Bone grafts in periodontal therapy Presenter: Dr. Rebicca Ranjit Lecturer Dept. of Periodontology & Oral Implantology Historical Review:  In orthopaedics, bone grafts have been used for years. Beuke and Silver, 1936 used boiled cow bone powder to successfully repair intrabony defects in humans. Melcher, 1962 used anorganic bone (bovine bone) which were followed for 3 years.

2. Bone grafts inBone grafts in
periodontalperiodontal
therapytherapy Presenter:
Dr. Rebicca Ranjit
3rd year Resident
Dept. of Periodontology & Oral Implantology

3. What is graft ?
It is a viable tissue or organ that after removal
from donor site is implanted or transplanted within
the host tissue, which is then repaired, restored and
remodeled.

4. What are bone
grafts?
Bone grafts are the materials used
for replacement or augmentation
of the bone.

5. Historical Review:
 In orthopaedics, bone grafts have been used for years.
Hegedus (1923) used autogenous tibial grafts for the reconstruction
of the deficient alveolar ridges as a result of “pyorrhea alveolaris.”
Linghorne in his detailed histological report proved autogenous grafts
to be beneficial in bone repair in comparison to OFD.
Nabers CL, O’Leary TJ. Autogenous Bone Transplants in the treatment of osseous defects. J Periodontol
1965;36:5-14

6.  Beuke and Silver, 1936 used boiled cow bone powder
to successfully repair intrabony defects in humans.
 Melcher, 1962 used anorganic bone (bovine bone) which
were followed for 3 years.

7. Rationale:Rationale:
♣ Enhances regenerative capacity of boneEnhances regenerative capacity of bone
♣ Achieve new attachment apparatusAchieve new attachment apparatus

8. Schallhorn (1976) defined the considerations that govern the selection of a material
as:

9. Graft placed into a positionGraft placed into a position
normally occupied by bonenormally occupied by bone
Graft placed into a positionGraft placed into a position
not normally occupied by bonenot normally occupied by bone
Key Notes on Plastic Surgery
By Adrian Richards, Hywel Dafydd

10. Biologic concept of using Bone
grafts
Trelli’s effect (Robert Genco)

11. Osteoconduction (Trelli’s effect)
“Physical effect” by which the matrix of the graft forms a scaffold that
favors outside cells to penetrate the graft and form new bone .
E.g: Alloplast, FDBA

12. Osteoinduction:
Cell mediators at the defect
(BMP)
Stimulation of
osteoprogenitor cells
Osteoblasts
New bone formation
Chemical process by which molecules contained in the graft (e.g., bone morphogenetic
proteins) convert the neighbouring cells into osteoblasts, which in turn form bone.
E.g: DFDBA

13. Osteogenesis :
Osteoblasts in the transplanted bone having
adequate blood supply & cellular viablity.
Forms new centers of ossification within
the graft
E.g: Autogenous graft

14. Osteopromotion:
It occurs when the grafted material does not possess the
osteoinductive properties but enhances osteoinduction by promoting
bone formation.
E.g: EMD do not stimulate denovo bone growth alone, but when
used with DFDBA, it enhances the osteoinductive effect of
DFDBA.

15. Osteoneutral effect:
That which merely fills the bone defect without
producing any effect & often gets encapsulated.

16. Accidentally discovered during sequential single photon emission computerized
tomography (SPECT), histologic correlation on animal models to validate bone
grafting technique and substitutes in the Ogunsalu sandwich bone regeneration
technique.
Histologically confirmed to be due to foreign body reaction.
(Christopher Ogunsalu, 2009)
Osteoobstruction:

18. Depending on the rate of their bioresorption:
Fast Resorbing: Wherein graft gets resorbed within 8-10 weeks after
placement.
Slow Resorbing: Grafted material stays for many months. E.g: B-
TCP
Nonresorbing: Those which do not resorb for years. E.g: Natural coral
materials,
hydroxyapatite

