autogenous bone grafting

Dr. Kritika Jangid 1

LET’SFIX BONES

TODAY


Dr. Kritika Jangid(MDS- Periodontics and Implantology)

AUTOGENOUS BONE GRAFTS


CONTENTS

• BONE• BONE LOSS IN

PERIODONTAL DISEASE

• AUTOGENOUS BONE GRAFTS


Circumferential lamellae


Concentric lamellae


OSTEON


Interstitial lamellae


•outer "fibrous layer" and• inner "cambium layer" (or "osteogenic layer").

PERIOSTEUM


Are responsible for formation, resorption and maintenance of osteoarchitecture

• Osteogenic cells

• Osteoprogenitors• Preosteoblasts• Osteoblasts• Osteocytes• Bone lining cells

• Osteoclast

BONE

CELLS


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 CHEMICALACTION

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


BONE GRAFTS


• 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


Vittorio Putti [1912]Principles considered as the basis of modern science of grafting

1. Ability to be critical2. Uniformity in graft

integration3. Osteogenic potential

of periosteum4. Biological capacity of

treated grafts5. Quality of tissue in

which graft is placed 6. Mechanical

characteristics of grafts and it’s fixation

7. Importance of asepsis

8. Importance of functional exercise

http://images.google.co.in/imgres?imgurl=http://www.diavlos.gr/orto96/ortowww/euputi.jpg&imgrefurl=http://www.diavlos.gr/orto96/ortowww/euputi.htm&usg=__Onc5UgRy-gjU6kXILoioM6jUFfU=&h=294&w=300&sz=6&hl=en&start=1&um=1&tbnid=XXZVU7jAExqi_M:&tbnh=114&tbnw=116&prev=/images?q=vittorio+putti+in+1912&hl=en&rlz=1T4SKPB_enIN278IN278&sa=N&um=1


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 bone4. Be osteogenic5. Be radiopaque6. Be easy to manipulate7. Non Allergenic8. 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

strength13. Have a surface amenable to

grafting14. Act as a matrix or vehicle for

other materials


• Reattachment Reunion of root and connective tissue separated by incision or injury

• New attachmentFormation 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.


• OsteogenesisFormation 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

• OsteoinductionChemical process by which molecules contained in the graft (BMP’s) convert the neighboring cells into osteoblasts , which in turn form bone

• OsteopromotionWhen 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


AUTOGENOUS BONE GRAFTS

34

1. Considered the GOLD STANDARD among all the graft materials

2. Gives more predictable results3. Contains live osteoblasts and

osteoprogenitor stem cells and heal by osteogenesis

Dr. Kritika Jangid

35

Graft Procurement

Bone Trap

Trephine Bur

Bone Shaving Device

Suction TrapDr. Kritika Jangid


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 tuberosityProcedure:– Bone removed from curved or cutting rongeur.– Ridge incision distally from the last molar


• Edentulous areaProcedure:– 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

Extra Oral Illiac Autografts1. 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

48Dr. Kritika Jangid

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

49Dr. Kritika Jangid


Healing Of AutograftsFour 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


KritikaShyam DarshanaArchana

AshaSheethalan

Sudarshana Avinash

autogenous bone grafting

Health & Medicine