Bone graft

Bone Grafts In Periodontics

1. Bone Grafts In
Periodontics
Dr. Anuj Singh Parihar
Senior Lecturer
Department of Periodontics

2. WHAT IS GRAFT ?
A viable tissue that after removal from a donor
site is implanted with in a recipient tissue is then
restored repaired & regenerated.

3. WHAT IS GRAFTING ?

Procedure used to replace / restore missing bone
or gum tissue.

4. WHAT ARE BONE GRAFTS?
Bone grafts are the materials used for replacement
or augmentation of the bone.
Food and Drug Administration (FDA) regulates bone
grafting materials

5. HISTORICAL ASPECT

6. RATIONALE

7. Ellgaard et al & Nielson et al ----- graft material
may be
 osteoproliferative (osteogenic)
Osteoconductive
osteoinductive

8. OSTEOINDUCTION
A chemical process by which molecules contained
in the graft(bmp)convert the neighbouring cells
into osteoblasts which in turn form bone.
Process by which graft material is capable of
promoting
- osteogenesis
- cementogenesis
- new PDL
(Urist & McLean)

9. A graft, a biomaterial or a substance is osteo
inductive when implanted in a non osseous
environment called as an ectopic site, bone
formation occurs.

10. OSTEOGENESIS
represents all the steps & processes leading to
bone formation. This term has been used by some
authors to define bone grafts capable of forming
bone through osteoblastic cells contained in the
transplanted graft

OR
 the process of bone formation, which begins with
either osteoblasts in the patient's natural bone or
from surviving cells in the bone graft that is
placed.

12. OSTEOCONDUCTION
A physical effect by which the matrix of the graft
forms a scafold that favours outside cells to
penetrate the graft and form new bone.
The Graft material acts as a passive matrix like
a trellis or scaffolding for new bone to cover over
itself.
( Urist & colleagues )

13. Process also known as Trell's effect
occurs with the ingrowth of capillaries in the new
connective tissue.
A material is osteo conductive when its structure
& its chemical composition facilitate new bone
formation from existing bone.

14. OSTEOSTIMULATION - “The stimulation of
osteoblast proliferation and differentiation as
evidenced during in vitro osteoblast cell culture
studies by increased DNA content and elevated
osteocalcin and alkalinephosphatase levels”
FDA 2005

15. CONTACT INHIBITION
The process by which the graft material prevents
apical proliferation of epithelium
(Ellegaard & colleagues 1972)

16. INDICATIONS FOR GRAFTS
Deep Intraosseous Defects
Tooth Retention
Support for Critical Teeth
 Bone Defects Associated With Aggressive
Periodontitis
Esthetics (Shallow Intraosseous Defects)
Furcation Defects

17. OBJECTIVES OF BONE GRAFTING
probing depth reduction
clinical attachment gain
bone fill of the osseous defect
regeneration of new bone, cementum, and
periodontal ligament

18. ADVANTAGE
Potential regeneration of non correctable
periodontal defect.
By reconstructing the periodontium, it is possible to
reverse the disease process.
Increased tooth support, improved function,
and enhanced esthetics are concomitant results of
successful bone graft therapy

19. DISADVANTAGE
Increased t/t time
Longer postop t/t
Autograft requires 2 site
Inc. postop care
Variability in repair & predictability
Greater expense
Availability
( Mellonig 1992)

20. CLASSIFICATION

21. Human bone
Autogenous grafts (autografts)
 Extraoral
 Intraoral
Allogenic grafts (allografts)
 Fresh frozen bone
 Freeze-dried bone allografts
 Demineralized freeze-dried bone
allografts

22. Bone substitutes
Xenogeneic grafts (xenografts)
 Bovine-derived hydroxyapatite
 Coralline calcium carbonate
Alloplastic grafts (alloplasts)
 Polymers
 Bioceramics
 - Tricalcium phosphate
 - Hydroxyapatite
 Bioactive glasses

23. SELECTION OF GRAFT MATERIAL
Osteoinductive potential
Predictability
Accessability
Availability
Safety
Rapid vascularization
( Bell 1964, Schallhorn 1976)

24. IDEAL CHARACTERISTIC OF BONE
GRAFT
Nontoxic
Nonantigenic
Resistant to infection
No root resorption or ankylosis
Strong and resilient
Easily adaptable
Readily and sufficiently available
Minimal surgical procedure
 Stimulates new attachment

25. AUTOGRAFTS
first bone replacement grafts reported for
periodontal applications
‘‘Gold Standard’’ for bone grafting procedures
Rich source of bone & marrow cells
osteogenic potential

26. SITES

27. BASED ON INDUCTIVE POTENTIAL
Extraoral—hip marrow
 Fresh
 Frozen
Intraoral
 Osseous coagulum—bone blend
 Tuberosity
 Extraction sites
 Osseous coagulum
 Continguous autograft