19. Autografts: A tissue transferred from one position to
another within the same individual .
Allografts / Homografts: Obtained from
genetically dissimilar individual of same species .
Xenografts / Heterografts: Tissue transferred from
one species to another species.
Alloplasts: A synthetic graft or inert foreign body
implanted into tissue.
Based on the origin:

20. Gold standard because:
(1) Osteogenic potential,
(2) A tissue reaction is induced without inducing immunological reactions,
(3) Minimal inflammatory reaction,
(4) Rapid revascularization around the graft particles and
(5) Potential release of growth & differentiation factors sequestered within grafts
(Marx 1994; Kim et al. 2005).

22. Hegedus, 1923 (Tibia)
Later, Schallhorn & Hiatt, 1960s
( Iliac crest)
Hegedus, 1923
Revived by Nabers O’ Leary, 1965

23. Autografts from
extraoral sitePioneered by Hegedus, 1923 (Tibia)
Later, Schallhorn & Hiatt, 1960s ( Iliac crest)… Preserved iliac cancellous marrow bone
Problems associated:- Schallhorn R.G (1972)-
* Postoperative infection,
* Bone exfoliation,
* Sequestration,
* Varying rates of healing,
* Root resorption,
* Rapid recurrence of the defect
* Increased patient expense
* Difficulty in procuring the donor material

24. All these disadvantages
+
Fact that alveolar defects do not demand large amounts of bone
Growing use of intra-oral graft
(Less intra-operative time; anaesthesia time; morbidity; discomfort)

25. Autografts from
intraoral site -Hegedus
(1923)Sources include:
Maxillary tuberosity
Exostoses
Healing wounds
Extraction sites ( Soehren et al, 1979)
Edentulous ridges.
Mandibular symphysis,
ramus
Osteoplasty /Osteotomy
sites
Areas distal to last tooth

26. Autografts from intraoral site
Osseous
coagulum
Cancellous Bone
Marrow Transplants
Bone Blend
Diem, 1972
R. Earl Robinson, 1969
Hecker, 1913
Bone swaging
Ewen, 1965

27. Bone removed with #6/#8 carbide bur at speed of 5,000-30,000 rpm
ADVANTAGES:
* Additional surface area for interaction of cellular &
vascular elements.
* Ease of obtaining bone from already exposed surgical site.
DISADVANTAGES:
* Unknown quality & quantity of bone fragments
* Inability to use aspiration during accumulation of coagulum
* Material’s fluidity
Osseous coagulum R. Earl Robinson, 1969
Bone dust (cortical bone) + Blood

28. Bone removed from pre-determined site
Placed in an autoclaved plastic capsule & with the help of
pestle
Triturated (10-30 sec) to a workable , plastic-like mass of 100
to 200 µm & packed into bony defect site
Bone Blend
Diem, 1972
Froum et al found osseous coagulum–bone blend procedures to be at least
as effective as iliac autografts and open curettage

29. Cancellous bone obtained from
 Maxillary tuberosity (Abundant cancellous
bone)
 Edentulous area &
 Healing socket
Cancellous Bone Marrow
Transplants Hecker, 1913
Instruments used:- Curettes, back-action chisels, trephine, Curved-
rongeurs, etc.
Precautions:
Avoid extending the incision too distally to avoid entering the mucosal tissue of pharyngeal area.
Analyze the location of the maxillary sinus on the radiograph

30. (Pediculated / Contiguous bone graft)
•Requires existence of an edentulous area adjacent to
the defect from which bone is pushed into contact with
the root surface without fracturing the bone at its
base.
•Disadvantages:
 Technical difficulty
 Limited usefulness
Bone swaging

31. Allografts:

32. Osteoconductive Osteoconductive + osteoinductive

33. Obtained from cortical bone within 12 hours of death
of cadaver
Defatted
Cut in pieces (500 µm to 5 mm)
Washed with absolute alcohol; 1 min
Placed in cold diluted HCl (0.5/0.6 N)
Freeze dried bone allografts
(FDBA)
Decalcified Freeze dried bone allografts
(DFDBA)
Ground sieved to particle sized 250-750 µm
Freeze-dried (-80 °C for 1-2 weeks)
Vaccum sealed in glass vials
Reduces its antigenicity (Lancet 1992)

34. FDBA is more effective than DFDBA in the following situations:
 Repair and restoration of fenestrations & dehiscences,
 Minor ridge augmentation,
 Fresh extraction site filler,
 Sinus lift & bone grafting
 Repair of failing implants.

