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Presented By
Dr. M. Shiva Shanker
III Year Post Graduate Student ,
Dept of Periodontics, Mamata Dental College.
• Introduction
• History
• Terminology
• Classification of bone grafts
• Objectives of bone grafts
• Ideal characteristics of bone grafts
• Advantages and disadvantages
• Allogenous bone grafts
• Procurement
• Bone graft technique
• Combination procedures
• Recent advances
• Conclusion
• References
• Hegedus in 1923 – transplanted autogenous bone from the tibia
to the jaws to treat advanced pyorrhea. First recorded human
autogenous bone graft in periodontics.

• Buebe and Silvers in 1936 – used boiled cow bone powder to

successfully repair intrabony defects in humans.

• Forsberg in 1956 – Ospurum (used ox bone in human intrabony


• Melcher in 1962 – anorganic bone ( bovine bone) in human

periodontal defects
History contd…

• Scopp et al in 1966 – used Boplant

• Allogenic freeze dried bone – introduced in early 1970

• Historically auto grafts were the first replacement grafts to

to be reported.
• Graft: Any tissue or organ used for implantation
or transplantation.

• Regeneration: is defined as the reproduction or

reconstitution of lost or injured part so that form
form and function of lost structures are restored

• Periodontal Regeneration is defined histologically

as regeneration of the tooth’s supporting tissues,
tissues, including alveolar bone, periodontal
ligament, and cementum over a previously
diseased root surface.

• Periodontal Repair refers to the healing of a

periodontal wound with tissue that restores
continuity but does not fully restore the
architecture and function of the support
Terminology contd…

• New attachment refers to the reunion of

connective tissue with a root surface that has
been deprived of its periodontal ligament.

• Reattachment is the reunion of connective tissue

with a root surface on which viable periodontal
tissue is present. Nothing new is formed.
Terminology contd…

• Osteogenesis : Refers to the formation or development

of new bone by cells contained in the graft.
• Osteoinduction : Is a chemical process by which
molecules contained in the grafts convert the
neighboring cells into osteoblasts which in turn form
form bone.
• Osteoconduction : Is a physical effect by which the
matrix of the graft forms a scaffold that favors outside
outside cells to penetrate the graft and form new
Terminology contd…

• Bone fill is defined as clinical restoration of bone tissue in a

previously treated periodontal defect.
• Auto graft : An auto graft is a tissue transferred from one
position to a new position in the same individual.

• Allograft : An allograft is a tissue graft between individuals

of the same species but with non identical genes. Allografts
Allografts were formerly called homografts.

• Xenograft : A xenograft is a tissue graft between members of

differing species. They were formerly called heterografts.

• Alloplast : An alloplast is an inert foreign body used for

implantation into tissues.
Classification (Nasr et al 1999)

Bone Alloplastic
Auto grafts Allografts substitutes
Bioactive glass

Bovine derived
Fresh frozen HA coralline
Extraoral bone calcium Polymers

Freeze dried
Intraoral Bioceramics

Freeze dried
bone phosphate

Hydroxyl apatite
•Dense, non
porous, non
•Porous, non
•Resorbable, HA
desired at low
Rose classification

Bone derived Non osseous

Bone graft:
material material

Vital bone Non vital

Organic Anorganic
graft bone graft

Autograft Allograft Dentin

Xenograft Cementum
sulfate HA



• Moderate-to-severe periodontal osseous defects

are often not amenable to osseous resection
without further compromising the support of
the involved and adjacent teeth.

• The ideal bone replacement graft material

should be able to trigger osteogenesis,
cementogenesis, and a functionally oriented
periodontal ligament at a more coronal level of
attachment to the root surface.
Objectives of bone grafts (Schallhorn,

• probing depth reduction,

• clinical attachment gain,
• bone fill of the osseous defect and
• regeneration of new bone, cementum and
periodontal ligament
GRAFT (Edwin rosenberg et al. 1998),

• Nontoxic
• Non antigenic
• Resistant to infection
• No root resorption or ankylosis.
• Strong and resilient.
• Easily adaptable.
• Readily and sufficiently available.
• Minimal surgical procedure.
• Stimulates new attachment
Advantages Of Bone Grafts

• Regeneration of the attachment apparatus.

