Drilling of the bony canal is routine in all lateral graft procedures, as it enlarges the field of surgery and allows satisfactory graft placement. Under continuous irrigation, drilling begins laterally and posteriorly with removal of the spine of Henle and the tympanosquamous suture line. Care is taken not to enter the mastoid air cells. Next, the anterior and inferior canal bulges are removed (Fig. 4-3). The posterior wall of the temporal mandibular joint represents the anterior wall of the bony canal. It is most prominent in the midportion of the bony canal in both the superior to inferior and medial to lateral planes. It is important not to violate the joint when drilling the bony canal, and therefore superior and inferior troughs are drilled first, followed by thinning of the midportion of the canal wall over the joint. Final medial dissection just lateral to the annulus completely exposes the anterior sulcus and converts the acute anterior meatal angle into an obtuse angle. This is critical to prevent postoperative blunting.
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