35. Freeze dried bone allografts
(FDBA)
• Osteoconductive
• Studied by Mellonig, Bowers & co-workers
FDBA reported > 50% bone fill in 67% of the defects
78% of the defects grafted with FDBA + autogenous bone.

36. FDBA + ANTIBIOTICS
Terranova V et al:-
Addition of tetracycline theoretically enhance its osteogenic potential. The addition
of the antibiotic appears to enhance fibroblast chemotaxis, be anti-collagenolytic, &
produce a zone of anti-bacterial activity during the critical stages of wound healing.
Yukna R 1982
FDBA + tetracycline in a 4:1 volume ratio has shown promise in t/t of osseous
defects associated with localized juvenile periodontitis.

37. Decalcified Freeze dried bone allografts
(DFDBA) -Marshall
Urist(1965)Demineralization of a bone allograft removes inorganic phase of bone
(Calcium) & exposes hydrophobic glycoprotein within the bone matrix i.e,
bone morphogenetic proteins.
Induces a cascade of events leading to cellular differentiation and the
formation of bone by inducing pleuripotential stem cells to differentiate
into osteoblasts
(Mellonig et al. 1992; Nasr et al. 1999).
Synonyms:-Synonyms:-
•Allogenic, autolysed, antigen-extracted (AAA) boneAllogenic, autolysed, antigen-extracted (AAA) bone
•Demineralised bone powderDemineralised bone powder
•Demineralised bone matrixDemineralised bone matrix
•Demineralised bone matrix gelatinDemineralised bone matrix gelatin
- James T. Mellonig- James T. Mellonig

38. Mellonig et al. 1981:-
Study in guinea pigs
DFDBA has equivalent osteogenic potential with autogenous bone
Libin et al, 1975:-
First to report the use of cortical & cancellous DFDBA in humans.

39. Bowers et al. 1991:-
Osteogenin/ BMP-3
Isolated from extracellular matrix of human bones
Tested in human periodontal defects ( Enhanced regeneration)
Pearson et al, 1981; Quintero et al, 1982:-
Cortical DFDBA (2.4 mm bone fill) >> Cancellous DFDBA (1.38 mm bone fill)

40. WHICH BONE TO USE….? ? ? ? ? ?
Cortical bone >>>>> Cancellous bone
- Urist et al, 1970
- American Academy of Periodontology
•Cancellous bone is more antigenic
•Cortical bone contains more bone matrix and consequently more osteoinductive
components
Its high concentrations of osteoblasts and osteocytes give cancellous bone superior
osteogenic potential. Additionally, its large trabecular surface area encourages
revascularization and incorporation at the recipient site.
Khan SN, Cammisa FP, Jr., Sandhu HS, Diwan AD, Girardi FP, Lane JM. The biology of bone grafting. J Am Acad
Orthop Surg. 2005;13:77–86.

41. A controversy remains as to whether cortical or spongy bone is the
material of choice for autologous bone grafts.
(Girdler and Hosseini 1992; Schwipper et al. 1997).

42. In contrast to this view, Becker et al (1995; 1998) suggested that DFDBA is not
osteoinductive because it does not contain the BMPs necessary to induce bone
formation.
Schwartz et al (1996) reported: variations in the amount of bone formation
induced by BMPs in DFDBA may be related to:
• Source (i.e, donor tissue) of the bone
• Techniques used to process it
• Age of donor: young donor bone results in signifcantly greater quantities of
BMPs retained in the bone allograft matrix compared with
older donor bone.