• To reverse the disease process.
• Increased tooth support, improved function,
and enhanced esthetics.
• Bone grafts have application of intra osseous
defect and certain furcation defects.
Disadvantages of bone grafts (Mellonig

• Increases treatment time.

• Additional postoperative care.
• The availability and added expenses
• Unpredictable and Technique sensitive.
• Graft resorption

• Allografts are grafts transferred between

genetically dissimilar members of the same
• Three types of bone allografts are being used in
• Demineralized freeze-dried bone
• Nondernineralized freeze-dried bone and
• Frozen iliac cancellous bone.

• Availability in adequate quantitites

• Predictable results
• Elimination of an additional donar site surgery

• Host incompatiability
• Potentially contaminated specimens resulting in
recipient site infection and potential
transmission of disease from donar to recipient
of the allograft

The goals of bone banking:

• To preseve the integrity of the graft and
the inductive protien
• To reduce its immunogenicity
• To ensure sterility
Pre- pocurement

• Notification of prospective donors death

• Determination of initial donor eligibility
• Consent
• Dispatch of recovery team
• Assignment of tracking number to
prospective donor
• Determination of additional donor
• Tissue procurement

• Acceptance of tissue donors begins with social

and medical history.
Exclusion of individuals (AATB, FDA)

• Donors from high-risk groups, as determined

by medical testing and behavioral risk
• Donors test positive for HIV antibody by ELISA
• Autopsy of donor reveals occult disease
• Donor bone tests positive for bacterial
• Donor and bone test positive for hepatitis B
• antigen (HBsAG) or hepatitis C virus (HCV)
• Donor tests positive for syphilis.
Donor screening and testing

• Blood Serology
• Microbiology
• Autopsy
• Excision of Bone Allografts
Frozen Iliac Cancellous bone

• The need for extensive cross matching of

donor and recipient and the possibility of
disease transfer restrict the use of iliac
cancellous bone.
• A mean coronal gain of bone amounting to
3.07mm in 26 patients at reentry has been
reported. (Hiatt et al)
• When compared to tricalcium phosphate,
frozen allogenic bone implants led to greater
bone apposition and reduction in probing
depth (strub et al)
• Leonetti et al in 2003 reported that the
allogenic bone block material used for
ridge augmentation and implant site was
an effective alternative to harvesting and
grafting autogenous bone for implant site
site development.
Freeze-Dried Bone Allograft

• Undemineralized FDBA was introduced to

periodontal therapy in 1976 (Mellonig et
• Freeze drying markedly reduces the antigenicity
of a periodontal bone allograft (Turner and
Mellonig, 1981; Quattlebaum et al, 1988).
Preparation of FDBA

• step 1. Soft tissue stripping

• step 2. Initial size reduction
• step 3. Initial cleansing and decontamination
• step 4. Microbiological treatment
• step 5. Freezing
• step 6. Dehydration
• step 7. Secondary size reduction
• step 8. Packaging
• step 9. Terminal sterilization
After processing

• Visual inspection test

• Residual moisture test
• Residual calcium test
Extraction socket

• Robert A et al in 2012 found a significantly

greater new bone formation with DFDBA
histologically as compared to FDBA in non-
molar extraction sockets grafted for ridge

• Samira M. Toloue et al in 2012 reported

there was more new bone formation after 3
months in postextraction sites treated with
calcium sulfate (CS) as compared to freeze-
dried bone allograft (FDBA).
Extraction socket contd…

• Thomas C et al in 2015 conducted a study

to examine the healing of intact extraction
extraction sockets grafted with leukocyte-
leukocyte-platelet rich fibrin (L-PRF) as
compared to freeze-dried bone allograft
(FDBA) and a resorbable collagen barrier
membrane (RCM). The alveolar ridge
dimension changes in intact posterior
extraction sockets may be similar when
either L-PRF or FDBA and RCM are utilized
utilized as socket grafting material.