28. EXTRAORAL SITES
Schallorn (1967/ 1968) introduced use of
autogenous” HIP MARROW “Grafts (illiac crest
marrow) in t/t of periodontal defects.
highest inductive potential
Obtained using a Turkell bone trephine

30. PRECLUDES USE IN PERIODONTAL
SURGERY

31. INTRAORAL SITES
overall mean bone fill of 3.0 to 3.5 mm
significant gains in probing attachment level in
treating one-, two-, or three-wall (or combination)
defects
(Nabers & O’Leary, 1965; Hiatt & Schallhorn,
1973; Froum, 1976;)

32. INSTRUMENTS USED

34. CORTICAL BONE CHIPS
Impetuss for modern-day use of periodontal bone
grafts can be traced to the work of Nabers &
O'Leary (1965)
Shavings of cortical bone removed by hand
chisels
during osteoplasty & ostectomy
Successfully to effect a coronal increase in bone
height

35. Zayer and Yukna, 1983
Relatively large particle size — 1,559.6 ×183µm
potential for sequestration

Were replaced

36. OSSEOUS COAGULUM (ROBINSON,
1969)
Technique uses mixture of bone shaving & blood
from surgical field
Concept based on fact that mineralized
substances can induce osteogenesis
Smaller the particle size of the donor bone, the
more certain its resorption and replacement with
host bone
extension of the technique developed by Nabers
and O’Leary (1965)

37. SITES
Exostoses
Tori
Heavy marginal ridges &
Adjacent sites undergoing osseous correction.

38. obtained with high- or low-speed round burs
during osteoplasty
Collected on a large retractor or mirror
Mixed with Pt’s blood in a sterile dappen dish

39. DISADVANTAGE
inability to aspirate during the collection process
 unknown quantity & quality of collected bone
fragments
Fluidity of the material

40. OSSEOUS COAGULUM- BONE
BLEND
Diem and colleagues (1972) modified Robinson’s
original technique
Permit easier access & collection of donor
material
Sites
 Extraction sites
 Exostoses
Tori
Edentulous ridges

42. BONE IS REMOVED FROM A
PREDETERMINED SITE, PLACED IN
STERILE
AMALGAM CAPSULE &
TRITURATED

43. Same regenerative potential as iliac marrow
Significantly greater regenerative potential than
that of open débridement
Froum and colleagues ( 1 9 7 5,
1 976)
particle size 2 1 0 x 10 5 µm

44. ADVANTAGES
Ease of procurement
Same surgical field
Benefits of both cancellous and cortical
techniques.

45. DISADVANTAGES
More extensive armamentarium
 Extensive defects may require more material
than can be procured with this approach.

46. TUBEROSITY SITE
Hiatt and Schallhorn (1973)
Alternative source to iliac crest
Tuberosity potential source for residual red
marrow
Cancellous bone potential source of osteoblast

48. Bone obtained after careful removal of cortical
plate by rongeurs & curets
Regeneration α Adequacy of soft tissue
coverage & with surface area of vascularized
bony wall
 α 1/ root surface area.

49. EXTRACTION SITE
Halliday (1969)
Artificial defect created using bone trephine.
Extraction required were timed to coincide with
treatment of intraosseous defect

51. BONE SWAGGING
Ewen (1965) --- treating bony defects
 Bone from an edentulous area was moved next
to the tooth to get rid of the defect.
This required that the bone be fractured, without
completely severing it to maintain the blood
supply, & at the same time be moved next to the
tooth (Nabers and O’Leary, 1 9 67)

53. LIMITATION
difficult, impractical technique, the results of
which have not been borne out by research.
It is further limited by the need for an adjacent
edentulous ridge and bone quality that permits
bending without fracturing.

54. INTRAORAL CANCELLOUS BONE
AND MARROW
Hiatt & Schallhorn, 1973
Healing bony wounds, healing extraction sockets,
edentulous ridges, mandibular retromolar areas, &
maxillary tuberosity have all been used as sources
Edentulous ridges can be approached with a flap,
and cancellous bone and marrow are removed with
curettes.
 Healing sockets are allowed to heal for 8 to 12
weeks, and is used as donor material. The particles
are reduced to small pieces

55. Bone fill in all types of intraosseous & furcation
defects has been demonstrated with this
material.
 A mean bone fill of 3.65 mm, with bone fill of up
to 12 mm in some defects & more than 50% fill on
a predictable basis has been reported.

56. Ellegaard & Loe ( 1971) reported that grafts of
intraoral cancellous bone & marrow did not
appear to influence the clinical outcome when
compared with surgical curettage.
Renvert e t al. ( 1985) found limited differences
between grafted & nongrafted sites.