43. Xenografts:

44. Bovine bone chemically treated with ethylenediamine to remove its organic
components
Trabecular & porous architecture is retained (Similar to human)
Clot stabilization & revascularization to allow cell migration of osteoblasts
Osteoconductive
(Hislop, Finlay & Moos 1993
Pinholt, Bang and Haanaes 1991)

45. Bio Oss in periodontal defects -Mellonig, Carmello
Bio Oss as graft material covered with resorbable membrane (Bio
Guide)
Bio Oss + Pepgen P-15 (Yukna et al):- Enhanced the bone-regenerative
results of the matrix alone in periodontal defects.
Yukna RA, Krauser JT, Callan DP, et al: Multi-center clinical comparison of combination
anorganic bovine-derived hydroxyapatite matrix (ABM)/cell binding peptide (P-15) and ABM in
human periodontal osseous defects: 6-month results. J Periodontol 71:1671, 2000

46. Boplant: Calf bone treated by detergent extraction, sterilized in
propriolactone & freeze dried. Scopp et al,1966
Kiel bone: Calf / ox bone denaturated with H2O2 (20%) dried with
acetone & sterlized with etylene oxide.
Ospurane: Cow bone soaked in KOH , acetone & salt solution.
Boiled bone: Cow bone boiled or autoclaved.

47. Carry the theoretical risk of transmission of bovine spongiform encephalopathy (BSE)
(Precheur 2007).
Several studies, however, indicate that the use of these materials does not carry a risk
for transmitting bovine spongiform encephalopathy to humans.
(Hönig et al. 1999; Wenz et al. 2001; Precheur 2007).

48. Alloplasts:
Synthetic inorganic inert material
Synthetic graft material function primarily as defect fillers. -World
Workshop (1996)
Characteristics:
- Biocompatible &/or Bioactive
- Osteoconductive
- Resorbable in long run.
Heals with fibrous encapsulation of the synthetic graft particles

49. Hydroxyapatite
Tricalcium
phosphate (α ; β)
Sodium,Calcium salts,
phosphates, silicon dioxides
Natural Coral
Coral-derived
porous HA

50. calcium-to-phosphate ratio =1.5,
(mineralogically β-whitlockite)
Partially bioresorbable (Within 24 months)
calcium-to-phosphate ratio = 1.67
(similar to that found in bone material)
Nonbioresorbable.
GEM 21S:- rh-PDGF (0.5ml) + β-TCP (0.5 c.c.)
….Carrier

51. HA Resorption rate
Macroporous >36 months
So, used where a more long-term matrix is desired (e.g. ridge augmentation or
subantral augmentation).
Microporous 6 to 12 months)
Less crystalline the material, the faster its resorption rate
(Le Geros 1983)

52. Tricalcium phosphate
Alpha beta
Crystal structure (a-Ca3(PO4)2) is monoclinic Has a rhombohedral structure.
& consists of columns of cations,
Less stable than beta and forms the
stiffer material calcium-deficient hydroxyapatite when
mixed with water
(Sukumar and Drízhal 2008; TenHuisen and Brown 1998)

53. Biphasic Alloplasts
Osteon:- 70% HA + 30% TCP
Tricos:- 60% HA + 40% TCP
Bone Ceramic: 60% HA (100% Crystalline) + 40% TCP (Particulate form)
Ceraform: 65% HA + 35% TCP

54. • Well-tolerated
• Result in clinical repair of periodontal lesions
• Several controlled studies on the use of hydroxylapatite (Periograf) &
Calcitite; clinical results were good, but histologically these materials
appeared to be encapsulated by collagen.
Calcium phosphate biomaterials…Contd

55. Bioactive glass:
Sodium & calcium salts, phosphates, and silicon dioxide.
Used in the form of irregular particles measuring 90 to 170 µm
(PerioGlas,) or 300 to 355 µm (BioGran).
When this material comes into contact with tissue fluids, the surface of the
particles becomes coated with hydroxy-carbonate apatite, incorporates
organic ground proteins such as chondroitin sulfate and glycosaminoglycans,
and attracts osteoblasts that rapidly form bone.

