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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 VSPMā€™S Dental College, Nagpur
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
Definition...
Graft-
ā€œis a piece of living tissue, organ etc transplanted
surgicallyā€
-Oxford Dictionary.
ā€œany tissue or organ for implantation or transplantationā€
- Dorlandā€™s Medical Dictionary 27th edition.
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.
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, Carranzaā€™s Clinical Periodontology,12th edition: 2015; saunders an imprint of
elsevier inc.
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, Carranzaā€™s Clinical Periodontology,12th edition: 2015; saunders an imprint of
elsevier inc.
What is a Bone Graft???
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 ā€˜autogenous 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.
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.
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.
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.
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.
ā€¢ Avoid contaminated sites.
ā€¢ Do not have graft exposed.
ā€¢ Ensure adequate blood supply to the graft.
ā€¢ Assess ā€œgraft 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.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
Risk factors for Bone grafting
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.
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.
Examples-
ā€¢ Autografts
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
Osteogenesis
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.
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
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.
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
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
Types of Bone grafts
Bone grafts can be classified:
1. Based on nature of bone (Graft anatomy).
2. Based on source of donor.
3. Based on form of grafts.
4. Based on grafting techniques.
5. Based on donor site.
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
ā€¢ Nature of the bone:
1. Cortical
3. Cortico-cancellous2. Cancellous
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
ā€¢ Source of the donor:
1. Autogenous bone graft
2. Allograft
3. Isogenic bone graft
4. Xenografts
5. Composite grafts
6. Alloplastic materials (synthetic).
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
1. Autogenous bone graft
Characteristics:
ā€¢ Historical standard of bone
grafting.
ā€¢ ā€˜Gold Standardā€™
ā€¢ Mechanisms:
- osteoconduction,
- osteoinduction, and
- osteogenesis
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Considerations:
ā€¢ Time of overall surgical procedure
ā€¢ Second site surgery to procure
autograft
ā€¢ Limited quantity of 50-55 cc
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
1. Autogenous bone graft
Complications:
ā€¢ Blood loss
ā€¢ Hematoma and arterial injury
ā€¢ Nerve injury and numbness
ā€¢ Hernia formation
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
1. Autogenous bone graft
ā€¢ Infection
ā€¢ Fracture and pelvic instability
ā€¢ Cosmetic defects
ā€¢ Chronic pain at donor site
Proposed Mechanism of Action:
Presence of osteoblasts provides direct osteogenesis,
presence of growth factors permits osteoinduction,
bone tissue allows osteoconduction.
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
1. Autogenous bone graft
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.
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.
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.
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.
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.
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.
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.
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.
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
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
B. Growth Factor Based
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
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
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
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
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
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
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.
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.
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.
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.
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.
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.
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
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.
ā€¢ Form of graft:
1. Bone blocks
2. Particulate bone
3. Bone slurry
4. Bone paste
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
1.Bone Blocks
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
2. Particulate Bone
-
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
3.Bone Slurry
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
4.Bone Paste
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
ā€¢ The Grafting technique:
Onlay graftsClothes pin (H grafts)
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Inlay graftsDowel graftsStrut grafts
ā€¢ Donor site:
ā€¢ Intra oral sites
ā€¢ Extra oral sites.
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Intra oral
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Extra oral
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
DONOR SITE MAXIMUM VOLUME
Posterior iliac crest 140 ml
Anterior iliac crest 70 ml
Tibia 20-40 ml
Cranium 40 ml
Ascending ramus 5-10 ml
Mandibular symphysis 5 ml
Maxillary tuberosity 2 ml
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
The main donor sites are:
1. Mandibular Symphysis
2. Mandibular Ramus
3. Maxillary Tuberosity
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
The miscellaneous sites are:
1. Residual ridge crest area
2. Canine eminence areas
3. Lateral to the nasal spine
4. Maxillary and mandibular tori and exostosis
5. Particulate bone from implant drills and screw taps.
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Mandibular Symphysis
Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Mandibular Symphysis
Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Advantages-
ā€¢ Easy access
ā€¢ Corticocancellous block
morphology
ā€¢ More cancellous bone than any other intra oral sites.
Mandibular Symphysis
Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Contraindication-
ā€¢ Mandible with longer anterior teeth
ā€¢ Inadequate mandibular height or width
ā€¢ Gross vertical bone loss
ā€¢ Width augmentation spanning more than four teeth.
Mandibular Symphysis
Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Complications-
ā€¢ Damaged submental and sublingual arteries
ā€¢ Damage to mandibular tooth roots
ā€¢ Mental nerve paresthesia
ā€¢ Temporary altered sensation of lower lip
ā€¢ Chin ptosis
Mandibular Symphysis
Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Mandibular Ramus
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Mandibular Ramus
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Mandibular Ramus
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Complications-
ā€¢ Potential damage to inferior
alveolar nerve
ā€¢ Limitation of size and shape of graft
ā€¢ Postoperative trismus
ā€¢ Potential damage to lingual nerve during flap incision
Mandibular Ramus
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Coronoid Process
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Coronoid Process
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Advantages
ā€¢ No facial scarring or damage
to teeth.