57. Advantages
Relative ease of procurement
Relatively high induction potential for osteogenesis
Disadvantages
 Additional Surgical exposure may be necessary to
procure donor material
Extensive defects may require more material than
can be obtained.

58. EXTRAORAL CANCELLOUS BONE &
MARROW
Cushing (1969 )--- extraoral cancellous bone &
marrow offer the greatest potential new bone
growth.
In 1968 Schallhorn obtained this material either
from anterior or posterior iliac crest.

59. Iliac Autografts - Data from human & animal
studies support its use, & the technique has proved
successful in bony defects with various numbers of
walls, in furcations.
It is generally agreed that extraoral cancellous
bone and marrow from the iliac crest offer the
greatest osteogenic potential.

61. Advantages:
 Greatest induction potential for osseous
regeneration
Sufficient quantities for extensive defects.
 May be stored for future use.

62. Disadvantages:
 Additional surgical insult to the patient.
additional expense i.e. orthopedic surgeon or
hematologist.
 Potential for root resorption with fresh material.

63. COMPLICATION
Schallhorn R.G (1972) described the post
operative problems associated with iliac bone
grafts
postoperative infection
exfoliation
sequestration
varying rates of healing
root resorption
rapid recurrence of the defect

64. ALLOGRAFT
Bone grafts harvested from one person for
transplantation in another.
Used in periodontal therapy since last 3 decades.
most frequently used alternative to autogenous
bone for bone grafting procedures in the US.

65. NEED …………….?????????????????
Problems associated with autogenous bone
procurement
- morbidity accompanying a second surgical
site
- need for a sufficient quantity of material to

fill multiple defects
(Mellonig, 1980 & 1991)

66. Classification
 fresh frozen bone
Demineralized freeze-dried bone allografts
Freeze-dried bone allografts (FDBAs)/
autogenuous bone grafts (ABGs)

67. FRESH FROZ EN BONE
Possibility of disease transfer
Antigenicity
4 C ASES OF HIV HAVE BEEN REPORTED
need for extensive cross-matching
DISALLOWED the use of fresh frozen bone in
modern periodontics.

68. Evidence suggest that freeze-drying markedly
reduces antigenicity & other health risks
associated with fresh frozen bone

Freeze-dried bone allografts

69. WHICH BONE TO USE….? ? ? ? ? ?
Cortical bone is recommended rather than
cancellous bone -------- American Academy of
Periodontology
cancellous bone is more antigenic
cortical bone contains more bone matrix and
consequently more osteoinductive components

70. Bone allografts are procured usually within 12
hours of death of a suitable donor.

71. STEPS IN PROCESSING

72. Freeze-drying removes more than 95% of the
water content from the bone.
It preserves three major specimen
characteristics; size, solubility, and chemical
integrity.
 freeze-drying destroys all cells & graft is
rendered non-viable

73. ADVANTAGES
Material is available in large quantities
No donor site within the patient
Reduces antigenicity
Facilitates long-term storage
Vacuum sealing in glass containers protects
against contamination and degradation of the
graft material while permitting storage at room
temperature for an indefinite period of time

74. DISADVANTAGE
Process of preparing the graft material’s
integrity & osteogenic potential, &
immunological response to it may diminish its
incorporation into the recipient bone
A major concern is potential for disease transfer,
particularly viral transmission more particularly
HIV

75. AMERICAN ASSOCIATION OF
TISSUE BANKS (AATB)
Excludes collection of bone under following
circumstances:
Donors from high-risk groups, as determined by
medical testing and/or behavioral risk assessments.
Donors test positive for HIV antibody by ELISA.
 Autopsy of donor reveals occult disease.
 Donor bone tests positive bacterial contamination.
 Donor & bone test positive for HBsAG or HCV.
 Donor tests positive for syphilis.

76. FDBA
Introduced to periodontal therapy in 1976
osteoconductive.
 Although FDBA contains inductive proteins, the
polypeptides are sequestered by calcium.
This material is resorbed and replaced by host
bone very slowly.
only graft material that has undergone extensive
field testing for the treatment of adult
periodontitis.

77.  Mellonig, Bowers, and co-workers - reported
bone fill exceeding 50% in 67% of the defects
grafted with FDBA and in 78% of the defects
grafted with FDBA plus autogenous bone.
FDBA-------- osteoconductive material
DFDBA-------osteoinductive graft.

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

79. Significantly greater bone fill and defect
resolution have been shown with the FDBA and
tetracycline composite than with the allograft
alone or the nongrafted control.

80.  Sanders et al 1 9 83 found that more than 50%
bone fill was achieved in 80% of test cases grafted
with FDBA + autogenous bone but in only 63% of
controls grafted with FDBA alone.
Mellonig 1990 DFDBA has a higher osteogenic
potential & provides more bone fill than FDBA.
FDBA is still used today, but a large-scale research
review showed that FDBA mixed with autogenous
bone is more effective at increasing bone fill than
FDBA alone by Mellonig 1991.

