Autogenous bone grafting

Dr. Kritika Jangid
(MDS- Periodontics and Implantology)
2Dr. Kritika Jangid

CONTENTS
• BONE
• BONE LOSS IN
PERIODONTAL
DISEASE
• AUTOGENOUS
BONE GRAFTS
3Dr. Kritika Jangid

Circumferential lamellae
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Concentric lamellae
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Interstitial lamellae
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•outer "fibrous layer" and
• inner "cambium layer" (or "osteogenic layer").
P
E
R
I
O
S
T
E
U
M
9Dr. Kritika Jangid

Are responsible for formation, resorption and maintenance of
osteoarchitecture
• Osteogenic cells
• Osteoprogenitors
• Preosteoblasts
• Osteoblasts
• Osteocytes
• Bone lining cells
• Osteoclast
B
O
N
E
C
E
L
L
S
10Dr. Kritika Jangid

WHAT HAPPENS IN
PERIODONTAL DISEASE???

Extension of inflammation from the
marginal gingiva into the supporting
periodontal tissues
Invasion of the bone surface and the
initial bone loss
Gingivitis Periodontitis
Bone loss in periodontal
disease

Pathways of inflammation

• Page & Schroeder- range of
effectiveness of dental plaque to
induce loss of bone is within about
1.5 to 2.5 mm.
• Acc to Loe & co-workers
– 8% severe periodontal diseases,
yearly loss of attachment 0.1-1mm
– 81%moderate periodontitis, CAL
0.05-0.5mm
– 11%mild Periodontitis, 0.05-0.09mm
Radius of Action

PLAQUE PRODUCTS
BONE
PROGENITOR
CELLS
OSTEOCLASTS
BONE DESTRUCTION
GINGIVAL
CELLS
AGENTS
1.
2.
3.
5.
4.
ACT AS COFACTOR
DIRECT CHEMICAL
ACTION
Hausmann,1974
Mechanism of Action

BONE DESTRUCTION PATTERNS
IN P.DISEASES
• Horizontal bone loss
• Osseous defects
• Vertical/Angular defects

VERTICAL/ANGULAR DEFECTS

• Osseous Craters
• Bulbous Bone Contours
• Reverse Architecture

• Ledges
• Furcation Involvements

• GRAFT is defined as the portion of
tissue removed from one site and placed
at another, either in same or in another
individual in order to repair a defect
caused by operation , accident or
disease.

History
• Job Van Meekeren 1668
– Performed the first heterologous graft by inserting a segment
of dog’s skull into the skull of an injured soldier
• Duhamel in 1743
– Periosteum has a pivotal role in osteogenesis
• Leopold Ollier in 1861
– Osteogenetic capability of periosteum to autologous and
homologous grafts

• Zoltan Hegedus in 1923
– Portion of tibia grafted to the labial surface of the mandibular
anteriors [1st recorded human autogenous bone graft in
periodontics]
• Buebe and Silvers 1936
– Used boiled cow bone powder to successfully repair
intrabony defects
• Forsberg in 1956
– Ospurum [ox bone ]
• Melcher in 1962
– Anorganic bone [ bovine bone ]
– Allogenic freeze-dried bone – introduced in early 1970
• Schallhorn in 1980
– Grafting successful for 20 years with daily plaque control by
patients & supervised periodontal maintenance program.
• Bower’s in 1989
– Bone grafting enhances regeneration of new attachment
aparartus 24Dr. Kritika Jangid

Vittorio Putti [1912]
Principles considered as the basis of modern science of grafting
1. Ability to be critical
2. Uniformity in graft
integration
3. Osteogenic potential of
periosteum
4. Biological capacity of
treated grafts
5. Quality of tissue in which
graft is placed
6. Mechanical
characteristics of grafts
and it’s fixation 25Dr. Kritika Jangid

Ideal bone graft should …….
Gross [1997]
1. Be biocompatible
2. Serve as scaffold [framework for new bone formation]
3. Be resorbable in the long term & have the potential
for replacement by host bone
4. Be osteogenic
5. Be radiopaque
6. Be easy to manipulate
7. Non Allergenic
8. Not support the growth of pathogen

9. Hydrophilic [to attract &
hold the clot in a particular
area]
10. Availability in particulate &
molder forms
11. Microporous
12. Have high compressive
strength
13. Have a surface amenable
to grafting
14. Act as a matrix or vehicle
for other materials

• Reattachment
Reunion of root and connective tissue separated by incision or
injury
• New attachment
Formation of new cementum with the insertion of new connective
tissue fibers about a tooth surface previously exposed to bacterial
plaque.
Epithelial attachment – by long junctional epithelium
• Regeneration
The formation of new bone, new cementum and PDL about a tooth
surface previously exposed to bacterial plaque.
• Repair
The healing of a wound by tissue that does not fully restore the
architecture or the function of the part i.e.; scar tissue .
-Melcher (1976)

TYPES OF BONE GRAFTS
• Autograft: A tissue graft transferred from one position to a new
position in the body of the same individual.
• Isograft: A tissue graft taken from one individual and transferred
to another individual of the same genetic make. Eg: Identical
twins
• Allograft: A tissue graft between individual of the same species
but of non –identical genetic.
• Xenograft: A tissue graft between members of differing species i.e
animal to man.
• Alloplast: A synthetic bone graft material, a bone graft substitute.