ā€¢ Harvesting the bone is relatively
easy.
Complications
ā€¢ Trismus
ā€¢ Damage to the buccal branch of the trigeminal nerve.
Coronoid Process
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
Maxillary Tuberosity
Kahnberg Karl-Erik, Bone Grafting Techniques for Maxillary Implants, 1st edition:
2005;Blackwell Munksgaard, a Blackwell Publishing company.
Complications ā€“
ā€¢ Oroantral fistula
ā€¢ Hematoma formation
from disruption pterygoid
venous plexus.
Maxillary Tuberosity
Kahnberg Karl-Erik, Bone Grafting Techniques for Maxillary Implants, 1st edition:
2005;Blackwell Munksgaard, a Blackwell Publishing company.
Extra Oral Donor Bone Grafts
The Preferred extra-oral donor sites of
autogenous bone include:
1. Tibia
2. Cranium and
3. The iliac crest
4. At a lesser degree rib and fibula
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
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.
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.
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.
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.
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.
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
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
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
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.
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.
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
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.
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.
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.
Sinus Lift Procedure Using
Bone Graft
Conclusion
Choice of graft should be according to osteogenic
potential of the site and the type of defect.
Intra oral autogenous bone grafts and allografts (FDBA)
are used in small defects with low to moderate
osteogenic potential.
Moderate to large reconstructions in defects of low to
moderate osteogenic potential are treated with extra oral
autogenous bone grafts-iliac crest grafts and tibial graft.
Small reconstruction with high osteogenic potential is
usually done with alloplasts like anorganic bovine bone
& microporous hydroxyapetite
Patients should be informed about possible
complications associated with bone harvest as well as
complications that may develop at the grafted site.
The predictable outcome of these procedures
depends on several biologic principles that must be
followed.
Diagnosis, treatment planning, careful execution of the
surgical treatment, postoperative follow-up, and
appropriate implant loading are all important factors in
achieving success.
Craig M. Misch Maxillary Autogenous Bone GraftingOral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2(May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
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, Carranzaā€™s 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.
ā€¢ Kahnberg Karl-Erik, Bone Grafting Techniques for Maxillary
Implants, 1st edition:2005;Blackwell Munksgaard, a Blackwell
Publishing company.
ā€¢ Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial
Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) -
Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
ā€¢ Craig M. Misch Maxillary Autogenous Bone Grafting Oral and
Maxillofacial Surgery Clinics of North America - Volume 23, Issue
2(May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
References
Thank You......

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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 VSPMā€™S 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- ā€œis a piece of living tissue, organ etc transplanted surgicallyā€ -Oxford Dictionary. ā€œany tissue or organ for implantation or transplantationā€ - Dorlandā€™s 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, Carranzaā€™s 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, Carranzaā€™s Clinical Periodontology,12th edition: 2015; saunders an imprint of elsevier inc.
  • 7. What is a Bone Graft???
  • 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 ā€˜autogenous 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 ā€œgraft 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.
  • 24. Types of Bone grafts Bone grafts can be classified: 1. Based on nature of bone (Graft anatomy). 2. Based on source of donor. 3. Based on form of grafts. 4. Based on grafting techniques. 5. Based on donor site. Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 25. ā€¢ Nature of the bone: 1. Cortical 3. Cortico-cancellous2. Cancellous Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 26. ā€¢ Source of the donor: 1. Autogenous bone graft 2. Allograft 3. Isogenic bone graft 4. Xenografts 5. Composite grafts 6. Alloplastic materials (synthetic). Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 27. 1. Autogenous bone graft Characteristics: ā€¢ Historical standard of bone grafting. ā€¢ ā€˜Gold Standardā€™ ā€¢ Mechanisms: - osteoconduction, - osteoinduction, and - osteogenesis Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 28. Considerations: ā€¢ Time of overall surgical procedure ā€¢ Second site surgery to procure autograft ā€¢ Limited quantity of 50-55 cc Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier. 1. Autogenous bone graft
  • 29. Complications: ā€¢ Blood loss ā€¢ Hematoma and arterial injury ā€¢ Nerve injury and numbness ā€¢ Hernia formation Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier. 1. Autogenous bone graft ā€¢ Infection ā€¢ Fracture and pelvic instability ā€¢ Cosmetic defects ā€¢ Chronic pain at donor site
  • 30. Proposed Mechanism of Action: Presence of osteoblasts provides direct osteogenesis, presence of growth factors permits osteoinduction, bone tissue allows osteoconduction. Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier. 1. Autogenous bone graft
  • 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.