81. DFDBA
 synonymous - allogeneic, autolyzed,
antigen-extracted (AAA) bone, demineralized
bone powder, demineralized bone matrix, and
demineralized bone matrix gelatin with
decalcified freeze-dried bone.

82. Demineralization of allografts was performed
because the bone mineral blocked the effect of the
factors stimulating bone growth sequestered in
bone matrix including BMP.

83. Experiments by Urist and co-workers have
established the osteogenic potential of DFDBA.
Demineralization in cold, diluted hydrochloric
acid exposes the components of bone matrix,
closely associated with collagen fibrils, that have
been termed bone morphogenetic protein.

84. BMP are a group of acidic polypeptides belonging
to the transforming growth factor-β gene super-
family. They stimulate bone formation through
osteoinduction by inducing pleuripotential stem
cells to differentiate into osteoblasts

85. Experimental animal studies have shown that
demineralized freeze-dried bone allograft has
osteogenic potential
The bioactivity appears to be age dependent.
Younger animals ≥ older animals

86.  Bowers & associates, in a histologic study in
humans, showed new attachment and periodontal
regeneration in defects grafted with DFDBA.
Mellonig & associates tested DFDBA against
autogenous materials in the calvaria of guinea pigs
and showed it to have similar osteogenic potential.
These studies provided strong evidence that
DFDBA in periodontal defects results in significant
probing depth reduction, attachment level gain,
and osseous regeneration

87. FACTORS AFFECTING
Delaying the procurement of donor bone after
death, improper storage conditions, or other
processing factors may play a significant role in
the bioactivity of the final DFDBA preparation
that makes its way to the clinician's office
age, gender, and medical status of deceased
donors may also affect osteogenic activity in the
grafts taken from them.

88. The inductive activity gradually decreases&
eventually is reduced to 0 within a period of 1 5
days when decalcification with 0.6 N HCI is
performed at 2 5 °C, whereas in the cold ( 2 °C)
the inductive activity is fairly maintained even at
30 days (Urist & Dowell, 1 9 68).
 Ethyl or isopropyl alcohols in 0.6 N HCI produce
total inactivation of inductive substrate.
 Heating above 60 °C inhibits bone formation

89. FUTURE DIRECTIONS WITH
DFDBA
The enhanced osteogenic potential of DFDBA is the
result of a variety of bone-inductive proteins
located within the bone matrix.
At the very least, nine BMPs (BMP-1 through
BMP-9) have been cloned and characterized, and
some are available in human recombinant form.
 Animal experiments have demonstrated that the
BMPs have the ability to induce bone and repair
bone defects at a variety of anatomic sites as
reported by Wang EA et al 199 0.

90. Osteogenin (BMP-3) isolated from long bones of
humans in association with a bone-derived
collagenous matrix will rapidly initiate the
cascade of bone development.

91. CONCERN
Potential for disease transfer, particularly viral
transmission,& particularly HIV.
More freezing of bone allografts reduces the risk
of disease transfer to 1 in 8 million
Russo et al The probability of HIV transfer
following appropriate DFDBA preparation has
been calculated to be 1 in 2.8 billion

92. X ENOGRAFT
Graft taken from a donor of another species.
naturally derived deproteinized cancellous bone
from another species (such as bovine or porcine
bone).
prepared by chemical or low-heat extraction of
the organic component from the bovine bone
C/d anorganic bone
osteoconductive

93. Boplant (Calf bone) : treated by detergent
extraction, sterilized, &freeze dried
Ospurum : Fosberg described the use of ospurum
for treatment of periodontal defects. This is Ox
bone which is soaked in warm potassium hydroxide
to remove connective tissue , in acetone to remove
lipids, and in a soft solution to remove proteins.
Anorganic bone is ox bone from which the organic
material has been extracted by means of
ethylenediamine, it is then sterilized by
autoclaving.

96. BOVINE DERIVED BONE REPLACEMENT
GRAFTS
Bovine bone is processed to yield natural bone
mineral - organic component.
act as an osteoconductive scaffold due to their
porosity
Provide structural components similar to that of
human bone.
Historically, bovine xenografts have failed due to
rejection in past, as materials used chemical
detergent extraction, which left residual protein &
therefore produced adverse reactions

97. Currently available graft are deproteinated
Eg- Osteograf/N and Bio-Oss
Both have been reported to have good tissue
acceptance with natural osteotrophic properties

98. CORALLINE CALCIUM CARBONATE
Biocoral C a CO
3
is obtained from a natural
coral, genus Porites, & is composed primarily of
aragonite (> 9 8% Ca CO3)
pore size of 100 to 200 pm is similar to the
porosity of spongy bone
It is resorbable, & highly osteoconductive
does not require a surface transformation into a
carbonate phase as do other bone replacement
grafts to initiate bone formation