56. Natural Coral Coral-derived Porous
Hydroxyapatite.
resorbed slowly (several months), not resorbed or takes years for resorption.
Both are biocompatible,
Coral-Derived Materials.
Clinical studies on these materials showed pocket reduction, attachment gain, and bone
level gain.
Coral-derived materials have also been studied in conjunction with membranes, with
good results.
Both materials have demonstrated microscopic cementum and bone formation, but their
slow resorbability or lack of resorption has hindered clinical success in practice.

57. Growth factor-based bone graft substitutes:
These are natural & recombinant growth factors used alone or with other
materials such as transforming growth factor-beta (TGF-beta), platelet-
derived growth factor (PDGF), fibroblast growth factor (FGF), and bone
morphogenetic protein (BMP).
E.g:- GEM 21S:- rh-PDGF (0.5ml) + β-TCP (0.5 c.c.)
INFUSE:- rh BMP-2 + Bovine type I collagen

58. Composite Grafts
An alternative that can potentially unite the 3 essential bone-forming properties in more
controlled and effective combinations without the disadvantages found with autograft.
A composite graft combines an osteoconductive matrix with bioactive agents that provide
osteoinductive and osteogenic properties, potentially replicating autograft functionality
E.g:
Bone marrow/synthetic composites,
Ultraporous b-TCP/ BMA composite,
Osteoinductive growth factors and synthetic composites,
BMP/polyglycolic acid polymercomposites and
BMA/BMP/polyglycolic acid polymer composite
(Giannoudis et al. 2005)

59. Biologic properties of various
bone grafts

61. Particulate bone graft (or bone chips)
 Smaller pieces of bone :- more rapid ingrowth of blood vessels (revascularization),
 Larger osteoconduction surface,
 More exposure of osteoinductive growth factors, &
 Easier biologic remodeling.
 Lack a rigid, supportive structure
 Easily displaced than block grafts
Particulate bone graft + secured barrier membrane combination becomes an
environment that is stable and supports new bone formation.

62. Monocortical bone graft (Horizontal deficiencies)
 Uses a cortical block of bone harvested from a remote site and used to increase the
width of bone.
 Taken from an intraoral (e.g., mandibular symphysis or ramus) or
extraoral (e.g., iliac crest or tibia) site
& fixated to the prepared recipient site with screws/ plates (removed after 6months).
 Revascularisation of large bony
block is not possible

63. AUTOGENOUS BONE & SINUS LIFT
Loss of teeth, infections, trauma, tumor resections, and/or developmental abnormalities.
Maxillary bone atrophy
(posterior maxilla :- difficult area for the installation and maintenance of implants
Solution:- Sinus Floor Elevation with bone augmentation

64. Studies have shown that bone grafting with Bio-Oss or Cerasorb may be as effective as
autogenous grafts for sinus floor augmentation procedures.
Esposito M, Grusovin MG, Rees J, Karasoulos D, Felice P, Alissa R, et al. Effectiveness of sinus lift procedures for
dental implant rehabilitation: A Cochrane systematic review. Eur J Oral Implantol 2010;3:7-26.
Implant success rates are equal to or better than that of implants placed in non-
grafted maxillary bone (i.e., areas of the posterior maxilla with adequate height of
existing native bone).

