|Year : 2016 | Volume
| Issue : 1 | Page : 30-34
Journey of bone graft materials in periodontal therapy: A chronological review
Jitendra Kumar1, Vaibhav Jain2, Somesh Kishore3, Harish Pal4
1 Department of Periodontics, KVG Dental College and Hospital, Sullia, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, KVG Dental College and Hospital, Sullia, Karnataka, India
3 Department of Pedodontics, KVG Dental College and Hospital, Sullia, Karnataka, India
4 Department of General Surgery, Max Super Speciality Hospital, Ghaziabad, Uttar Pradesh, India
|Date of Web Publication||1-Jul-2016|
Department of Periodontics, KVG Dental College and Hospital, Sullia, Karnataka
Source of Support: None, Conflict of Interest: None
Bone, the basic building block of the healthy periodontium, is affected in most of the periodontal diseases and can be managed either by mechanically recontouring it or by grafting techniques, which encourages regeneration where it has been lost. Bone replacement grafts are widely used to promote bone formation and periodontal regeneration. Bone grafting, placing bone or bone substitutes into defects created by the disease process, acts like a scaffold upon which the body generates its own, new bone. A wide range of bone grafting materials, including bone grafts and bone graft substitutes, have been applied and evaluated clinically, including autografts, allografts, xenografts, and alloplasts. This review provides an overview of the clinical application, biologic function, and advantages and disadvantages of various types of bone graft materials used in periodontal therapy till date with emphasis on recent advances in this field.
Keywords: Alloplast, bone allograft, bone autograft, periodontal regeneration, xenograft
|How to cite this article:|
Kumar J, Jain V, Kishore S, Pal H. Journey of bone graft materials in periodontal therapy: A chronological review. J Dent Allied Sci 2016;5:30-4
|How to cite this URL:|
Kumar J, Jain V, Kishore S, Pal H. Journey of bone graft materials in periodontal therapy: A chronological review. J Dent Allied Sci [serial online] 2016 [cited 2019 Nov 18];5:30-4. Available from: http://www.jdas.in/text.asp?2016/5/1/30/185195
| Introduction|| |
Modern day periodontics aims at maintaining the health of teeth and their supporting structures with the main goal of controlling the infection and regenerating the lost supporting structures., The basic dogma of tissue regeneration is to stimulate a cascade of healing events which, if coordinated, can result in the completion of integrated tissue formation and may prove to be a huge step-up in managing advanced periodontal disease and preventing tooth loss. Hence, this review article focuses on the advantages and disadvantages of various bone graft materials available till date in the light of recent advances in this field.
| Historical Background|| |
The use of bone grafts for reconstructing intraosseous defects produced by periodontal disease dates back to Hegedus in 1923. Bone grafts have undergone a major turnover from then to the present day. Here, we are reviewing various bone graft substitutes in a chronological way for better understanding of the development that has taken place. After Hegedus, it was revived in 1965 by Nabers and O'leary, they used shavings of cortical bone removed by hand chisels during osteoplasty and ostectomy and they were used to treat one, two-wall defect. Allografts of iliac bone and marrow were used by Schallhorn et al. in 1970. Freeze-dried bone allografts (FDBAs) have shown that 60–68% of the defects had 50% or more bone fill on re-entry which was found in a study done by Mellonig et al. in 1981. Dense hydroxyapatite (HA) has been shown to compare favorably with debridement in the reduction of probing depth and increasing clinical attachment level by Meffert et al. in 1985. Yukna in 1990 did a clinical 6-month study on hard tissue replacement (HTR) polymer (HTR synthetic bone) and showed a significant defect fill and improved attachment level relative to open flap debridement (OFD). Bio-Oss is a bovine bone from which all inorganic components are removed and used for regeneration by Richardson et al. in 1999.
| Objective of Bone Graft Therapy|| |
The objectives of bone graft therapy as stated by Schallhorn et al. in 1970 include:
- Probing depth reduction
- Clinical attachment gain
- Bone fill of the osseous defect
- Regeneration of new bone, cementum, and periodontal ligament.
We feel that for better efficacy and result of bone graft therapy, the following additional objectives should also be considered – easy availability, good handling properties, easy storage, no/less adverse tissue reactions, and cost-effectiveness.
| Classifications|| |
Various researchers have classified bone graft materials in different ways.
Hyatt and Butler  have classified tissue grafts as follows:
- Autograft: Tissue taken from one operative site and grafted in another operative site within the same individual
- Homograft/allograft: Tissue taken from one operative site in one individual and grafted in the operative site in another individual of the same species
- Heterograft/xenograft: Tissue taken from one individual and grafted in the operative site of another individual of the different species
- Syngensio grafts: Tissue graft removed from blood-related relatives
- Orthotopic graft:Tissue grafted into an anatomical site normally occupied by that tissue, for example, bone to bone and skin to skin.
Carranaza and Newman  have broadly classified bone as shown in [Table 1].
| Mechanism of Bone Grafting|| |
- Osteogenesisrefers to the formation and development of new bone by cells contained in the graft
- Osteoinductionis defined as a chemical process by which molecules contained in the graft convert the neighboring cells into osteoblasts, which, in turn, form bone
- Osteoconduction is a physical effect by which the matrix of the graft forms a scaffold that favors outside cells to penetrate the graft and form new bone
- Osteopromotion involves the enhancement of osteoinduction without the possession of osteoinductive properties.
