Dept of Periodontics

1. BONE
GRAFTS
K I R T I R A N K A
F I N A L Y E A R B . D . S .

2. CONTENTS
• DEFINITION
• INDICATIONS
• REQUIREMENTS
• CLASSIFICATION
• BONE GRAFTING TECHNIQUE
• EVALUATION
• CONCLUSION
• REFERENCES

3. WHAT IS A GRAFT?
• A graft is a viable tissue/organ that
after removal from the donor site is
implanted/transplanted within the host
tissue, which is then repaired, restored
and remodeled.

4. WHEN SHOULD YOU
CONSIDER THIS OPTION?
Ridge augmentation and implants
Furcation defects

5. Deep intrabony
defects(2-3 walled
defects)
Advanced bone loss Aggressive periodontitis
Aesthetics Sinus lift procedures

6. WHAT TO EXPECT AFTER
THIS PROCEDURE?
• Attachment gain
• Reduction in pocket depth
• Bone fill
• Regeneration of other surrounding
tissues

8. IDEAL REQUIREMENTS
• Biological acceptibility
• Predictability
• Facilitate vascularisation
• Clinical feasibility
• Minimum operative hazards
• Minimum post-op. sequelae
• Acceptance by the patient
• Not too expensive

9. CLASSIFICATION
According to the type of graft
According to their mode of action

10. BONE
GRAFTS
AUTOGRAFTS
ISOGRAFTS
ALLOGRAFTS
XENOGRAFTS
ALLOPLASTS
COMPOSITE
GRAFTS
According to the type of
graft

11. According to their mode of action
OSTEOGENIC/
OSTEOPROLIFERATIVE
OSTEOINDUCTIVE
OSTEOCONDUCTIVE
OSTEOPROMOTIVE

12. AUTOGRAFTS
• Within same individual
• GOLD STANDARD
• Osteogenic, Osteoinductive & Oteoconductive
potencies Tori,Exostosis
Ramus,
Chin
Tuberosity
Edentulous spaces,
Symphysis
Extraction sites
Tibia
Fibula
Ribs
Iliac crest

14. • Mixture of bone dust obtained by grounding cortical bone and
blood.
• Round carbide bur-25,000-30,000 rpm
• Donor bone Small particles Patient’s blood coating
Coagulum
• Sources: -Lingual ridge on the mandible
-Exostosis
-Edentulous ridges
-Bone distal to the terminal tooth
-Bone removed from osteoplasty
OSSEOUS COAGULUM

15. ADVANTAGES
• Relatively rapid technique
• Complements osseous
resective procedures that
may be required at the
surgical site.
• Particle size provides
additional surface area for
the interaction between
cellular and vascular
elements
DISADVANTAGE
S
• Cannot be used in larger
defects because of
inability to procure
adequate material
• Poor surgical visibility
• Relatively low
predictability
• Inability to use aspiration
during accumulation of
coagulum
• Fluidity of the material
makes it difficult to handle

16. • Removal of bone from accessible intra oral donor sites by
chisels.
• Placing them in a sterile plastic amalgam capsule
• Triturating it with a pestle.
BONE BLEND

17. BONE SWAGING
• Edentulous area near the defect required
• Bone is pushed into the root surface without fracturing
the bone at the base
• Technically difficult

18. ISOGRAFTS
• Monozygotic twins
• A.k.a. “Syngenous grafts”

19. BONE GRAFT
HARVESTING1. Cortico-cancellous block grafts harvested with a 6-mm trephine
and ground to particulated bone chips in a bone mill
2. Bone chips harvested with a sharp bone scraper
3. Bone particles collected from the aspirator with a bone trap filter
during the preparation of the osteotomy
4. Bone particles harvested with a piezo-surgery device. It is for
harvesting particulate autogenous bone

20. PRECAUTIONS WHILE
HARVESTING BONE
GRAFTS• Carefully evaluate the donor sites for any risks-
Radiographically
• Use extreme care in making incisions laterally towards
the mental nerve and dissect the area with blunt
instruments to locate the foramen
• Do not elevate or reflect the muscle attachments
beyond the inferior border of the mandible.
• Suture the wound in layers (muscles and overlying
mucosa separately) to prevent post-op wound
separation.
• While using trephines, drills or saws to cut the bone it
must always be done with profuse irrigation to keep the
instruments and bone cool. Exceeding 47ºC can cause
bone necrosis

21. • Do not elevate or reflect the muscle attachments beyond the inferior
border of the mandible.
• Limit bone cuts to at least 5mm away from the tooth apices, inferior
border of mandible and mental foramen.
• Do not extend cuts beyond 6mm deep
• Do not include both the lingual and the labial cortical plates

22. HEALING :
• Granulation Stage : When hematoma develops , an inflammatory
response occurs and the formation of granulation tissue
takes place
• Callus Stage : Mesenchymal cell differentiates mainly into osteoblasts
• Remodelling Stage : Hard callus tissue is replaced by lamella bone
• Modelling Stage : Bone adapts to the structural demands due to
functional stimuli

23. 7 days: Initiation of new bone formation
21 days: Cementogenesis
3 months: New PDL
8 months: Graft fully incorporated into the host
with functionally oriented
fibers between the bone and
the cementum
Maturation may take as long as 2 years