• Massoud Seifi et al in 2012 conducted a

study to investigate histologic interaction
following orthodontic tooth movement
and concluded that FDBA and DFDBA can
can be used as biocompatible bone
substitutes for bone defects subjected to
orthodontic tooth movement.
Sinus lift procedure

• Roni kolerman et al in 2012 conducted a

split mouth study to compare DBBM and
FDBA in five patients undergoing bilateral
bilateral maxillary sinus floor
augmentation. After 9 months, core biopsy
biopsy specimens were harvested. Mean
newly formed bone values were 31.8%
and 27.2% at FDBA and DBBM, suggesting
suggesting that both materials are equally
equally suitable for sinus augmentation.
• Schwartz et al confirmed the hypothesis
that new bone formation is dependent on
the DFDBA formulation used and
demonstrated that DBX, alone or in
combination with other materials, can be
used successfully for sinus floor elevation.
• Andreana et al reported that calcium
sulfate can be successfully used alone or in
in combination with DFDBA for sinus lift
procedures and that possible residues of
DFDBA can be found within newly
generated bone.
• Landi et al reported the combination of
Osteograf/N and DFDBA appears to be
osteoconductive and may be considered a
a valid alternative to autogenous bone
grafts in sinus lift procedures.

• Joseph Nissan et al in 2009 evaluated the

outcome of ridge augmentation with
cancellous freeze-dried block bone
allografts in the posterior atrophic
mandible followed by placement of dental
dental implants.
• Implant placement in the posterior
atrophic mandible following augmentation
augmentation with cancellous freeze-dried
dried bone block allografts may be
regarded as a viable treatment alternative
• Fagan et al used freeze-dried mineralized
bone allograft (FDBA), recombinant human
platelet-derived growth factor mixture with a
a titanium-reinforced membrane, and a
pediculated connective tissue graft (PCTG) to
to simultaneously augment the hard and soft
soft tissue for delayed and immediate implant
implant placement cases.
• Concluded that technique can be used
effectively to simultaneously augment hard
and soft tissue.
Intra bony defects

• Shigeki Ogihara et al in 2014 studied the

relative efficacy of EMD/FDBA versus
EMD/DFDBA when managing intrabony
defects and found that both combinations
combinations resulted in greater soft
tissue improvement at 1 and 3 years of
follow-up compared to EMD alone.

• Tyler D. Borg et al in 2015 reported the

first histologic evidence showing greater
new bone formation with a combination
mineralized/demineralized allograft
compared to 100% mineralized FDBA in
AR preservation in humans. Combination
Combination allograft results in increased
increased vital bone formation while
providing similar dimensional stability of
the AR compared to FDBA alone in AR
Commercially available FDBA
Decalcified Freeze-Dried Bone Allograft
• Urist and co-workers showed through
numerous animal experiments that
demineralization of a cortical bone graft induces
new bone formation and greatly enhances its
osteogenic potential.
Preparation of DFDBA

• step 1. Soft tissue stripping

• step 2. Initial size reduction
• step 3. Initial cleansing and decontamination
• step 4. Microbiological treatment
• step 5. Freezing
• step 6. Dehydration
• step 7. Secondary size reduction
• step 8. Demineralization
• step 9. Buffering
• step 10. Final rinse
• step 11. Packaging
• step 12. Terminal sterilization
• The sequence of bone induction with a
demineralized bone graft is believed to follow a
bone induction cascade (Reddi et al, 1987;
Bowers and Reddi, 1991).
• At day 1, there is chemotaxis of fibroblasts and
cell attachment to the implanted demineralized
bone matrix.
• At day 5, there is continued cell proliferation
and differentiation of chrondroblasts.
• At day 7, chrondrocytes synthesize and secrete
• From days 10 to 12, there is vascular invasion,
differentiation of osteoblasts and bone
formation, and mineralization

• Andleregg et al compared 15 pairs of

periodontal osseous defects treated by GTR
with DFDBA or GTR alone and found bone fill
fill to be significantly more favorable with the
the use of the bone graft and the barrier.
• Vishal Kiran Kher et al in 2013 reported that
the use of a GTR membrane with bone graft
has significantly improved PPD, CAL and
defect depth tested as compared with the use
use of bioresorbable membrane alone in the
treatment of infrabony defects characterized
by unfavorable architecture.
GTR contd…

