Project

overview
What is Graft?
What is Grafting?
What are Bone Grafts?
Historical Review
Objectives & Rationale of Bone Grafts
Biologic concept of using Bone Grafts
Bone Grafts used in correction of
periodontal defects
Technique
 What is graft
?
A viable tissue that after
removal from a donor site is
implanted with in a recipient
tissue is then restored repaired
& regenerated.

What is
grafting ?
 What are bone
grafts?
Bone grafts are the
materials used for
replacement or
augmentation of the
 Historical Review:
The use of bone grafts for
reconstructing osseous
defects produced by
periodontal disease dates
back to Hegedus in (1923 )

Revived by Nabers &

ctives & Rationale of Bone Gra
Increase in clinical bone
defect fill.
To preserve & augment bone
for future implant placement
& / or esthetics.
Formation of functional P D L
 Biologic concept of
using Bone grafts

1) Contains bone forming cells

(osteogenesis)
2) Serve as scaffold for bone
formation (osteoconduction)
3) Matrix of bone grafting
material contains bone
inductive substances
(osteoinduction)
 Biologic concept of
using BoneGrafts:
Osteoconduction:
Formation of bone by
osteoblasts from the margins of
defect on the bone graft material.
Osteoconductive material
facilitate bone formation by
bridging the gap between the
existing bone & a distant location
that otherwise would not be
Osteoinduction:
Cell mediators at
the defect
(BMP)

Stimulation of
osteoprogenitor cells
Osteoblasts

New bone formation

Osteogenesis :
Osteoblasts in the
transplanted bone
having adequate
blood supply &
cellular viablity.

Forms new
centers of
ossification
within the graft
Bone Grafts used in
correction of
Periodontal Defects:
Autografts
Allografts /
Homografts
Xenografts /
Hetrografts
Alloplasts
Autografts: A tissue transferred
from one position to another within
the same individual .
Allografts / Homografts: Obtained
from genetically dissimilar individual
of same species .
Xenografts / Hetrografts: Tissue
transferred from one species to
another species.
Alloplasts: A synthetic graft or inert
foreign body implanted into tissue.
Autografts :
Widely used in periodontics
for treatment of intrabony
defects.
Promotes bone healing
through osteogenesis & / or
Osteoconduction.
Can be harvested from
either intraoral or extraoral
donor sites.
 Autografts from
intraoral site
-Hegedus
Sources include: (1922)
Maxillary tuberosity
Mandibular
Exostoses symphysis

Healing wounds Mandibular

body
Extraction sites
Osteoplasty
Edentulous ridges.
Osteotomy sites
Bone Grafts harvested
from intraoral sites are:

Osseous coagulum
Bone Blend
Intraoral Cancellous Bone
Marrow Transplants
Bone swaging
Osseous Coagulum:
-
•Technique uses (Robinson)
mixture of bone
dust & blood
•Small particles ground from cortical
bone used
ADVANTAGES:
* Additional surface area for
interaction of cellular & vascular
elements.
* Ease of obtaining bone
from already exposed surgical site.
DISADVANTAGES:
Bone Blend:
•Uses an autoclaved capsule &
pestle.
• Bone removed from
perdetermined site , triturated
in capsule to a workable ,
plastic like mass, & packed into
bony defects

Intraoral Cancellous Bone

Marrow:
•Cancellous bone obtained
Bone Swaging:
Technique requires
existance 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.
 Autografts from
extraoral site
Schallorn (1967/ 1968)
introduced the use of
autogenous” HIP MARROW
“Grafts (illiac crest marrow)
in treatment of intrabony
defects.
 Not recommended now a
days due to:
- Morbidity of donor site.
- Ankylosis & Root resorption.
- Post op’ impaction,
exfoliation, & sequestration.
- Rapid reoccurence of defect.
- Patients expense &
difficulty.
Allografts:
Allografts used in the treatment of
intrabony defects could be:
Frozen cancellous iliac
bone and marrow
Cryopreserved bone from
the head of a femur
Freeze-dried bone allograft
(FDBA)
Demineralized freeze-dried
bone allograft. (DFDBA)
 Freeze dried bone
allografts (FDBA)
Osteoconductive
Cortical bone is deflated, cut
into pieces, washed in
absolute alcohol , deep frozen,
freeze dried & vaccume
sealed.
Ground particle size : 250 –
750 micron.
50 – 60% bone fill.
Decalcified Freeze dried
bone allografts (DFDBA)
-
Decalcified with 0.6N Hcl ,
Urist(19
washed in sodium phosphate
65)
buffer & vaccume sealed to
expose the bone inducing agent
c/a bone morphogenic
proteins(BMP).
These proteins are
osteoinductive.
More osteogenic potential than
 Frozen iliac crest
marrow

