and 10.46 ± 3.70 mm
for the ramus, and 29.76 ± 7.17 mm, 8.38 ± 2.66 mm,
and 13.36 ± 3.71 mm for the symphysis, respectively. In
addition, the maximum bone volume was calculated at
0.90 ± 0.42 cm3 for the ramus and 3.14 ± 1.05 cm3 for the
symphysis. In a cadaver study, the average size of sym-
physis bone block was reported to measure 20.9 mm
× 9.9 mm × 6.9 mm, while the volume was 4.71 mL.37
Güngörmüş and Yavuz38 calculated 2.36 mL for the vol-
ume of the ascending ramus bone block. The amount
of bone harvested from the symphysis and ramus was
assessed in a study using 59 cadaver specimens where
volumes were calculated at 1.15 and 2.02 mL for the
symphysis and ramus, respectively.32 In another study,
the volume, size, and HU of bone blocks that can be har-
vested from the symphysis were analyzed on 15 CT im-
ages, and values were reported to be 3,491.08 ± 772.12
mm3, 38.75 × 11.05 × 7.8 mm, and 958.95 ± 98.11 HU,
respectively.39 Verdugo et al40 also calculated the vol-
ume of symphysis and ramus block grafts at 1.4 ± 0.5 mL
and 0.8 ± 0.2 mL, respectively. In another study, Zeltner
et al19 assessed symphysis and retromolar regions using
60 CBCT images. CBCT scans yielded maximum poten-
tial bone volumes of 3.5 ± 1.3 mL and 1.8 ± 1.1 mL for
the symphysis and ramus, respectively.19 The results of
the present study were in the range of the results pub-
lished in the literature. Among the studies, differences in
values may be explained by different anatomical border
selection and different study methods and designs.

In this study, the maximum bone volume was calcu-
lated to be 0.62 ± 0.30 cm3 for the palatal harvest site,
and the dimensions of the maximum graft were 5.76
± 1.69 mm × 9.71 ± 2.69 mm × 14.72 ± 4.81 mm. In a
separate study, the authors evaluated the diameter and
height of the potential bone block with a cylindrical
shape for each maxillary incisor, canine, and first pre-
molar tooth in 76 CBCT scans. The osteotomy diameter
was 7.8 mm. However, the osteotomy lengths in the
central, lateral, canine, and first premolar areas were
5.9, 5.2, 4.7, and 4.1 mm, respectively.21 Contrary to that
study, the present study measured one-piece rectangu-
lar block graft for the same region, which may explain
differences in values based on various graft designs.
Maxillary tuberosity is widely preferred as a donor
site in various augmentation techniques.22,41,42 How-
ever, no study published in English has evaluated the
tuberosity bone block graft sizes and volume. In the
present study, the authors calculated the maximum
potential width, length, height, and volume as 7.80 ±
3.87 mm, 7.92 ± 4.10 mm, 7.23 ± 4.09 mm, and 0.53 ±
0.34 cm3, respectively.
In the literature, mandibular edentulous sites are re-
ported to have higher HU values than maxillary eden-
tulous sites.43,44 In addition, increasing bone density
values were identified as measured from the posterior
to anterior for both arches.43,44 In agreement with other
studies, the present study noted that the symphysis
possessed the highest density values, while the max-
illary tuberosity had the lowest density values. This is
important, as bone density may be a key factor in pre-
venting bone resorption and maintenance of osteo-
conductive function of autogenous bone graft.
Intraoral bone blocks can provide surgeons with an
adequate amount of autogenous, intramembranous
bone with minimal morbidity for successful clinical
outcomes. When selecting the optimal donor site, the
amount of bone required for the recipient site, the aver-
age quantity and quality of bone available, and the po-
tential complications should be accurately evaluated.
CBCT scans are essential for planning these procedures.
The results of the study present overall dimensions, vol-
ume, and bone quality values as guidance for practitio-
ners. When interpreting the results of the present study,
the following limitation should be taken into consider-
ation. Evaluating bone density using grayscale values
derived from CBCT seems to not be as accurate and
stable as HU derived from CT.45,46 However, a strong
correlation between the grayscales of the CBCT scan
and HUs of the CT scan was also presented.47 Contrary
to this, CBCT-HU can be applied to assess the bone den-
sity by using the “HU” option of the Simplant software
according to a recent publication.28 Within the limita-
tion of the present study, while comparing all potential
intraoral bone block sites, symphysis had a larger bone
© 2020 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
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Ataman-Duruel et al
volume with high bone quality. Maxillary tuberosity
had lower density values with a possible tendency to
resorb during the healing period after augmentation
procedures.
CONCLUSIONS
The use of intraoral bone blocks for bone augmentation
procedures has various restrictions due to surround-
ing vital anatomical structures. The surgeons should
consider all parameters, and accurate CBCT evaluation
should be performed. Based on the results, the volume
and CBCT-HU of the maximum bone block harvesting
from the symphysis was higher in comparison with the
ramus, palatal, and tuberosity bone blocks.
ACKNOWLEDGMENTS
The authors reported no conflicts of interest related to this study.
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