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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 8  |  Issue : 1  |  Page : 36-38

Bone grafts and bone substitutes in dentistry


1 Department of Periodontics, Government College and Hospital, Srinagar, Jammu and Kashmir, India
2 Department of Public Health Dentistry, Government College and Hospital, Srinagar, Jammu and Kashmir, India
3 Department of Public Health Dentistry, Surendera Dental College and Research Institute, Sri Ganganagar, Rajasthan, India

Date of Web Publication16-May-2016

Correspondence Address:
Aasim Farooq Shah
Department of Public Health Dentistry, Government College and Hospital, Shireen Bagh, Srinagar - 190 010, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4987.182488

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  Abstract 

Bone resorption is a natural phenomenon and can occur due to old age, loss of teeth, prolonged denture wear, or as a result of systemic conditions. For the replacement of teeth by fabrication of prosthesis or the use of implants, a minimum amount of bone density is required. Bone grafting is a method by which bone-deficient areas are built up, with the use of different materials, such as autografts, allografts, alloplasts, and xenografts. Over recent times, the use of frozen bone matrix formulations and synthetic ceramics has been used in greater frequency. This article discusses the use of human bone material (allografts), synthetic materials (alloplasts) and blood components as successful grafting materials. Their use has shown an effective amount of bone formation and proliferation in the defective sites and proves to be a beneficial choice in bringing back lost bone.

Keywords: Bone grafts, bone resorption, bone substitutes, grafts


How to cite this article:
Saima S, Jan SM, Shah AF, Yousuf A, Batra M. Bone grafts and bone substitutes in dentistry. J Oral Res Rev 2016;8:36-8

How to cite this URL:
Saima S, Jan SM, Shah AF, Yousuf A, Batra M. Bone grafts and bone substitutes in dentistry. J Oral Res Rev [serial online] 2016 [cited 2020 Aug 6];8:36-8. Available from: http://www.jorr.org/text.asp?2016/8/1/36/182488


  Introduction Top


Bone grafting is a surgical procedure which entails replacement of missing bone with material from either patient's own body, an artificial or natural substitute. The rationale behind grafting is that bone grafting is possible because bone tissue can regenerate completely into the space which it has to develop. As natural bone grows, it generally replaces the graft material completely, resulting in a completely integrated region of new bone.[1] It is indicated in prosthodontic cases where requirement of minimal amount of bone is a prerequisite, such as implant placement and denture fabrication.

Defects in the alveolar ridge develop as a consequence of surgery, trauma, infection, or congenital malformations. The lack of intraosseous stimulation by periodontal ligament fibers after tooth loss results in rapid resorption of alveolar bone as happens in pneumatization of maxillary sinus following tooth loss.[1] Nevertheless, due to increased frequency of localized or generalized bone defects of the alveolar ridge, as a result of atrophy, dental trauma, extractions or periodontal disease, reconstructive surgery is obligatory to regenerate such defects to have successful rehabilitation.[2],[3] The goals of osseous replacement are maintenance of contour, elimination of dead space, and reduction of postoperative infection, thereby enhancing bone and soft tissue healing. Bone grafts are a therapeutic option to correct abnormal intermaxillary relations and to attain appropriate bone volume and morphology.[4] They are used as a scaffold to allow formation of bone and promote wound healing and act as a mineral reservoir which helps in new bone formation.

The biologic mechanisms that provide a rationale for bone grafting are osteoconduction, osteoinduction, and osteogenesis.


  Osteoconduction Top


Osteoconduction occurs when bone graft material serves as a scaffold for new bone growth, which is perpetuated by the native bone. Osteoblasts from the margin of defect that is grafted utilize the bone graft material as a framework upon which to spread and generate new bone. In the very least, a bone graft material should be osteoconductive.


  Osteoinduction Top


Osteoinduction involves stimulation of osteoprogenitor cells to differentiate into osteoblasts and then begins formation of new bone. The most widely studied type of osteoinductive cell mediators is bone morphogenic proteins (BMPs). Bone graft material that is osteoconductive and osteoinductive will not only serve as a scaffold for currently existing osteoblasts but will also trigger formation of new osteoblasts, promoting faster integration of the graft.


  Osteopromotion Top


It involves enhancement of osteoinduction without possession of osteoinductive properties. For example, enamel matrix derivative enhances the osteoinductive effect of demineralized freeze-dried bone allograft (DFDBA) but will not stimulate bone growth alone.


  Osteogenesis Top


It occurs when vital osteoblasts originating from bone graft material contributes to the growth of new bone along with bone formation.


  Types of Bone Grafts Top


Schallhorn [5] defined the considerations that govern the selection of a graft as follows: Biologic acceptability, predictability, clinical feasibility, and minimal postoperative sequelae. Graft materials have been developed and tried in many forms.


  Autograft Top


In 1923, Hegedus [6] attempted to use bone grafts for reconstruction of osseous defects. This method was later revived by Nabers and O'Leary [7] in 1965.