99. Advantages
they are osteoconductive
readily available
Disadvantage
bovine-derived grafts can cause disease
transmission, which was evident in the case of
bovine spongiform encephalopathy reported in
Great Britain

100. Bone graft substitute ---------Gross 1997

101. ALLOPLASTS
The 1 9 9 6 World Workshop in Periodontics
concluded “synthetic graft materials function
primarily as defect fillers”
AAP 2003 / Position paper 2005 Synthetic graft
materials function predominantly as biologic
space fillers & that other materials should be
considered if regeneration is desired

102. ADVANTAGES
Absence of antigenicity
NO potential for disease transmission
Unlimited supply

103. Alloplasts marketed for periodontal regeneration
fall into 2 broad classes:
Ceramics &
 Polymers

104. CERAMIC-BASED BONE GRAFTS
Widely used
Function primarily through osteoconduction
Have also been considered osteointegrative,
because of the tenacious, intimate bond formed
between the new mineralized tissue & graft
material

106. CALCIUM SULFATE
Calcium sulfate or plaster of Paris was first
documented as being used for fracture treatment
by the Arabs in the 10th century, who would
surround the affected limb in a tub of plaster.
In 1852 a Dutch army surgeon named Mathysen
incorporated plaster into the bandageable form
which we are familiar with today

107. Osteoconductive matrix for the in- growth of
blood vessels and associated fibrogenic and
osteogenic cells.
For this to occur, it is critically important that
the implanted calcium sulfate is adjacent to
viable periosteum or endosteum
Reabsorbed by a process of dissolution Over a
period of 5–7 weeks,

108. Medical grade calcium sulfate impregnated with
tobramycin is commercially available (Osteoset)
Calcium sulfate in its set form has a compressive
strength greater than cancellous bone and a
tensile strength slightly less than cancellous
bone.
Requires a dry environment to set and if it is re-
exposed to moisture it tends to soften &
fragment.
No reliable mechanical properties in vivo and its
application is limited

109. TRICALCIUM PHOSPHATE
Porous form of calcium phosphate
most commonly used form β -tricalcium
phosphate
Biological filler which is partially resorbable &
allows bone replacement

110. α & β TCP produced similarly
Display different resorption properties.

112. Structurally porous beta TCP has a compressive
strength & tensile strength similar to that of
cancellous bone.
 It undergoes resorption over a 6–18 month
period.
The replacement of beta TCP by bone does not
occur in an equitable way
There is always less bone volume produced than
the volume of the graft material resorbed.

113. TCP as a bone substitute has gained clinical
acceptance, but results are not always
predictable.
In direct comparison with allogeneic cancellous
grafts, allogeneic grafts appear to outperform
TCP
 Amler MH TCP particles generally become
encapsulated by fibrous connective tissue & do
not stimulate bone growth

114. HYDROXYAPATITE
 The primary mineral component of bone
Became available in the 1 970’s.
Available in resorbable & non-resorbable
Depends on the temperature at which it is
prepared

117. DENSE HYDROXYAPATITE GRAFTS
Osteophillic , osteoconductive
Act primarily as inert biocompatible fillers
They have produced clinical defect fill greater
than flap debridement alone in the treatment of
intrabony defects
Histologically, new attachment is not achieved
They yield similar defect fill as other bone
replacement grafts & the clinical improvement
is more stable than with debridement alone

118. POROUS HYDRO X YAPATITE
Obtained by the hydrothermal conversion of
CaCO
3
exoskeleton of the natural coral genus
Porites into the calcium phosphate hydroxyapatite
pore size of 1 9 0 to 200 µm
Which allows bone ingrowth into the pores &
ultimately within the lesion itself
Clinical defect fill, probing depth reduction, and
attachment gain have been reported

119. Kenney et al. provided histological evidence
suggesting that porous hydroxyapatite supports
bone formation.
But since no evidence of a new CT attachment or
cementum was noted, it should be considered a
biocompatible filling material

120. RESORBABLE PARTICULATE GRAFT
non-sintered (nonceramic) precipitate
Particles size 300 to 400 µm.
It has been proposed that non-sintered
hydroxyapatite resorbs acting as a mineral
reservoir inducing bone formation via
osteoconductive mechanisms
Its reported advantage is the slow resorption
rate, allowing it to act as a mineral reservoir at
the same time acting as a scaffold for bone
replacement

121. BIPHASIC CALCIUM
PHOSPHATE
Combination of the two primary forms of calcium
phosphate
A histological study---------Hashimoto-Uoshima et
al. biphasic calcium phosphate supported active
bone replacement from surrounding bone which
may have been triggered by macrophages.
However, further studies are needed before clinical
acceptance

122. BIOACTIVE GLASSES
Composed of CaO, Na
2
O, SiO,, P
2
0
5

Bond to bone through the development of a
surface layer of carbonated hydroxyapatite
When exposed to tissue fluids in vivo, the
bioactive glass is covered by a double layer
composed of silica gel and a calcium phosphorus-
rich (apatite) layer.