• Deept Jain et al compared the efficacy of

freeze-dried bone allograft (FDBA) with
and without bioabsorbable guided tissue
regeneration (GTR) membrane
Healiguide® in the treatment of Grade II
furcation defects.
• There was no significant improvement in
the probing depth, horizontal furcation
depth, and RAL at 6 months postsurgery in
in the treatment of Grade II furcation
GTR contd…

• Zenobio et al reported that combination of

GTR and DFDBA for treatment of root
perforations along with periodontal
surgery resulted in minimal probing
depths, minimal attachment loss, and
radiographic evidence of bone gain after
follow-up evaluations that ranged from 2
to 4 years

• Kohal et al compared different graft

materials along with GBR to evaluate the
quality of implant osseointegration.
• It can be concluded that the type of grafting
material will not influence torque removal
values, but that early membrane exposure
and removal will negatively influence the
torque measurements
Intrabony defects

• Simone D et al in 2011 compared the use

of enamel matrix derivative (EMD) and
demineralised freeze-dried bone allografts
allografts (DFDBA) with DFDBA alone for
for the treatment of human periodontal
intrabony defects at 12 months post-
surgery, At 12 months post-surgery, the
combined use of DFDBA and EMD seemed
seemed to produce a statistically
significant improvement of PD reduction,
reduction, CAL gain,
Intrabony defects contd…

• Chhaya bansal et al in 2013 studied the

efficacy of autologous PRF +
demineralized freeze-dried bone allograft
(DFDBA) to DFDBA alone in the treatment
treatment of periodontal intrabony defects
defects in 10 patients. It was found that
combination treatment demonstrated
better results in probing pocket depth
reduction and clinical attachment level
gain as compared to DFDBA alone.
• Vikas Jindal et al in 2013 compared
efficacy of intra-oral autogenous graft and
and decalcified allogenic bone matrix
(DABM) in the treatment of periodontal
intrabony defects.
• it establishes the superiority of the intra-
oral free osseous autograft over that of
DABM graft in correcting the intrabony
Intrabony defects contd…

• Mohana krishna et al in 2015 presented a

clinical and radiographic case series on three
three wall intrabony periodontal defects
treated with PRP and demineralized
freeze dried bone allograft (DFDBA). On
surgical treatment with PRP and DFDBA, six
six months follow up revealed a significant
progress in reduction of PPD and RAL gain.
Therefore, they concluded that PRP is
clinically and radiographically effective in the
the treatment of intrabony defects.
Ridge augmentation

• Krishnajaneya reddy et al in 2015

published case reports using a novel
technique of a long palatal connective
tissue rolled pedicle graft with
demineralized freeze-dried bone allografts
allografts (DFDBAs) plus Platelet-rich
fibrin (PRF) in Class III localized anterior
anterior maxillary anterior alveolar ridge
defect. They found a predictable ridge
augmentation, which could be attributed
to the soft and hard tissue augmentation.

• Masters et al reported that there is no

significant benefit from reconstituting the
the allograft with 50 mg/ml of tetracycline
tetracycline hydrochloride.
• Ashish et al in 2013 reported that no
added benefits of local doxycycline, as
compared with bone graft alone, for
regeneration of non-contained human
periodontal infrabony defects.
• Mabry et al reported that the combination
of local and systemic tetracycline coupled
with freeze-dried bone allografts was the
treatment of choice for defects associated
with juvenile periodontitis.

