Donor Site Morbidity of Nonvascularized Bone Graft: A Systematic Review

This study was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) in PubMed, Proquest, Science Direct, and Ebsco. A total of 12 studies met the criteria of studies in humans using iliac and fibular nonvascularized bone grafts in mandibular reconstruction after mandibular resection.

Results:

A greater proportion of patients received iliac nonvascularized bone graft (88.9%) than fibular nonvascularized bone graft (11.1%). Of the 385 cases of iliac bone graft, 153 cases (40%) experienced complications at the iliac donor site, whereas in 48 cases of fibular bone graft, two (4%) experienced complications at the donor site. Hemorrhage, bone fracture, infection requiring debridement, and hematoma were the major complications.

Conclusion:

The morbidity rate of the nonvascularized bone graft donor site of the fibula (4%) tended to be lower than that of the ilium (40%). Patient age and defect size were not significantly correlated with the occurrence of morbidity donor sites in either the ilium or fibula.

Keywords:
Mandibular Reconstruction; Morbidity; Bone Transplantation; Ilium; Fibula

Year	Author	Random Selection in Population	Defined Inclusion/ Exclusion Criteria	Report of Loss to Follow-Up	Validated Measurements	Statistical Analysis	Potential Risk of Bias
2011	Gadre et al. [¹⁸[18] Gadre PK, Ramanojam S, Patankar A, Gadre KS. Nonvascularized bone grafting for mandibular reconstruction: myth or reality? J Craniofac Surg 2011; 22(5):1727-35. https://doi.org/10.1097/SCS.0b013e31822e633b https://doi.org/10.1097/SCS.0b013e31822e... ]	Yes	Yes	Yes	Yes	No	Moderate
2011	Rana et al. [⁹[9] Rana M, Warraich R, Kokemüller H, Lemound J, Essig H, Tavassol F, et al. Reconstruction of mandibular defects-clinical retrospective research over a 10-year period -. Head Neck Oncol 2011; 3(1):23. https://doi.org/10.1186/1758-3284-3-23 https://doi.org/10.1186/1758-3284-3-23... ]	Yes	Yes	Yes	Yes	Yes	Low
2012	Obimakinde et al. [¹⁹[19] ObimakindOkoje VN, Obimakinde OS, Arotiba JT, Fasola AO, Ogunlade SO, Obiechina AE. Mandibular defect reconstruction with nonvascularized iliac crest bone graft. Niger J Clin Pract 2012; 15(2):224-7. https://doi.org/10.4103/1119-3077.97334 https://doi.org/10.4103/1119-3077.97334... ]	Yes	Yes	No	Yes	Yes	Moderate
2013	Bai et al. [²⁰[20] Bai XF, Wushou A, Zheng J, Li G. An alternative approach for mandible reconstruction. J Craniofac Surg 2013; 24(2):e195-e198. https://doi.org/10.1097/SCS.0b013e3182802269 https://doi.org/10.1097/SCS.0b013e318280... ]	Yes	Yes	Yes	Yes	No	Moderate
2013	Magesh et al. [²¹[21] Magesh DP, Kumaravelu C, Maheshwari GU. Efficacy of PRP in the reconstruction of mandibular segmental defects using iliac bone grafts. J Maxillofac Oral Surg 2013; 12(2):160-7. https://doi.org/10.1007/s12663-012-0418-y https://doi.org/10.1007/s12663-012-0418-... ]	Yes	Yes	No	Yes	Yes	Moderate
2013	Scheerlink et al. [²²[22] Scheerlinck LM, Muradin MS, van der Bilt A, Meijer GJ, Koole R, Van Cann EM. Donor site complications in bone grafting: comparison of iliac crest, calvarial, and mandibular ramus bone. Int J Oral Maxillofac Implants 2013; 28(1):222-7. https://doi.org/10.11607/jomi.2603 https://doi.org/10.11607/jomi.2603... ]	Yes	Yes	Yes	No	Yes	Moderate
2014	Akbay and Andogan [²³[23] Akbay E, Aydogan F. Reconstruction of isolated mandibular bone defects with non-vascularized corticocancellous bone autograft and graft viability. Auris Nasus Larynx 2014; 41(1):56-62. https://doi.org/10.1016/j.anl.2013.07.002 https://doi.org/10.1016/j.anl.2013.07.00... ]	Yes	No	No	Yes	No	High
2014	Ndukwe et al. [²⁴[24] Ndukwe KC, Aregbesola SB, Ikem IC, Ugboko VI, Adebiyi KE, Fatusi OA, et al. Reconstruction of mandibular defects using nonvascularized autogenous bone graft in Nigerians. Niger J Surg 2014; 20(2):87-91. https://doi.org/10.4103/1117-6806.137309 https://doi.org/10.4103/1117-6806.137309... ]	Yes	No	Yes	Yes	Yes	Moderate
2015	Akinbami and Akadiri [²⁵[25] Akinbami BO, Akadiri OA. Reconstruction of the mandible following benign tumor ablations: an audit of 20 cases. J Oral Maxillofac Surg Med Pathol 2015; 27(5):650-5. https://doi.org/10.1016/j.ajoms.2015.01.009 https://doi.org/10.1016/j.ajoms.2015.01.... ]	Yes	Yes	No	Yes	No	High
2018	Osborn et al. [⁴[4] Osborn TM, Helal D, Mehra P. Iliac crest bone grafting for mandibular reconstruction: 10-year experience outcomes. J Oral Biol Craniofac Res 2018; 8(1):25-9. https://doi.org/10.1016/j.jobcr.2017.12.001 https://doi.org/10.1016/j.jobcr.2017.12.... ]	Yes	Yes	Yes	Yes	Yes	Low
2019	Marechek et al. [²⁶[26] Marechek A, AlShare A, Pack S, Demko C, Quereshy FA, Baur D. Nonvascularized bone grafts for reconstruction of segmental mandibular defects: is length of graft a factor of success? J Oral Maxillofac Surg 2019; 77(12):2557-66. https://doi.org/10.1016/j.joms.2019.05.008 https://doi.org/10.1016/j.joms.2019.05.0... ]	Yes	Yes	Yes	Yes	Yes	Low
2020	Sharma et al. [²⁷[27] Sharma S, Hotkar S, Matne A, Vallabhaneni S, Ravipati A, Khandelwal A. Reconstruction of continuity defects of the mandible with non-vascularized bone grafts- Original study. Adv Med Dent Sci Research 2020; 8(11):23-6. https://doi.org/10.21276/jamdsr https://doi.org/10.21276/jamdsr... ]	Yes	Yes	Yes	Yes	Yes	Low