123. calcium phosphate-rich layer
Promotes adsorption and concentration of
proteins
Used by osteoblasts to form a mineralize
extracellular matrix.

124. It is theorized that these bioactive properties guide
and promote osteogenesis,allowing rapid & quick
formation of new bone
There are two forms of bioactive glass currently
available.
PerioGlas (BioGlass synthetic bone graft particulate)
Biogran (resorbable synthetic bone graft).

125. PerioGlas – osteoconductive
Particle size ranging from 90 to 710 μm,
 Fetner AE 1 9 9 4 -------In surgically created
defects in nonhuman primate, 68% defect repair
was achieved when measuring new attachment
He also compared T C P, HA, &unimplanted
controls, & showed PerioGlas to produce
significantly greater osseous and cementum repair.
It also appeared to retard epithelial downgrowth,
which the authors contend may be responsible for
its enhanced cementum and bone repair.

126. Biogran
Particle size - 300 to 355 μm
Formation of hollow calcium phosphate growth
chambers occurs with this particle size because
phagocytosing cells can penetrate the outer silica
gel layer by means of small cracks in the calcium
phosphorus layer and partially resorb the gel.
leads to formation of protective pouches where
osteoprogenitor cells can adhere, differentiate, &
proliferate.

127. According to the manufacturers, larger particles
do not resorb in the same manner, which slows
the healing process theoretically because bone
healing must progress from the bony walls of the
defect and smaller particles cause a transient
inflammatory response, which retards the
stimulation of osteoprogenitor cells.
Optimal particle size 100-300 micron

128. POLYMER
S

129. Polymers are more widely used as barrier
materials in GTR procedures for t/t of periodontal
defects.
At present, several polymer systems are being
used for bone & periodontal regeneration
Polylactic acid (PLA)-based polymers
Copolymers
These polymers have proved to be effective in
periodontal applications as barrier materials

130. Biocompatible microporous polymer containing
PMMA, PHEMA, & calciumhydroxide is available
hydrophilic and osteophilic
Histologic evaluations revealed that the polymer
was associated with minimal inflammation &
infrequent foreign body giant cells, with evidence of
both bone apposition & soft tissue encapsulation, at
1 to 30 months following implantation

131. HTR (BIOPLANT)
Nonresorbable biocompatible microporous
composite of PMMA,PHEMA& calcium hydroxide.
Favorable clinical results have been achieved with
HTR for T/t of infrabony & furcation defects.
Improved clinical results with this synthetic
substitute have not always been achieved.
 Shahmiri et al 1 9 9 2 -----no clinical
improvement in probing depth, most reports have
supported the use of HTR as a bone substitute.

132. NANOCYSTALLINE HYDROXY
APPATITITE
65% water
35% nanstructured appatitite
Introduced for augmentation procedure in
osseous defect
Advantage
-Close contact with surrounding tissue
-Quick resorption
-Large no. of molecule on the surface

133. CLINICAL EVALUATION OF NANOCRYSTALLINE
HYDROXYAPATITE PASTE IN THE TREATMENT OF
HUMAN PERIODONTAL BONY DEFECTS – A RANDOMIZED
CONTROLLED CLINICAL TRIAL: 6-MONTH RESULTS
JOURNAL OF PERIODONTOLOGY MARCH 2008, VOL. 79, NO.
3, PAGES 394-400
Twenty-eight subjects, each displaying one
intrabony defect with probing depth (PD) ≥6 mm
& radiographic evidence of an intraosseous
component ≥3 mm participated in the study.
significant improvement in PD and CAL was
observed at 6 months after surgery compared to
baseline in both treatment groups (P <0.001).
T/t of intrabony periodontal defects with NHA
paste significantly improved clinical outcomes
compared to open flap debridement

134. INJECTABLE CALCIUM
PHOSPHATE CEMENT
Comparison of Injectable Calcium Phosphate Bone Cement
Grafting and Open Flap Debridement in Periodontal Intrabony
Defects: A Randomized Clinical Trial
Journal of PeriodontologyJanuary 2008, Vol. 79, No. 1,
Pages 25-32
Injectable, moldable fast setting
bioabsorbable
Has high compressive strength
Orthopeadic & material study
In vivo
Osteoconductive carbonated appatite
Chemical & physical characteristic similar
to mineral stage of bone
Gradually replaced by natural bone

135. Thirty subjects (mean age, 53.4 ± 9.1 years) with
periodontitis and narrow intrabony defects were
enrolled in the study.
This study failed to demonstrate any superior
clinical outcomes for the CPC group compared to
the OFD group

136. SUPERPOROUS
HYDROXYAPATITE (HA)
BLOCK
A superporous (85%) hydroxyapatite (HA) block
was recently developed to improve
osteoconductivity, but it was often not clinically
successful when used to treat periodontal osseous
defects. 