Autologous or autogenous bone grafting involves utilizing bone obtained from same individual receiving the graft. Sources of bone include iliac crest, mandibular symphysis (chin area), anterior mandibular ramus (coronoid process), and bone removed during osteoplasty and osteectomy.[8] When a block graft will be performed, autogeneous bone is the most preferred because there is less risk of graft rejection as the graft is originated from the patient's body. It would be sosteoinductive and osteogenic, as well as osteoconductive. Disadvantage of autologous grafts is that additional surgical site is required, another potential location for postoperative pain and complications. Types of autograft include osseous coagulum,[9] bone blend,[10] cancellous bone marrow transplant, and bone swaging.[11]


  Allografts Top


Allograft is derived from humans. The difference is that allograft is harvested from an individual other than the one receiving the graft.[12] Allograft bone is taken from cadavers that have donated their bone, so that it can be used for living people who are in need of it which is typically sourced from a bone bank.

Types of bone allograft include:

  • FDBA.
  • DFDBA (Decalcified FDBA).


The use of allografts for bone repair often requires sterilization and deactivation of proteins normally found in healthy bone. Contained in the extracellular matrix of bone tissue are the full cocktail of bone growth factors, proteins, and other bioactive materials necessary for osteoinduction and successful bone healing the desired factors and proteins are removed from the mineralized tissue using a demineralizing agent such as hydrochloric acid. The mineral content of the bone is degraded, and the osteoinductive agents remain in a demineralized bone matrix.[13]

Xenografts obtained from species other than human-like calf bone have been used to treat osseous defects.[14] Currently bovine-derived bone Bio-oss has been used in periodontal defects and in implant surgery. Nonbone graft materials have also been used to restore periodontium. These include sclera, cartilage plastic materials ceramics, and coral derived materials. Calcium sulfate is also known as plaster of Paris. It is biocompatible, bioactive, and resorbable after 2 weeks. Significant loss of its mechanical properties occurs upon its degradation; therefore, it is a questionable choice for load bearing applications.


  Synthetic Variants Top


Hydroxyapatite (HA) composite has a mineral to organic matrix ratio, approximating that of human bone. Artificial bone can be created from ceramics such as calcium phosphates (e.g., HA and tricalcium phosphate), bioglass, and calcium sulfate and is biologically active depending on solubility in physiological environment. These materials combine with growth factors, ions such as strontium or mixed with bone marrow aspirate to increase biological activity. The presence of elements such as strontium can result in higher bone mineral density and enhanced osteoblast proliferation.


  Bioactive Glass Top


Bioactive glass consists of sodium calcium salts, phosphates, and silicon dioxide. For its dental applications, it is used in the form of irregular particles measuring 90-170 µm (Perioglas) or 300-355 µm (Biogran). When this material comes into contact with tissue fluids, the surface of the particles get coated with hydroxyl-carbonate apatite, incorporates glycosaminoglycans attracts osteoblasts that rapidly form bone.[15]


  Growth Factors Top


Growth factors-enhanced grafts are produced using recombinant DNA technology. They consist of either human growth factors or morphogens (BMPs in conjunction with a carrier medium, such as collagen). The factors and proteins that exist in bone are responsible for regulating cellular activity. Growth factors bind to receptors on cell surfaces and stimulate intracellular environment to act. In general, this activity translates to a protein kinase that induces a series of events resulting in transcription of messenger ribonucleic acid and ultimately into the formation of a protein to be used intracellularly or extracellularly.[16] These factors, residing in extracellular matrix of bone, include transforming growth factor-beta (TGF-β), insulin-like growth factors I and II, platelet-derived growth factor (PDGF), fibroblast growth factor, and BMPs. The addition of TGF-β and BMP2, BMP4, and BMP7 to the culture media can also influence the stem cells toward osteogenic lineage. BMP's are members of the family of TGFs. Fifteen different BMP's have been identified all having different degrees of cellular activity, including bone inducing properties. Two recombinant proteins are available at present - recombinant human BMP-2 (rhBMP-2) and rhBMP-7. Two rhBMP associated carrier systems have received approval from the US Food and Drug Administration.

  • Osteogenic protein-1 consists of rhBMP-7 and bovine collagen (Stryker Biotech Hopkinton, Massachussetts).
  • In Fuse System (Medtronic Sofamor Danek Warsaw, Indiana) consists of rhBMP-2 on an absorbable bovine type I collagen sponge carrier. BMPs were originally isolated from bovine bone by Urist.[17]


As a growth factor, BMPs induce differentiation of mesenchymal cells to become bone forming osteoblast cells. Thus, unlike proliferation factors that increase number of cells, BMPs are differentiating factors stimulating cells to produce bone tissue. BMPs bind to collagen within minutes and have been shown to be released over time for 2-3 weeks at defect site. This extended release kinetics allows undifferentiating mesenchymal cells to migrate into wound site to be exposed to growth factors. rhBMP-2 combined with bone type I collagen is used in sinus augmentation and ridge augmentation in maxillary anterior extraction sites with bone loss.