65. Demineralised Dentin Matrix as Bone Graft:
Dentin & Bone share similar biochemical properties:
• 80% HA crystals;
• 20% Type I collagen;
• GFs: IGF-II, TGF-b, BMP;
• Proteins: Osteopontin, Bone sialoprotein, dentin sialoprotein,
Osteocalcin
DDM can be Autogenous or Allogenous

66. Preparation of dentin derived bone graft
Adult extracted 3rd
molars
Crushed in liq. N2
Washed in NaCl (1M)
Demineralised in acidic medium (Acetic acid, HCl)
Rinsed in cold distilled water
Lyophillized to get the graft

67. Clinical applications of Autogenous DDM:
•Tooth Socket Preservation
•Ridge augmentation
•GBR
•Sinus augmentation
Pioneer studies by Yeoman & Urist (1967) proved that autogenous DDM possessed
regenerative property.
Gomes et al, 2006 (Human studies)
Kim et al

68. HEALING AFTER BONE GRAFT
Bone is formed in response to graft materials in overlapping phases.
•First few days after grafting:- Revascularization occur
(Blood vessels originating from the host bone invade the graft)
•Revascularization is followed by incorporation of the grafted bone particles by new bone
emanating from the host.
• If graft contains vital osteogenic precursor cells, it contribute to new bone formation.
Osteoinductive graft matrix contains bone inductive substances (BMP) that stimulates
osteoprogenitor cells to form new bone. Or graft may simply act passively as a lattice
network over which the new host bone forms. (Osteoconduction)

69. •As the graft is being incorporated, it is gradually resorbed &
replaced by new host bone.(Creeping substitution).
•Final phase of healing:- Bone remodelling.

70. Bone remodeling cycle is composed of 5 consecutive phases:
•Activation phase:- initiation of the bone remodeling signal;
•Resorption phase:- Osteoclasts digest the old bone;
•Reversal phase:- Generates an osteogenic environment;
•Formation phase:- Process by which new bone is produced;
•Termination phase:- Informs the remodeling machinery to cease remodeling cycle

72. BIOMATERIAL COMMERCIAL NAME
Anorganic bone Bio Oss; PepGen P-15; OsteoGraf
Hydroxyapatite PerioGraf, Osteogen, ProOsteone, Ostim, Bio Graft
Tricalcium phosphate Synthograft, Bioresorb
Hard-tissue replacement polymer Bioplant
Coralline Calcium carbonate Biocoral
Collagen CollaPlug, CollaCote, Gelfoam
Bioactive glass PerioGlas

73. NovaBone:- Calcium-Phosphosilicate bone graft material
G-Bone, Sybograft:- Hydroxy apatite
Bio Oss:- Xenograft
R. T. R:- Beta-tricalcium phosphate

74. 1. Carranza F.A and Newman M.G : Clinical Periodontology 11th
/12th
edition.
2.Periodontal therapy. Clinical approaches and evidence of success. Myron Nevins,
James T. Mellonig.
3.Tissue Banking of Bone Allografts Used in Periodontal Regeneration JOP 2001
4.Bone and Bone substitutes. Nasr H.Fet al. Perio 2000, 1999 :74-86.
5. Synthetic Bone grafts in periodontics. Yukna R.A Periodontology 2000;1993:1:92-
99
REFERENCES:

75. 6. Mellonig JT. Autogenous and allogeneic bone grafts in periodontal therapy. Critical
Reviews in Oral Biology & Medicine. 1992 Jan 1;3(4):333-52.
7. Pandit N, Pandit IK. Autogenous bone grafts in periodontal practice: A literature review. J
Int Clin Dent Res Organ 2016;8:27-33.
8. Bhattacharjya C, Gadicherla S, Kamath AT, Smriti K, Pentapati KC. Tooth Derived Bone
Graft Material. World Journal of Dentistry. 2016 Jan;7(1):32-5.
9. Bone Substitution & Validation: Christopher Ogunsalu Chapter 6; Implant Dentistry – The
Most Promising Discipline of Dentistry

79. Bone fillers/ Bone traps (Robinson, 1969)
Titan filter sieve
Osseous coagulum trap
Bone trap
Suction cannulae wth filter system

81. Optimal Nature Of Bone Graft:

82. For augmentation - Cortical bone
For regeneration - Cancellous bone