137. BONE GRAFT AVAILABLE
Bone graft property type
ORTOGRAF-LD/PB osteoinductive and
osteogenic properties.
90% hydroxyapatite
(HA) & 10% tri
calcium phosphate
(TCP).
Ossifi - Bone Graftosteoconductive Hydroxyapatite and ß-
tricalcium phosphate
in 70/30 ratio
Osseograft osteo-inductive demineralised bone
graft material
Osseomold osteo-inductive demineralised bone
graft material
DFDBA-TATA
MEMORIAL TISSUE
BANK
osteo-inductive

138. Bone graft Property Type
BioGraft Bone
Substitute
osteoconductive 100% Synthetic
Hydroxyaptite 
100% Beta Tri
Calcium Phosphate 
Biphasic 60%
Synthetic
Hydroxyaptite and
40% Beta Tri
Calcium Phosphate 
Biphasic 70%
Synthetic
Hydroxyapatite and
30% Beta Tri
Calcium Phosphate 

139. Bone graft Property Type
FISIOGRAFT type
SPONGE - POWDER
- GEL
l-d-polylactic acid
and polyglycolic acid.
G-Bone porous
hydroxyapatite 
Perioglass Osteoconductive &
osteostimulation
calcium phospho
silicate 
Dental putty Osteoconductive &
osteostimulation
Calcium
phosphosilicate

140. Bone graft Property Type
Bone medik Osteo-conductive Coralline
hydroxyapatite
Ostofom Osteo-conductive &
osteo-inductive
Hydroxyapatite &
collagen
Sybograft Osteo-conductive Nano cyrstalline
hydroxyappetite
RTR Osteo-conductive ß-tricalcium
phosphate
Bio-oss granule Porcine collagen

141. BONE GRAFT TECHNIQUE

142. REMOVE ALL ETIOLOGIC
FACTORS
Local and systemic factors must be under
control for grafts to be successful.

143. STABILIZE TEETH IF NECESSARY
Generally temporary, provisional or permanent
stabilization of teeth undergoing grafting is not
necessary.
Teeth with slight to moderate mobility appear to
heal well whether splinted or not.
However, extremely mobile teeth that are going
to be treated may benefit from provisional
stabilization for at least 6 months postsurgically
is of therapeutic measures such as root planning.

144. FLAP DESIGN
Internally beveled scalloped incisions with full
gingival preservation are necessary to be able to
completely close the site at the completion of
surgery.
Full thickness flaps, reflected beyond the
mucogingival junction, are recommended.Vertical
releasing incisions should be used as necessary
for proper access to the defect

145. DEGRANULATION OF DEFECT
AND FLAP
All granulomatous soft tissues should be
removed from the bony walls of the defect and
the associated tooth surfaces.
 The inner aspect of the flap should be checked
for tissue tags & epithelial remnants, which
should also be removed

146. ROOT PREPARATION
It is essential that all calculus, bacterial plaque,
other soft debris & altered cementum be removed
from the involved root surfaces.
Ultrasonic and hand instruments as well as
finishing burs are useful for this purpose.
This aspect of therapy is the most tedious,
difficult & time-consuming but the most essential
aspect.

147. There is some suggestion that the use of
chemicals such as citric acid or tetracycline paste
may be an aid in root detoxification & in making
the root surface more biologically acceptable for
healing.

148. ROOT SURFACE BIOMODIFICATION
Earliest reported clinical approaches to prepare
root surfaces for optimal attachment of
periodontal tissues and regeneration.
Agents
Citric acid
Tetracycline
EDTA
 Result detoxification, demineralization &
collagen fiber exposure.

149. Ann Periodontol 2003
Chemical root modifiers do not enhance
reductions in probing depth or gains in clinical
attachment level following periodontal surgery

150. ENCOURAGE A BLEEDING BONY
SURFACE
Generally already accomplished by proper defect
debridement.
 However, if the defect walls are relatively dry
and/or glistening, healing may be enhanced by
intramarrow penetration to encourage bleeding
and allow the ingress of reparative cells, vessels
and other tissues.
 Such penetrations can be accomplished with a
small round bur or hand instruments.