Platelet-rich plasma (PRP) is a source of platelet derived growth factors (PDGF) and TGF-β that is obtained by sequestering and concentrating platelets by a process of gradient density centrifugation. PRP has been shown to enhance bone formation in periodontal osseous defects. Currently, recombinant human PDGF (rhPDGF)-BB is approved by US Food and drug administration only for periodontal regeneration as part of dental bone filling device GEM-21s. This commercial product is indicated in treatment of intrabony periodontal defects, furcation periodontal defects. GEM-21s consists of 0.5cc of β tricalcium phosphate which acts as a carrier and 0.5 ml rhPDGFBB (0.3 mg/ml). Camelo et al. reported human histologic evidence of periodontal regeneration in intraosseous defects and furcation defects using a combination of rhPDGF-BB and decalcified FDBA.[18]


  Uses Top


The most common use of bone grafting is in application of dental implants, to restore edentulous area of a missing tooth. In general, bone grafts are either used in block (such as from chin or ascending ramus area of lower jaw) or particulated, to be able to adapt it better to a defect. The grafted, vascularized fibulas, have been used to restore skeletal integrity to long bones of limbs in which congenital bone defects exist and to replace segments of bone after trauma or malignant tumor invasion. The periosteum and nutrient artery are generally removed with piece of bone so that the graft will remain alive and grow when transplanted into new host site. Once the transplanted bone is secured into its new location, it generally restores blood supply to the bone on which it has been attached. Besides the main use of bone grafting in dental implants, this procedure is used to fuse joints to prevent movement, repair broken bones that have bone loss, and repair broken bone that has not yet healed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kumar P, Vinitha B, Fathima G. Bone grafts in dentistry. J Pharm Bioallied Sci 2013;5 Suppl 1:S125-7.  Back to cited text no. 1
    
2.
Esposito M, Grusovin MG, Coulthard P, Worthington HV. The efficacy of various bone augmentation procedures for dental implants: A Cochrane systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants 2006;21:696-710.  Back to cited text no. 2
    
3.
Sorní M, Guarinós J, García O, Peñarrocha M. Implant rehabilitation of the atrophic upper jaw: A review of the literature since 1999. Med Oral Patol Oral Cir Bucal 2005;10 Suppl 1:E45-56.  Back to cited text no. 3
    
4.
Chiapasco M, Zaniboni M, Boisco M. Augmentation procedures for the rehabilitation of deficient edentulous ridges with oral implants. Clin Oral Implants Res 2006;17 Suppl 2:136-59.  Back to cited text no. 4
    
5.
Schallhorn RG. Present status of osseous grafting procedures. J Periodontol 1977;48:570-6.  Back to cited text no. 5
    
6.
Hegedus Z. The rebuilding of alveolar process by bone transplantation. Dent Cosmos 1923;65:736.  Back to cited text no. 6
    
7.
Nabers CL, O'leary TJ. Autogenous bone transplants in the treatment of osseous defects. J Periodontol 1965;36:5-14.  Back to cited text no. 7
    
8.
Hiatt WH, Schallhorn RG. Intraoral transplants of cancellous bone and marrow in periodontal lesions. J Periodontol 1973;44:194-208.  Back to cited text no. 8
    
9.
Robinson E. Osseous coagulum for bone induction. J Periodontol 1969;40:503-10.  Back to cited text no. 9
    
10.
Diem CR, Bowers GM, Moffitt WC. Bone blending: A technique for osseous implants. J Periodontol 1972;43:295-7.  Back to cited text no. 10
    
11.
Ewen SJ. Bone swaging. J Periodontol 1965;36:57-63.  Back to cited text no. 11
    
12.
Bovers GM, Koch R. Clinical evaluation of bone allografts in periodontal osseous defects. J Periodontol 1978;49:9-14.  Back to cited text no. 12
    
13.
Urist MR. Bone morphogenic Proteins. Growth Factors 2004;22:233-41.  Back to cited text no. 13
    
14.
Arrocha R, Wittwer JW, Gargiulo AW. Tissue response to heterogenous bone implantation in dogs. J Periodontol 1968;39:162-6.  Back to cited text no. 14
    
15.
Anderegg CR, Alexander DC, Freidman M. A bioactive glass particulate in the treatment of molar furcation invasions. J Periodontol 1999;70:384-7.  Back to cited text no. 15
    
16.
Cochran DL, Wozney JM. Biological mediators for periodontal regeneration. Periodontol 2000 1999;19:40-58.  Back to cited text no. 16
    
17.
Urist MR, Strates BS. Bone morphogenic proteins. J Dent Res 1971;50:1392.  Back to cited text no. 17
    
18.
Camelo M, Nevins ML, Schenk RK, Lynch SE, Nevins M. Periodontal regeneration in human Class II furcations using purified recombinant human platelet-derived growth factor-BB (rhPDGF-BB) with bone allograft. Int J Periodontics Restorative Dent 2003;23:213-25.  Back to cited text no. 18
    



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  In this article
Abstract
Introduction
Osteoconduction
Osteoinduction
Osteopromotion
Osteogenesis
Types of Bone Grafts
Autograft
Allografts
Synthetic Variants
Bioactive Glass
Growth Factors
Uses
References

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