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Bone grafts
1. Presented by:
Dr. Sapna K Vadera
(P.G. Student)
Guided by:
Dr. S.R.Shenoi
(Prof, Guide and H.O.D)
Dept Of Oral and Maxillofacial Surgery VSPMāS Dental College, Nagpur
2. Contents
ā¢ Definition
ā¢ Introduction
ā¢ What is a bone graft?
ā¢ History of bone graft
ā¢ Uses of bone graft
ā¢ Principles of bone grafting
ā¢ Risk factors for bone grafting
ā¢ Mechanism of bone regeneration and augmentation
ā¢ Types of bone grafts
ā¢ Sinus lift surgery
ā¢ Conclusion
ā¢ References
3. Definition...
Graft-
āis a piece of living tissue, organ etc transplanted
surgicallyā
-Oxford Dictionary.
āany tissue or organ for implantation or transplantationā
- Dorlandās Medical Dictionary 27th edition.
4. ā¢ Graft is a tissue that is detached from its own blood
supply and is placed in a new area (recipient site) with
a new blood supply i.e it does not maintain its original
blood supply.
ā¢ Flap is a tissue used for reconstruction or wound
closure that retains all or part of its original blood
supply after the tissue has been moved to the
recipient site i.e it maintains original blood supply.
Definition...
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
5. Introduction
Bone grafts have been employed for repair for more
than a hundred years.It is a dynamic process and is
extensively used in reconstructive surgery.
Bone, which has been lost as a result of excision,
resorption or sequesterization, will not repair by
normal process of healing.
So they are to be replaced by means of alloplast, bone
grafts or its substitutes.
For a successful regeneration, bone graft when applied
should heal, become incorporated, revascularise and
eventually assume the desired form.
Kiokkevold R Perry , Localized bone augmentation and implant site development; Newman
Michael et al, Carranzaās Clinical Periodontology,12th edition: 2015; saunders an imprint of
elsevier inc.
6. To satisfy the ideal goals of implant dentistry, the hard and
soft tissues need to present ideal volumes and quality.
The alveolar process is affected so often after tooth loss,
augmentation is usually indicated to achieve optimum
results.
Because of an improved understanding of biomechanics,
requirements for long term prosthesis survival and the
increasing use of implants in esthetic restorations, ridge
reconstruction before implant placement has become a
necessary procedure for a number of edentulous patients.
Introduction
Kiokkevold R Perry , Localized bone augmentation and implant site development; Newman
Michael et al, Carranzaās Clinical Periodontology,12th edition: 2015; saunders an imprint of
elsevier inc.
8. History of bone graft
ā¢ The earliest known repair of cranial and facial defects is by
use of alloplast. Neolithic Peruvians used hammered gold
and silver plates over frontal bone defect.
ā¢ In 1889,Seydel was first surgeon to use autogenous bone
graft in facial region. He used autogenous bone from tibia.
ā¢ In 1978 & 1982 ,Bradley reported a two-stage procedure for
reimplantation of āautogenous freeze treated mandibular
bone.
Craig M. Misch,autogenous bone grafting for dental implants, Raymond Fonseca; Oral and
maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
9. ā¢ In 1989,McCarthy first applied the principle of distraction in
maxillofacial region.
ā¢ In 2008, R. Gutta and P.D. Waite described an extraoral
approach for cranial bone grafting with simultaneous implant
placement to the atrophic mandible.
ā¢ In 2010,Amrani et al. evaluated the utility of autogenous
extended mandibular ramus and coronoid process bone
grafts for maxillofacial reconstructive surgery.
History of bone graft
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
10. ā¢ In 2013,Kolerman et al. conducted a study to evaluate the
regenerative potential of a fully synthesized homogenous
hydroxyapatite Ī²-tricalcium phosphate alloplast material in
sinus lift procedures.
History of bone graft
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
11. Uses of Bone graft
To encourage healing of non united fractures.To reconstruct posttraumatic deformity.To fill cavities following cyst enucleation.To restore continuity of bone following tumour excision.To improve facial contour for cosmetic purpose.To augment alveolar bone.To repair congenital defects.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
12. Principles of Bone grafting
ā¢ Harvest bone from areas familiar.
ā¢ Contour bone graft to fit the defect.
ā¢ Fix the bone graft to the defect in a tension free manner.
ā¢ Ensure absolute immobilisation.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
13. ā¢ Avoid contaminated sites.
ā¢ Do not have graft exposed.
ā¢ Ensure adequate blood supply to the graft.
ā¢ Assess āgraft takeā periodically.
Principles of Bone grafting
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
14. Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
Risk factors for Bone grafting
15. Mechanisms of bone
regeneration and augmentation
ā¢ Osteogenesis
ā¢ Osteoinduction
ā¢ Osteoconduction
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
16.