151. PRESUTURING
Loose placement of sutures, left untied, prior to
the filling of the defect reduces the possibility of
displacing the graft material during the suturing
process.
 It also simplifies the last steps of the procedure,
in that once defect fill has been completed, the
already placed sutures need only to be tied to
complete the surgical procedure

152. CONDENSE GRAFT MATERIAL
WELL
The graft material should be placed in small
increments
sterile plastic or Teflon-lined amalgam carriers
place the material and sterile amalgam squeeze
cloths to use over the suction tip to dry the defect
without removing any of the graft material
process is repeated until the defect is filled

153. FILL TO A REALISTIC LEVEL
defects should be filled with the synthetic graft
materials only to the level of the defect walls,
There is little suggestion that overfilling with
these materials results in supracrestal bone
formation.
Overfilling may actually be counterproductive in
that it may preclude proper flap closure, thereby
retarding healing

154. GOOD TISSUE COVERAGE
If flap design has been good, primary closure
with replaced flaps and contact of the
interproximal papillae can usually be obtained .
If tissue coverage of the alloplastic graft material
is not satisfactory, additional releasing incisions
or reflection may be necessary.

155. PERIODONTAL DRESSING
The use of a firm, protective periodontal
dressing for 10 days following bone
replacement graft surgery is suggested.
It has become popular not to use dressing for
many periodontal surgical procedures, but
prudence would seem to suggest that the possible
impingement of foreign materials into the graft
site, flap displacement and loss of graft material
that would jeopardize the success of treatment
make the use of protective dressings preferable.

156. ANTIBIOTIC COVERAGE
Tetracycline-type drugs are the antibiotics of
choice for immediate postsurgical plaque
suppression due to their broad spectrum of
activity, attraction to healing wound sites and
concentration in GCF.
 They are administered in therapeutic doses for
the first 10 days following surgery or until the
patient can practice proper plaque control in the
area

157. POSTSURGICAL CARE
If the dressing and sutures are removed prior to
10 days, another dressing is often indicated.
When the first postoperative treatment is at 10
or more days following surgery,additional
dressings are rarely indicated
The patient is started immediately on gentle but
thorough plaque-control methods, including the
use of antibacterial rinses

158. Schedule for professional plaque control in the
office as follows:
every 10 days for 3 visits;
every month for 2 visits; and
every 3 months

159. The grafted areas should not be probed prior to 3
months postsurgically
Radiographs taken prior to 6 months provide
uncertain information.

160. HEALING
First wound-healing phase is revascularization.
 initiated within the first few days following the
grafting procedure. Blood vessels originating
from the host bone invade the graft.
A pore size of 100 to 200 µm is very conducive to
vascular invasion.

161. incorporation of the grafted bone particles by new
bone emanating from the host.
 If the graft material contains vital osteogenic
precursor cells that survive the transplantation
process, these cells may contribute to new bone
formation.

162. The graft may possess inductive proteins that
actively stimulate the host to form new bone, or
the graft may simply act passively as a lattice
network over which the new host bone forms

163. Creeping substitution - As the graft is being
incorporated, it is gradually resorbed and
replaced by new host bone.
The final phase of healing is bone remodeling.
Resorption, replacement , and remodeling take
many years.

164. FATE OF BONE GRAFT
Once the material is placed in the bony defect it
may act in a number of ways which may decide
the fate of the graft material.
The various possibilities include:
Bone graft material may have no effect at all.
The bone graft material may act as a scaffolding
material for the host site to lay new bone.
The bone graft material may itself deposit new
bone because of its own viability.

165. CONCLUSION
Future bone grafting materials will likely build
on innovative polymeric &ceramic platforms with
controlled biophysical properties that enable the
targeted delivery of drugs, biologics,& cells,
thereby improving the degree & predictability of
periodontal regeneration

166. REFERENCES
Carranza F.A and Newman M.G : Clinical
Periodontology 9th edition.
Periodontal therapy. Clinical approaches and
evidence of success. Myron Nevins, Iames T,
Mellonig. Vol-I 1998.
Periodontal Surgery: A Clinical Atlas. – Naoshi
Sato
Atlas of Cosmetic and Reconstructive
Periodontal Surgery, 3rd Ed by Edward Cohen

167. Periodontics Medicine, Surgery, And Implants 
by Louis F. Rose, Brian L. Mealey,Robert J.
Genco,Walter Cohen
January 2010 (Vol 54, Issue 1 Treatment of
periodontal disease
Tissue Banking of Bone Allografts Used in
Periodontal Regeneration JOP 2001
Periodontal regeneration JOP 2005

168. Bone replacement grafts, Bone substitutes.
Aichelmann Reidy : DCNA 2005:491-504.
Bone and Bone substitutes. Nasr H.Fet al. Perio
2000, 1999 :74-86.
Synthetic Bone grafts in periodontics. Yukna R.A
Periodontology 2000;1993:1:92-99
Development and regeneration of th
periodontium parallel &contrasts. Periodontology
2000, Vol. 19, 1999, 8-20