Author	Type of Study	Patient Characteristics			Defect Size (cm)	Donor Site
Author	Type of Study	N / Sex	Age (Years)			Graft Performed	Complications
Gadre et al. [¹⁸[18] Gadre PK, Ramanojam S, Patankar A, Gadre KS. Nonvascularized bone grafting for mandibular reconstruction: myth or reality? J Craniofac Surg 2011; 22(5):1727-35. https://doi.org/10.1097/SCS.0b013e31822e633b https://doi.org/10.1097/SCS.0b013e31822e... ]	Cohort Retrospective	N = 87 Male: 59 Female: 28	13-85 Mean: 40.24	BENIGN LESION: 55 Ameloblastoma (34) Odontogenic keratocyst (16) Aneurysmal bone cyst (2) Central giant cell granuloma (1) Chondrosarcoma (1) Ossifying fibroma (1) Peripheral neuroectodermal tumor (1) MALIGNANT LESION: 31 Squamous cell carcinoma (31)	Not reported	Iliac: 68 Fibular: 16 Others: 3	ILIAC BONE GRAFT: Infection (1) Temporary gait disturbances (2)
Rana et al. [⁹[9] Rana M, Warraich R, Kokemüller H, Lemound J, Essig H, Tavassol F, et al. Reconstruction of mandibular defects-clinical retrospective research over a 10-year period -. Head Neck Oncol 2011; 3(1):23. https://doi.org/10.1186/1758-3284-3-23 https://doi.org/10.1186/1758-3284-3-23... ]	Cohort Retrospective	N = 178 Male: 131 Female: 47	13-85 Mean Male: 55.1 Female: 55.4	BENIGN LESION: 23 Ameloblastoma (9) Keratocystic odontogenic tumor (5) Dentigerous cyst (2) Central giant cell granuloma (3) Adenomatoid odontogenic tumor (1) Pindborg tumor (1) Odontogenic myxoma (2) OTHERS: 35 Post-temporomandibular joint ankylosis defects (35) INFECTIONS: 26 Osteomyelitis of the mandible (24) Osteosarcoma of the mandible (2) TRAUMA: 44 Post-traumatic defects (44) MALIGNANT LESION: 50 Squamous cell carcinoma(50)	4-9 Mean: 6	Iliac: 80 Fibular: 31 Others: 67	ILIAC BONE GRAFT: Pain (80) Infection (2) Paresthesia (3) Postoperative limp (5) FIBULAR BONE GRAFT: Infection (2)
Obimakinde et al. [¹⁹[19] ObimakindOkoje VN, Obimakinde OS, Arotiba JT, Fasola AO, Ogunlade SO, Obiechina AE. Mandibular defect reconstruction with nonvascularized iliac crest bone graft. Niger J Clin Pract 2012; 15(2):224-7. https://doi.org/10.4103/1119-3077.97334 https://doi.org/10.4103/1119-3077.97334... ]	Cohort Retrospective	N = 47 Male: 26 Female: 21	12-45 Mean: 24.6	BENIGN LESION: 41 Ameloblastoma (36) Primordial cyst (1) Dentigerous cyst (2) Ossifying fibroma (2) MALIGNANT LESION: 4 Fibromyxoma (1) Ameloblastic carcinoma (2) Osteosarcoma (1) TRAUMA: 2 Gunshot (1) Mandibular fracture (1)	Not reported	Iliac: 47	ILIAC BONE GRAFT: Infection (3) Paresthesia (2) Initial gait disturbance (2) Wound dehiscence (3)
Bai et al. [²⁰[20] Bai XF, Wushou A, Zheng J, Li G. An alternative approach for mandible reconstruction. J Craniofac Surg 2013; 24(2):e195-e198. https://doi.org/10.1097/SCS.0b013e3182802269 https://doi.org/10.1097/SCS.0b013e318280... ]	Cohort Retrospective	N = 7 Male: 3 Female: 4	20-47 Mean: 31.8	BENIGN LESION: 7 Ameloblastoma (6) Odontogenic calcifying epithelioma (1)	6-12 Mean: 9.15	Iliac: 7	NO COMPLICATIONS