17. Osteogenesis
ā¢ Osteogenesis refers to the growth
of bone from viable cells
transferred within the graft.
ā¢ New bone is regenerated from
endosteal osteoblasts and
marrow stem cells transferred
with the graft.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
18. Examples-
ā¢ Autografts
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
Osteogenesis
19. Osteoinduction
ā¢ Osteoinduction involves new bone
formation from osteoprogenitor
cells derived from primitive
mesenchymal cells under the
influence of one or more inducing
agents that arise from the bone
matrix.
ā¢ Capable of inducing bone
formation in a non-bony site by
recruiting and inducing(pluripotent)
cells to become osteoblasts
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
20. ā¢ The most commonly used
osteoinductive materials in
implant dentistry are bone
allografts and autografts.
ā¢ Frozen bone
ā¢ Freeze ā Dried (FDBAs) and
ā¢ Demineralized freeze ā Dried
(DFDBAs)
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
Osteoinduction
21. Osteoconduction
ā¢ Osteoconduction characterizes bone
growth by apposition from the surrounding
bone.
ā¢ Biocompatible material that provides a
physical structure into and along which
bone may grow
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
22. ā¢ The most common osteo-
conductive bone grafting
materials used in implant
dentistry are alloplasts and
xenografts.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
Osteoconduction
23. Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
31. 2. Allograft
ā¢ Characteristics
ā¢ Cortical allografts may provide
structural support and may be
immediately load bearing.
ā¢ Various geometric and shapeable
forms.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
32. ADVANTAGES:
ā¢ It reduces additional surgery and the
resultant morbidity.
ā¢ Operating time is reduced.
ā¢ All the bone required is readily
available
2. Allograft
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
33. DISADVANTAGES:
ā¢ Chances for disease transmission.
ā¢ Difficult storage of graft.
ā¢ Loss of viable osteo-progenitor
cells.
2. Allograft
ā¢ Graft rejection due to immune
reaction.
ā¢ Reputed tissue bank required.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
34. Proposed Mechanism of Action:
Primarily acts through osteoconduction. Cancellous
allograft may have some osteoinductive potential but it will
vary depending on the source and how it was processed and
sterilized.
2. Allograft
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
35. A. Allograft Sub-set
Cortical bone with mineral removed (via
acid extraction) leaving collagenous and
non-collagenous proteins with a low
concentration of growth factors.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
36. Characteristics:
ā¢ Contains type I collagen,non-collagenous proteins,and a
low concentration of growth factors (BMP) which may
impart osteoinductivity.
A. Allograft Sub-set
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
37. Proposed Mechanism of Action:
Primarily acts through osteoconduction.
Studies reports that the presence of growth factors
(e.g. BMP) imparts osteoinductivity.
A. Allograft Sub-set
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
38. B. Growth Factor Based
Growth factors bind to receptors
on cell surfaces stimulating the
formation of proteins to be used
inside the cell or externally (e.g.
formation of extracellular
matrices like bone tissue)
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
39. Bone MorphogeneticProteins (BMPs)
(aka recombinant human bone
morphogenetic protein or rhBMP)
Insulin-Like
Growth Factor 1 & 2
(IGF-1), (IGF 2)
Platelet Derived Growth
Factor (PDGF)
Transforming Growth
Factor Beta
(TGF-Ī²)
Fibroblast Growth
Factor (FGF)
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
Growth
Factors
40. Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
B. Growth Factor Based
41. Considerations:
ā¢ Most common complications include osteolysis,
swelling/ edema, heterotopic bone formation, and
antibody reaction.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
B. Growth Factor Based
42. Proposed Mechanism of Action:
Acts via osteoinduction.
BMP binds to mesenchymal stem cell receptors resulting
in proliferation and differentiation into osteoblasts.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
B. Growth Factor Based
43. Platelet Rich Plasma (PRP) is obtained by fractioning
whole autologous blood by centrifugation
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
C. Cellular Based:
PRP
44. Characteristics:
ā¢ PRP contains PDGF, EGF,
and FGF-2 which stimulate
proliferation of osteoblast
progenitors.
ā¢ Also contains TGF-Ī² which
increases type I collagen
synthesis.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
C. Cellular Based:
PRP
45. Considerations:
ā¢ Outcome is donor dependent and varies with preparation
technique.
ā¢ Proteases present in the platelet fraction may degrade
some of the growth factors.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
C. Cellular Based:
PRP
46. Proposed Mechanism of Action:
Platelet gels provide a rich source of growth factors
that direct mechanisms involved in bone healing and
subsequent osteogenesis.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
C. Cellular Based:
PRP
47. 3. Alloplastic materials
Alloplastic material:
A. Ceramic based
B. collagen based
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
48. ā¢ Calcium Sulfate
ā¢ Calcium Phosphate
ā¢ Synthetic Hydroxyapatite
ā¢ Tricalcium Phosphate (TCP)
COLLAGEN BASED MATERIAL
ā¢ Typically composites
with ceramic materials.