24. ALLOGRAFTS
• Genetically dissimilar members of the same species.
• Eg. :-Demineralized Freeze Dried Bone Allografts(DFDBA)
– Freeze Dried Bone Allografts(FDBA)
DFDBA FDBA
Demineralised Not Demineralized
More radiolucent More radiopaque
Rapid resorption Breakdown by way of foreign
body reaction
Primary indication-Periodontal
disease asso. with natural tooth
Primary indication-Bone
augmentation asso. with implant
treatment
Osteoinductive Osteoconductive
More BMP Less BMP

25. Colllect the graft tissue within 12
hours of the death of the donor
Defatten,Cut in pieces, Wash in
absolute alcohol,Deep freeze for
further use
Demineralize the material
Ground and sieve- 250-300µm
Freeze dried, vacuum sealed in
glass vials

26. To supress their antigenic potential
RADIATION
TREATMEN
T
• 6 mega
Rads of
high
intensity
gamma
radiation.
FREEZING
• Deep
freezing -
197ºc liq.
N2 freezer
for 4
weeks
CHEMICAL
TREATMEN
T
• Keeping
the graft in
Merthiolate
solution

27. XENOGRAFTS
• Donor is of another species.
• They are usually referred to as “anorganic bone”
• Available source: – Bovine bone
-Natural coral
-Calf bone
-Kiel bone

28. ALLOPLASTS
• A.k.a. Inert biologic fillers
• Eg. :Tricalcium phosphate(TCP)
– Hydroxyapatite(HA)
– Bioactive glass

29. Biocompatibility composite polymers(Bioplant HTR)
• Polymethyl methacrylate + Polyhydroxyethyl methacrylate beads
• Coated with Calcium Hydroxide
• Calcium Hydroxide forms Calcium Carbonate when introduced into
the body
• Surface for osteoblast cell attachment and bone deposition
• 1-3 years later- complete bone formation

30. COMPOSITE GRAFTS
• Made of- Na2O–CaO–SiO2–P2O5
• Reffered to as 45S5 bioactive glass.
• The material exists in particulate form(90-710µm diameter)-
PerioGlas and (300-350µm diameter)- BioGran
• Facilitates bone formation

31. BONE GRAFTING PROCEDURE
INCISION
Sulcular incisison made on the lingual and facial
aspects

32. FLAP DESIGN
Prevent flap perforation, Removal of granulation tissue from the lesion that
usually attaches to the inner aspect of the flap.
Excess thinning of the flap hampers blood supply

33. ROOT DEBRIDEMENT
Remove hard and soft accretions on the root surface
Root biomodification-Saturated solution of Citric Acid (pH=1)

34. DEFECT DEBRIDEMENT
Debride defects of soft tissues using hand, ultrasonic, rotating instruments

35. PREPARATION OF GRAFT MATERIALS
Bone grafts should be wetted with patient’s blood rather than saline or
water

36. PROMOTION OF BLEEDING SURFACE
In case of a chronic bone lesion the bone is perforated, forms a bleeding
environment .

37. PRESUTURING
Loose sutures placed prior to filling the defect to reduce displacement of
bone graft during suturing

38. PLACEMENT OF GRAFT INTO OSSEOUS DEFECT
The bone graft is transferred with bone graft scoop. Graft is packed firmly
but not too tight and should not be overfilled

39. FINAL SUTURING
Monofilament sutures placed as interrupted or vertical mattress suture
technique

40. EVALUATION
• CLINICAL METHODS
1. Probing depth measurement
2. Clinical gingival indices
3. Determine the attachment level
• RADIOGRAPHIC METHODS
-Careful standardized techniques for reproducing the position of the
film and tube are required.
-Linear-CADIA method offers the highest level of accuracy.

41. • SURGICAL RE-ENTRY
-The state of the bony crest, after healing can be compared with
the state of the bone before surgery. Models can also be used.
-Disadvantages- Requires frequent and unnecessary 2nd
operation.
-Does not show the type of attachment that exists.
• HISTOLOGIC METHODS
-The type of attachment can be determined by this method only.
-The tooth needs to be removed along with its periodontium after
successful treatment to assess the attachment.
-Limited to volunteers who undergo extraction for prosthetic or
other reasons and agree to the procedure.

42. CONCLUSION
• A graft is a viable tissue/organ that after removal from the donor
site is implanted/transplanted within the host tissue, which is then
repaired, restored and remodeled.
• Classification- Based on type, mode of action
• Autografts-GOLD STANDARD
• Technique- Incision,
Flap design
Root debridement
Defect debridement
Preparation of Graft material
Promotion of bleeding surface
Presuturing
Placement of graft
Final suturing
• Evaluation- Clinically, Radiographically, Surgical re-entry,
Histologically.

43. REFERENCES
• DENTAL BULLETIN (VOL.15 NO.3 MARCH 2010)
Intra-oral Autogenous Bone Grafting for Dental Implant Site
Preparation by Dr. Gregory TAYLOR
• ARTICLE BY NCBI-Bone Grafts in dentistry
• CLINICAL PERIODONTOLOGY- Caranzza 10th Edition
• TEXTBOOK OF PERIODONTICS- Shalu Bathla

44. THANKYOU
© k i r t i r a n k a