• Osteogenesis
Formation or development of new bone by cells contained in the
graft :eg –autogenous graft.
• Osteoconduction
Physical effect by which the matrix of the graft forms a scaffold
that favors outside cells to penetrate the graft and form new
bone. Eg; Alloplasts
• Osteoinduction
Chemical process by which molecules contained in the graft
(BMP’s) convert the neighboring cells into osteoblasts , which in
turn form bone
• Osteopromotion
When the grafted material does not possess the property of
osteoinduction but enhances osteoinduction by promoting new
bone formation. For eg: Enamelmatrix derivatives do not
stimulate de novo bone growth alone, but when used with
DFDBA, enhances the osteoinductive effect of DFDBA.

INDICATIONS
• Two walled intra bony defect
• Three walled intra bony defect
• Grade II, III Furcation involvement
• Ridge augmentation
• Sinus lifting procedure
• Regeneration around implants
• Socket conservation
• Filling donor side bone defects

1. Considered the GOLD STANDARD among all
the graft materials
2. Gives more predictable results
3. Contains live osteoblasts and
osteoprogenitor stem cells and heal by
osteogenesis

Graft Procurement
Bone
Trap
Trephine
Bur
Bone Shaving Suction
Trap

INTRA-ORAL SITES
• Healing extraction wounds
• Bone from edentulous ridges
• Bone trephined from the jaw without damaging
the roots
• Bone removed during osteoplasty or ostectomy
• Mental and mandibular retromolar areas
• Maxillary tuberosity
• Exostoses

EXTRA- ORAL SITES
• Hip marrow grafts – from iliac crest
• Gerdi’s tubercle – from tibia

BONE GRAFTS HARVESTED
FROM INTRA-ORAL SITES
• Cortical Bone Chips
• Osseous coagulum
• Bone Blend
• Intra oral Cancellous Bone Marrow Transplants
• Bone swaging

Cortical Bone Chips
• Nabers & O’Leary [1965 ] – shavings of
cortical bone removed during osteoplasty &
ostectomy
• Large particle size
• Potential for sequestration

OSSEOUS COAGULUM
• R. Earl Robinson
• Technique uses mixture of
bone dust & blood
• Small particles ground from
cortical bone used
• Sources: Lingual ridge on the
mandible, exostosis, edentulous
ridges, bone distal to the
terminal tooth, bone removed
from osteoplasty or ostectomy.

• ADVANTAGES:
Additional surface area for interaction of
cellular & vascular elements.
Ease of obtaining bone from already exposed
surgical site.
• DISADVANTAGES:
Inadequate materials for large defects.

BONE BLEND
• Uses an autoclaved capsule & pestle.
• Bone removed from pre-determined site ,
triturated in capsule to a workable , plastic
like mass, & packed into bony defects

INTRA ORAL CANCELLOUS
BONE MARROW TRANSPLANTS
• From maxillary tuberosity
Procedure:
– Bone removed from curved or cutting rongeur.
– Ridge incision distally from the last molar

• Edentulous area
Procedure:
– Raising a flap
– Bone and its marrow are removed from curettes
and back action chisels

• Healing sockets.
Procedure:
– After 8-12 weeks of healing
– Apical portion used as donor material
– Particals are reduced to small pieces

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

SOURCE OF INTRAORTAL
BONE- Imp.
• Predominantly , cortical in nature which is less
osteogenic
• Cancellous bone provides better osteogenic
potential
Dr. Kritika Jangid 47

Extra Oral Illiac Autografts
1. The use of fresh or
preserved illiac cancellous
marrow has been extensively
investigated
2. Studies show that there was
a mature PDL and about
2mm supracrestal new
attachment formation
3. No longer in use owing to
some problems such as

1. Root resorption
2. Post operative infections
3. Tooth loss & sequestration
4. Varying rates of healing
5. Rapid recurrence of defects
6. Difficulties in procuring the
graft material

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

7 days: Initiation of new bone formation
21 days: Cementogenesis
3 months: New PDL
8 months: Graft fully incorporated into the host with functionally
oriented fibers between the bone and the cementum
Maturation may take as long as 2 years
[Dragoo 1972 ; Dragoo & sullivan 1973]

Autografts ……..
Advantages
1. Promotes osteogenesis
2. Risk of disease transfer
avoided
3. Easily procured
Disadvantages
1. Inadequate material
2. Not comfort with
hospitilization
3. Inflicting surgical trauma in
other parts of the body

Autogenous bone grafting

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