CERAMICS
3. Alloplastic materials
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
49. A.Ceramic Based
Characteristics:
ā¢ Osteoconductive
ā¢ Can be used in the presence of infection
ā¢ Resorption (5-7 week period)
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
50. Considerations:
ā¢ Mechanical properties variable, due to high dissolution
rate.
ā¢ Implantation should be limited to confined defects.
ā¢ Calcium sulfate ā complications associated with
inflammatory reactions.
A.Ceramic Based
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
51. Proposed Mechanism of Action:
Calcium sulfate serves as an osteoconductive matrix for
the ingrowth of osteogenic cells.
A.Ceramic Based
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
52. B.Collagen Based
Characteristics:
ā¢ Collagen is the most abundant
protein found in bone tissue
ā¢ Osteoconductive matrix with a
favourable physical and
chemical matrix for bone
regeneration
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
53. Considerations:
ā¢ Weak structural and mechanical properties
ā¢ Collagen is usually coupled with other bone
substitutes (HA, Ī²-TCP, bone marrow, etc.)
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
B.Collagen Based
54. Proposed Mechanism of Action:
ā¢ Primarily acts through osteoconduction and/ or via
mechanisms from the component that is added to
it.
B.Collagen Based
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
82. Cranial Bone
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
83. Cranial Bone
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
84. Advantages ā
ā¢ Slow resorption
ā¢ High stability for osteo
integration
ā¢ Low morbidity at donor site
ā¢ Easy screw fixation
ā¢ Harvesting of large grafts
Cranial Bone
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
85. Complications-
ā¢ Surgical wound infection
ā¢ Dural injuries
ā¢ Transitory neurological defects
ā¢ Epidural hematoma
ā¢ Alopecia
Cranial Bone
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
86. Tibia
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
87. Advantages-
ā¢ 20 to 40 cu.cm of noncompressed cancellous bone can
be harvested from the marrow space.
ā¢ Procedure straightforward
ā¢ Less surgical time 20-40mins
ā¢ Minimal postoperative pain and dysfunction.
ā¢ Immediate postoperative weight
ā¢ Blood loss is minimal
ā¢ Drainage is not required.
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
Tibia
88. Contraindication-
ā¢ Patients younger than 18 years
ā¢ Patients with knee injury or knee surgery
ā¢ Patients with advanced rheumatoid or degenerative
arthritis
ā¢ Patients with metabolic bone disease
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
Tibia
89. Complications-
ā¢ Potential entrance into joint space
ā¢ Post operative edema
ā¢ Large/unsightly scar
ā¢ Gait disturbance
ā¢ Fracture
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
Tibia
90. Iliac Crest
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
91. Advantages
ā¢ excellent source of large segments of cortico-cancellous
grafts or pure cortical or cancellous grafts.
ā¢ Sculptured segments can be used for onlay,
interposition or construction in craniomaxillofacial
surgery.
ā¢ Iliac cortico cancellous grafts are easily incorporated
into rigid fixation plates and provide immediate
mechanical strength.
Iliac Crest
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
92. Complications
ā¢ Perforation of the bowel
ā¢ Hernia
ā¢ Gait disturbance-damage to gluteus medius or
gluteus maximus muscle
Iliac Crest
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
ā¢ Cosmetic deformity
ā¢ Injury to sensory nerves-iliohypogastric nerve,
lateral femoral cutaneous nerve
ā¢ Fractures
93. Rib
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
94. Advantages-
ā¢ Can be harvested in length of 10 to 15cm and then split to
double the surface area of the graft.
ā¢ Cortico-cancellous ribs are quite malleable and are easily
fashioned for use in the curved contours of cranio-facial
skeleton.
ā¢ Rib regenerate from the ends if the periosteal sheath is
preserved.
Rib
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
95. Disadvantages-
ā¢ The regenerated bone from the rib is never the same
quality as the original rib.
ā¢ Potential for pneumothorax, chest wall depression,
persistent pleuritic pain with exercise.
ā¢ The cortices are thinner. So incorporation of implants
are not successful.
ā¢ It has minimal cancellous bone
Rib
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
99. References
ā¢ Craig M. Misch,autogenous bone grafting for dental implants,
Raymond J Fonseca; Oral and maxillofacial surgery;2nd
edition:2009;saunders an imprint of elsevier inc.
ā¢ Kiokkevold R Perry , Localized bone augmentation and implant
site development;Newman Michael et al, Carranzaās Clinical
Periodontology,12th edition:2015;saunders an imprint of
elsevier inc.
ā¢ Garg K Arun, Bone biology, Osseointegration, and Bone
grafting, Implant Dentistry;2nd edition:2010; an affiliate of
elsevier inc.