Magesh et al. [²¹[21] Magesh DP, Kumaravelu C, Maheshwari GU. Efficacy of PRP in the reconstruction of mandibular segmental defects using iliac bone grafts. J Maxillofac Oral Surg 2013; 12(2):160-7. https://doi.org/10.1007/s12663-012-0418-y https://doi.org/10.1007/s12663-012-0418-... ]	Cohort Retrospective	N = 13 Male: 7 Female: 6	19-48 Mean: 29	BENIGN LESION: 13 Ameloblastoma (9) Odontogenic keratocyst (4)	4-6 Mean: Not reported	Iliac: 13	NOT MENTIONED
Scheerlinck et al. [²²[22] Scheerlinck LM, Muradin MS, van der Bilt A, Meijer GJ, Koole R, Van Cann EM. Donor site complications in bone grafting: comparison of iliac crest, calvarial, and mandibular ramus bone. Int J Oral Maxillofac Implants 2013; 28(1):222-7. https://doi.org/10.11607/jomi.2603 https://doi.org/10.11607/jomi.2603... ]	Cohort Retrospective	N = 99 TREATED WITH ILIAC CREST N = 55 Male: 21 / Female: 34 TREATED WITH CALVARIUM N = 26 Male: 10 / Female: 16 TREATED WITH MANDIBULAR RAMUS N = 18 Male: 8 / Female: 10	16-65 Mean: 42	TRAUMA: 24 Posttraumatic defect (21) Resection defect (3) OTHERS: 75 Mandibular or maxillary atrophy (38) Oligodontia (30) Pseudoarthrosis (3) Orbital/zygomatic defect (3) Graves' orbipathy (1)	Not reported	Iliac: 55 Others: 44	ILIAC BONE GRAFT: Pain (20) Infection (1) Paresthesia (3) Hemorrhage (1) Fracture (2) Accidental bicortical harvesting (1) Hematoma (7)
Ndukwe et al. [²⁴[24] Ndukwe KC, Aregbesola SB, Ikem IC, Ugboko VI, Adebiyi KE, Fatusi OA, et al. Reconstruction of mandibular defects using nonvascularized autogenous bone graft in Nigerians. Niger J Surg 2014; 20(2):87-91. https://doi.org/10.4103/1117-6806.137309 https://doi.org/10.4103/1117-6806.137309... ]	Cohort Retrospective	N = 25 Male: 12 Female: 13	13-73 Mean Male: 32.7, Female: 35.0	BENIGN LESION: 22 Ameloblastoma (17) Central giant cell granuloma (1) Cementifying fibroma (3) Odontogenic myxoma (1) OTHERS: 2 Hemifacial hypoplasia (1) Fibrous dysplasia (1) TRAUMA: 1 Gunshot (1)	Not reported	Iliac: 8 Others: 17	NO COMPLICATIONS
Akbay & Aydogan [²³[23] Akbay E, Aydogan F. Reconstruction of isolated mandibular bone defects with non-vascularized corticocancellous bone autograft and graft viability. Auris Nasus Larynx 2014; 41(1):56-62. https://doi.org/10.1016/j.anl.2013.07.002 https://doi.org/10.1016/j.anl.2013.07.00... ]	Case Series	N = 11 Male: 10 Female: 1	10-56 Mean: 32.27	BENIGN LESION: 2 Ameloblastoma (1) Giant cell granuloma (1) TRAUMA: Firearm injury (9)	3-14 Mean: 5.3	Iliac: 9 Fibular: 1 Others: 1	NO COMPLICATIONS