• Richard J. Miron et al in 2013 tested the

ability of EMD to adsorb to the surface of
DFDBA particles and determine the effect
effect of EMD coating on downstream
cellular pathways such as adhesion,
proliferation, and differentiation of
primary human osteoblasts and
periodontal ligament cells and found that
it may influence periodontal regeneration
regeneration by stimulating PDL cell and
osteoblast proliferation and
Combination contd…

• Ahmad et al in 2014 histologically and

histomorphometrically evaluated whether
whether bone formation would increase
by the combined use of PRGF and
demineralized freeze-dried bone allograft
• The present study showed better socket
preservation subsequent to the
application of DFDBA and PRGF
combination in comparison with the two
other groups.
Combination contd…

• Agarwal A et al in 2015 compared PRP

combined with a demineralized freeze-
dried bone allograft to DFDBA with a
saline solution in 48 noncontained human
human periodontal intrabony defects.
Their findings indicate that a combination
combination of PRP and DFDBA is more
effective in such cases.
Comparison of FDBA and DFDBA
• Not demineralized • Demineralized
• better space • More bone
maintenance morphogenic proteins
• Slower resorbtion rate expression potential
compared with DFDBA • Rapid resorption
• Osteocondutive • Possible osteoinduction
• More radiopaque • Osteoconductive
• Breakdown by way of • More radiolucent
foreign body reaction
• Primary indication:
bone augmentation
associated with
implant treatment.
Human mineralized bone

• Puros (Zimmer Dental, Carlsbad, California)

It is human bone that undergoes a process involving
• delipidization with acetone and ultrasound,
• osmotic treatment,
• oxidation with hydrogen peroxide to destroy unwanted
• solvent dehydration with acetone to preserve the
collagenous fiber structure, and
• low-dose gamma irradiation.
• Christian Martin Schmitt et al in 2013 compared
clinical and histological characteristics after sinus
floor augmentation with biphasic calcium phosphate,
phosphate, anorganic bovine bone (ABB), mineralized
mineralized cancellous bone allograft (MCBA), or
autologous bone (AB).
• After augmentation of the maxillary sinus with ABB,
BCP, MCBA, or AB followed by a healing period of 5
months, biopsies were taken with simultaneous
implant placement. AB can be considered to remain
the gold standard in sinus floor augmentation.
Extraction sockets

• Musante et al in 2013 investigated the efficacy of

porous cancellous particulate allograft bone in the
the regeneration of post extractive sites. The
radiographic and histological analyses
demonstrate an optimal bone regeneration, both
in terms of quality and quantity using puros.
• James Rudolph et al in 2014 evaluated the healing
of extraction sockets after implantation of a
biphasic calcium sulfate (CS) alone or in
combination with a gamma-radiated human
mineralized allograft. biphasic calcium sulfate
combination with an allograft resulted in the
greater amount of new bone formation in alveolar
alveolar ridge preservation procedures.
Grafton DBM (BioHorizons, Birmingham,

• is processed from cadaver long bones by aseptically

processing the bone to remove lipid, blood, and
cellular components before it is frozen.
• Cortical bone is milled into elongated fibers of 0.5
mm in diameter or pulverized into particles of 100 to
500 mm.
• It is combined with a glycerol carrier to stabilize the
proteins and improve the graft handling.
• It can be used in the as putty, or as matrix plugs
Intrabony defects

• Mahantesha et al in 2013 evaluated the efficacy of

demineralized bone matrix (DBM) as a bone graft
graft material in the treatment of human intrabony
Bleached Bone

• number of commercial bone allograft distributors

promote allografts on the basis of their whiteness.
• Chalk white bone is bleached.
• Bleaching is usually achieved by bathing allografts in
a solution of hydrogen peroxide [H202]. Exposure to
H202 diminishes or abolishes osteoinductivity, but
the effect is time-dependent. This is balanced
against disinfecting activity of the compound.
• Holzclaw et al., one hour exposure to H202 does not
have a profound effect on osteoinduction by bone
Safety of bone allografts
• There are two major concerns regarding the use of bone allografts,
antigenicity and the risk of disease transmission.