Need for cross –

matching to decrease
the likelihood of graft
rejection as well as
disease transmission
eliminate the use of
frozen iliac crest
marrow.
Xenografts:
Anorganic bovine bone (ABB) :
Bovine bone that has been
chemically treated with
ehylenediamine to remove its
organic components, leaving a
trabecular & porous architecture
similar to human bone.It is
osteoconductive.
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.
Alloplasts:
Synthetic inorganic inert
material
Synthetic graft material function
primarily as defect fillers. -World
Workshop (1996)
Characterstics:
- Biocompatible &/or Bioactive
- Osteogenic potential
- Resorbable in long run.
 Classification: on the
basis of their ability to
be resorbed as:

Absorbable Nonabsorbable
materials
Ceramics, materials
 Porous
Beta tricalcium hydroxyapatite

phosphate  Dense
Hydroxyapatite hydroxyapatite
Calcium sulfate  Bioglass
Calcium  Calcium-coated
carbonate. polymer of
hydroxyethylmethac
Bioceramics: Composed of CaPO4
with Ca & Po4 ratio similar to
bone
Beta tricalcium phosphate:
Porous form of CaPo4
Hydroxyapetite:
Porous non resorbable
Solid non resorbable or
solid resorbable.
Polymers:
2 types
1) A non-resorbable ,
calcium hydroxide coated co-
polymer of poly - methyl –
methacrylate(PMMA).
2) Poly – hydroxylethyl
- methacrylate(PHEMA) / (HTR)
Hard tissue replacement.
Bioactive glass: CaO, Na2O,
SiO2,P2O5
Bonds to bone through
development of surface layer of
carbonated hydroxyapetite.
Bio glasses exposed to tissue
fluids….formation of double layer of
silica gel & calcium phosphate on
their surfaces….absorption &
concentration of proteins through
this layer….proteins used by
osteoblasts to form extracellular
bone matrix.
 Technique

Patient
selection

• Should be in good physical health

• Should demonstrate an acceptable
level of oral hygiene
• Could be committed to a long-term
maintenance program.
• Ideally should be a nonsmoker
Defect selection
 Preoperative
preparation

Perform plaque control .

Occlusal therapy consisting
of adjustment or splinting of
teeth .
A pre-procedural rinse with
a substantive antimicrobial
agent, such as 0.12%
chlorhexidine gluconate for 30
seconds, immediately prior to
Anesthesia

Regional Anesthesia
for patients comfort
Local infilteration
with epinephrin to
facilitate hemostasis
 Flap design

A sulcular incision full thickness flap is reflected. A

three wall intrabony defect is visualized at the distal
of the first molar.
 Defect or root
debridement

Rotary instrumentation using a multifluted surgical length

bur on a high-speed handpiece is needed to gain access to
the depth of the lesion and to plane the root surface,
which is subsequently treated with citric acid (pH 1).
 Graft
management
The choice of graft material
should be based on clinical
considerations, including
treatment objectives and
potential patient morbidity.
If morbidity with graft
procurement is a concern, an
allograft of demineralized freeze-
dried bone may be used.
There are no reports of
 Placement of demineralized freeze-dried bone
allograft is accomplished with light incremental
pressure so that the graft overfills the defect. The root
surface has been treated with citric acid (pH 1) and the
 Flap closure

A monofilament suture is used to close the flaps by

primary closure.
Postoperative
management/periodontal
maintenance
Post operative antibiotics to aid in
plaque control
Topical antimicrobial rinse
Postoperative visits include
plaque removal
(both mechanically and with
topical chlorhexidine)
Periodontal probing or recording
of attachment levels should not be
Pre op

Post op
Pre op

Post op
 Summa
Bone grafts are the material
ry
used for replacement or
augmentation of the bone around
the teeth.

Biologic concept of using Bone

grafts :
* Osteoconduction
* Osteoinduction
* Osteogenesis
Bone Grafts used in
correction of periodontal
defects: Autografts
Allografts /
Homografts
Xenografts /
Hetrografts
Alloplasts