Akinbami & Akadiri [²⁵[25] Akinbami BO, Akadiri OA. Reconstruction of the mandible following benign tumor ablations: an audit of 20 cases. J Oral Maxillofac Surg Med Pathol 2015; 27(5):650-5. https://doi.org/10.1016/j.ajoms.2015.01.009 https://doi.org/10.1016/j.ajoms.2015.01.... ]	Cohort Prospective	N = 20 Male: 10 Female: 10	10-54 Mean: 24.3	BENIGN LESION: 19 Ameloblastoma (16) Odontogenic keratocyst (2) Ossifying fibroma (1) MALIGNANT LESION: 1 Central basal adenoma (1)	4-8 Mean: not reported	Iliac: 20	ILIAC BONE GRAFT: Pain (week 1: 20; week 2: 15; week 4: 5) Restriction of limb movement (2) Altered gait (1)
Osborn et al. [⁴[4] Osborn TM, Helal D, Mehra P. Iliac crest bone grafting for mandibular reconstruction: 10-year experience outcomes. J Oral Biol Craniofac Res 2018; 8(1):25-9. https://doi.org/10.1016/j.jobcr.2017.12.001 https://doi.org/10.1016/j.jobcr.2017.12.... ]	Cohort Retrospective	N = 60 Male: 37 Female: 23	13-67 Mean: not reported	BENIGN LESION: 30 MALIGNANT LESION: 1 TRAUMA: 2 INFECTIONS: 9 OTHERS: 18	<6->9 Mean: not reported	Iliac: 60	ILIAC BONE GRAFT: Pain (3) Wound dehiscence (1)
Marechek et al. [²⁶[26] Marechek A, AlShare A, Pack S, Demko C, Quereshy FA, Baur D. Nonvascularized bone grafts for reconstruction of segmental mandibular defects: is length of graft a factor of success? J Oral Maxillofac Surg 2019; 77(12):2557-66. https://doi.org/10.1016/j.joms.2019.05.008 https://doi.org/10.1016/j.joms.2019.05.0... ]	Cohort Retrospective	N = 29 Male: 17 Female: 12	17-81 Mean: 55 y	BENIGN LESION: 13 Ameloblastoma (6) Odontogenic keratocyst (4) Myxoma (1) Ossifying fibroma (2) MALIGNANT LESION: 2 Squamous cell carcinoma (1) Osteosarcoma (1) INFECTIONS: 11 Osteomyelitis/osteonecrosis (11) OTHERS: 3 Fibrous dysplasia (1) Nonunion (1) Pathological fracture (1)	2-22 Mean: 4.1 cm (for defect ≤6 cm) Mean: 11.5 cm (for defect >6 cm)	Iliac: 28 Others: 1	ILIAC BONE GRAFT: Infection (1) Wound dehiscence (1) Fracture (1)
Sharma et al. [²⁷[27] Sharma S, Hotkar S, Matne A, Vallabhaneni S, Ravipati A, Khandelwal A. Reconstruction of continuity defects of the mandible with non-vascularized bone grafts- Original study. Adv Med Dent Sci Research 2020; 8(11):23-6. https://doi.org/10.21276/jamdsr https://doi.org/10.21276/jamdsr... ]	Cohort Retrospective	N = 16 Male: 10 Female: 6	17-81 Mean: 42 y	BENIGN LESION: 9 Ameloblastoma (4) Odontogenic keratocyst (2) Ossifying fibroma (2) Myxoma (1) INFECTIONS: 3 Osteomyelitis (3) OTHERS: 4 Pathological fracture (4)	3-22 Mean: Not reported	Others: 16	ILIAC BONE GRAFT: Infection Wound dehiscence Fracture

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[1] Correspondence: Lilies Dwi Sulistyani, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Universitas Indonesia. Jalan Salemba Raya No. 4, Jakarta Pusat, Indonesia 10430, Indonesia. E-mail: liliesdwi_s@yahoo.co.id