• Antigenicity of the donor material arises with any dental/medical
procedure using tissues derived from human donors.
• In humans, chromosome 6 contains the MHC, which codes for the
human lymphocyte antigens.
• These antigens are expressed on the cell surface of nearly every
nucleated cell in the body and represent the primary stimulus for
transplant rejection when HLA mismatches occur between donor
and recipient.
• Detection of donor specific anti HLA antibody formation in a patient
receiving allografts is an important measure of the clinical
immunogenicity of the respective graft material.
Risk of disease transmission
• The potential for disease transfer particularly viral
transmission and even more particularly HIV is a
crucial factor associated with use of bone allografts.
• First case of HIV transmission through allogenic
bone was reported in 1988.
• Most frequently used methods of assuring graft
sterility is irradiation.
• Smith et al reported that, even at doses at which
tissue quality begins to be compromised, irradiation
failed to be virucidal for HIV type 1.
Human Bone Allograft Tracking

• FDA regulations require human bone allografts

must be tracked so that tissue banks and
clinicians can notify recipients in the event of a
product recall.
• HCT/P processing facilities must label each
manufactured HCT/P with a unique
alphanumeric identification code that does not
contain the donor's name or Social Security
Bone graft technique

• Patient selection:
• Defect selection
• Remove all etiologic factors
• Flap design with a plan for closure
• Degranulation of defect and flap
• Root preparation.
• Encourage a bleeding bony surface
• Condense graft materials well
• Good tissue coverage
• Periodontal dressing
• Antibiotic coverage
• Post surgical care
Various forms

• Injectable and moldable form: alpha graft duos,

AlphaGRAFT DuoFuse bone graft substitute
combines the osteoinductivity of demineralized bone
matrix with the osteoconductivity, moldability,
structure and hard-setting characteristics of a
proprietary nanocrystalline calcium phosphate
• Strip form: steri graft,
Ilium Bicortical Strip, L = 38 - 42 mm
40 mm W = 19 - 25 mm
T1 > 9 mm, T2 >5 mm

Ilium Bicortical Strip, 45 L = 43 - 47 mm

mm W = 19 - 25 mm
T1 > 9 mm, T2 > 5 mm
Ilium Bicortical Strip, 50 L = 48 - 52 mm
mm W = 19 - 25 mm
T1 > 9 mm, T2 > 5 mm
Ilium Bicortical Strip, 55 L = 53 - 57 mm
mm W = 19 - 25 mm
T1 > 9 mm, T2 > 5 mm
Ilium Bicortical Strip, 60 L = 58 - 62 mm
mm W = 19 - 25 mm
T1 > 9 mm, T2 > 5 mm
• Particulate form:
• 125 to 1000 μm possess a higher osteogenic
• Optimal particle size appears to be between 100 to
300 μm.
• 250 to 750 μm is the most frequently available.
Sponge Strips (OSSIF)

• Sizes: 10 x 7 x 6 mm, 20 x 7x 6 mm
• The first particulate
dental bone grafting
product combining
mineralized and
demineralized bone in a
single vial
• Periomix
• Demineralized Bone Matrix
with cancellous chips
< 0.7 mm.
Combination procedures

• 89 clinicians implanted a total of 997 sites with FDBA

alone and 524 sites with FDBA plus autogenous
• Complete or >50% bone fill was obtained in 220
(67%) sites treated with FDBA and 137 (78%) of the
sites treated with FDBA + A.
• It can be concluded that FDBA in combination with
autogenous bone is more efficacious than FDBA
alone, especially in furcation invasion defects.
• A composite graft of FDBA and tetracycline in a 4:1
volume ratio has shown promise in the treatment of the
osseous defects associated with localized juvenile
periodontitis (Yukna and Sepe, 1981; Evans et al, 1989).
• A study that compared FDBA with and without
tetracycline to a nongraft procedure in 12 juvenile
periodontitis patients demonstrated significantly greater
bone fill and resolution of osseous defects in grafted as
opposed to control sites (Mabry et al, 1985).

• Although bone grafts have shown to be efficacious

for the treatment of periodontal osseous lesions. The
reconstruction appears to be limited to a mean bone
fill of approximately 3mm irrespective of the bone
graft material used. Because , the ultimate goal of
periodontal therapy is to reverse the disease process
& completely regenerate the periodontium ,
additional stimuli to enhance the regenerative
process is clearly needed.
• As there is a continuing search for new materials &
new approaches for bone repair, the future of bone
graft will always be expanding topic……..
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