  • 55. ā€¢ Form of graft: 1. Bone blocks 2. Particulate bone 3. Bone slurry 4. Bone paste Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 56. 1.Bone Blocks Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 57. 2. Particulate Bone - Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 58. 3.Bone Slurry Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 59. 4.Bone Paste Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 60. ā€¢ The Grafting technique: Onlay graftsClothes pin (H grafts) Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier. Inlay graftsDowel graftsStrut grafts
  • 61. ā€¢ Donor site: ā€¢ Intra oral sites ā€¢ Extra oral sites. Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 62. Intra oral Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 63. Extra oral Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 64. DONOR SITE MAXIMUM VOLUME Posterior iliac crest 140 ml Anterior iliac crest 70 ml Tibia 20-40 ml Cranium 40 ml Ascending ramus 5-10 ml Mandibular symphysis 5 ml Maxillary tuberosity 2 ml Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 65. The main donor sites are: 1. Mandibular Symphysis 2. Mandibular Ramus 3. Maxillary Tuberosity Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 66. The miscellaneous sites are: 1. Residual ridge crest area 2. Canine eminence areas 3. Lateral to the nasal spine 4. Maxillary and mandibular tori and exostosis 5. Particulate bone from implant drills and screw taps. Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 67. Mandibular Symphysis Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 68. Mandibular Symphysis Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 69. Advantages- ā€¢ Easy access ā€¢ Corticocancellous block morphology ā€¢ More cancellous bone than any other intra oral sites. Mandibular Symphysis Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 70. Contraindication- ā€¢ Mandible with longer anterior teeth ā€¢ Inadequate mandibular height or width ā€¢ Gross vertical bone loss ā€¢ Width augmentation spanning more than four teeth. Mandibular Symphysis Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 71. Complications- ā€¢ Damaged submental and sublingual arteries ā€¢ Damage to mandibular tooth roots ā€¢ Mental nerve paresthesia ā€¢ Temporary altered sensation of lower lip ā€¢ Chin ptosis Mandibular Symphysis Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 72. Mandibular Ramus Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 73. Mandibular Ramus Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 74. Mandibular Ramus Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 75. Complications- ā€¢ Potential damage to inferior alveolar nerve ā€¢ Limitation of size and shape of graft ā€¢ Postoperative trismus ā€¢ Potential damage to lingual nerve during flap incision Mandibular Ramus Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 76. Coronoid Process Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 77. Coronoid Process Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 78. Advantages ā€¢ No facial scarring or damage to teeth. ā€¢ Harvesting the bone is relatively easy. Complications ā€¢ Trismus ā€¢ Damage to the buccal branch of the trigeminal nerve. Coronoid Process Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 79. Maxillary Tuberosity Kahnberg Karl-Erik, Bone Grafting Techniques for Maxillary Implants, 1st edition: 2005;Blackwell Munksgaard, a Blackwell Publishing company.
  • 80. Complications ā€“ ā€¢ Oroantral fistula ā€¢ Hematoma formation from disruption pterygoid venous plexus. Maxillary Tuberosity Kahnberg Karl-Erik, Bone Grafting Techniques for Maxillary Implants, 1st edition: 2005;Blackwell Munksgaard, a Blackwell Publishing company.
  • 81. Extra Oral Donor Bone Grafts The Preferred extra-oral donor sites of autogenous bone include: 1. Tibia 2. Cranium and 3. The iliac crest 4. At a lesser degree rib and fibula Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North America;Volume 23,Issue 2 (May 2011).Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 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.
  • 96. Sinus Lift Procedure Using Bone Graft
  • 97.
  • 98. Conclusion Choice of graft should be according to osteogenic potential of the site and the type of defect. Intra oral autogenous bone grafts and allografts (FDBA) are used in small defects with low to moderate osteogenic potential. Moderate to large reconstructions in defects of low to moderate osteogenic potential are treated with extra oral autogenous bone grafts-iliac crest grafts and tibial graft. Small reconstruction with high osteogenic potential is usually done with alloplasts like anorganic bovine bone & microporous hydroxyapetite Patients should be informed about possible complications associated with bone harvest as well as complications that may develop at the grafted site. The predictable outcome of these procedures depends on several biologic principles that must be followed. Diagnosis, treatment planning, careful execution of the surgical treatment, postoperative follow-up, and appropriate implant loading are all important factors in achieving success. Craig M. Misch Maxillary Autogenous Bone GraftingOral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2(May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier.
  • 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, Carranzaā€™s 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.
  • 100. ā€¢ Kahnberg Karl-Erik, Bone Grafting Techniques for Maxillary Implants, 1st edition:2005;Blackwell Munksgaard, a Blackwell Publishing company. ā€¢ Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier. ā€¢ Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North America - Volume 23, Issue 2(May 2011) - Copyright Ā© 2011 Saunders, An Imprint of Elsevier. References