For example, enamel matrix derivative has been shown to enhance the osteoinductive effect.
| Selection of Bone Graft Material|| |
According to Schallhorn in 1977, the considerations that govern the selection of a material are biologic acceptability, predictability, clinical feasibility, minimal operative hazards, minimal postoperative sequelae, and patient acceptance.
An ideal bone graft material should be easy to use and should provide desirable results with minimal complications. Various bone graft materials have been used and tested in the field of medical science in the last few decades and many are still under trial, ensuring promising results and may put end to the search for a suitable bone graft material. Different bone graft materials that are available, along with their properties, are comprehensively explained in the following sections.
| Autogenous Bone Graft|| |
Autogenous grafts can be harvested from intraoral or extraoral sites. In 1923, Hegedus attempted to use intraoral autogenous bone grafts for the reconstruction of bone defects produced by periodontal disease. This method was revived by Nabers and O'leary in 1965. They used cortical bone shavings removed by hand chisels from within the surgical site and reported coronal increases in bone height.
| Osseous Coagulum|| |
Robinson in 1969 described a technique using a mixture of bone dust and blood that he termed as osseous coagulum. The use of such material is based on the principle that the small particle size is resorbed and replaced by host tissue.
Disadvantages of the osseous coagulum derive from the inability to use aspiration during accumulation of the coagulum; another problem is the unknown quality and quantity of bone fragments in the collected material.
The bone blend technique uses an autoclaved plastic capsule and pestle. Bone is removed from a predetermined site, triturated in the capsule to a workable, plastic-like mass, and packed into bony defects.
This technique requires the existence of an edentulous area adjacent to the defect from which the bone is pushed into contact with the root surface without fracturing the bone at its base. Bone swaging is technically difficult and its usefulness is limited.
| Intraoral Cancellous Bone Marrow Transplants|| |
Cancellous bone can be obtained from the maxillary tuberosity, edentulous areas, and healing sockets. The maxillary tuberosity frequently contains a good amount of cancellous bone, particularly if the third molars are not present; also, foci of the red marrow are occasionally observed.
| Extraoral Autogenous Bone Graft|| |
Schallhorn et al. in 1967 and 1968 introduced the use of autogenous hip marrow grafts (iliac crest marrow) in the treatment of furcation and intrabony defects. As much as 3–4 mm gain in crestal bone was reported following the treatment of intrabony defects with hip marrow grafts by Schallhorn et al. in 1970. Red, hemopoietic marrow is usually obtained from the anterior or posterior superior iliac crest and is used fresh or frozen.
Disadvantages include due to the added expense, time, and surgical procedure required, iliac crest marrow grafts are not used in regenerative periodontal therapy today. In addition, one of the inherent problems of using hemopoietic cells is that they contain monoblastic precursors to osteoclasts, and therefore, might cause some resorption when the autograft is juxtaposed to the tooth roots.
Allografts are grafts transferred between genetically dissimilar members of the same species. The types of allografts used are as follows:
- Frozen iliac cancellous bone and marrow
- Mineralized FDBAs
- Decalcified FDBAs (DFDBAs).
| Freeze-Dried Bone Allograft|| |
FDBAs were first used in periodontal therapy in the early 1970s by Mellonig et al. in 1976, although they have been used clinically in orthopedic therapy since 1950. The development of bone allograft as an alternative source of graft material was spurred by the disadvantages of autogenously bone, which include the need for a secondary surgical site to procure graft material and the lack of intraoral sites to obtain sufficient quantities of bone for deep or multiple grafts.
| Decalcified Freeze-Dried Bone Allograft|| |
DFDBA was first used in dentistry and medicine in 1965 by Urist who showed through numerous animal experiments that DFDBA could stimulate the formation of new bone by osteoinduction. This graft material induces the host undifferentiated mesenchymal cells to differentiate into osteoblasts with subsequent formation of new bone. The demineralization of the allograft with HCl induces the bone-inducing agent, which has been called the bone morphogenic proteins.
| Xenograft|| |
In contrast to DFDBA, bone mineral has also been produced, which is free of organic component. This product, a xenograft, is known as bovine anorganic cancellous bone. It is produced from bovine bone by a special process, which removes its organic components, but retains its inorganic structure. This product contains biological apatite crystals, and it is either produced as cancellous blocks or granules.
Recently, new processing and purification methods have been utilized which make it possible to remove all inorganic components of a bovine bone source and leave a nonorganic bone matrix in an unchanged inorganic form (Bio-Oss, Endobone, Laddec, Bon-Apatite).
A porcine nonantigenic collagen, known as Bio-Oss collagen, is also available. This is produced from healthy pigs, and the collagen undergoes prolonged alkaline treatment, which produces a bilayer structure and eliminates any risk of bacterial and viral contamination. During further processing, the terminal peptides (telopeptides) are split off from the collagen molecules, and this process removes the area's most concerned with the antigenicity of the molecule.
The main drawback with these materials is the risk of transmission of bovine or porcine viruses or other infective agents.
| Alloplastic Materials|| |
Alloplastic materials are synthetic, inorganic, biocompatible, and/or bioactive bone graft substitutes, which are claimed to promote bone healing through osteoconduction. The available alloplastic materials are Plaster of Paris, polymers, calcium carbonate, and ceramics.
Ceramics can be classified into resorbable (e.g., tricalcium phosphate and resorbable HA) and nonresorbable (dense HA, porous HA, and bioglass).
Bioglass developed by Hench is one of the latest and promising substitutes for bone graft materials.
Various alloplastic materials are illustrated in the following sections.
| Calcium Phosphate Ceramics|| |
Larger number of ceramics are available, the calcium phosphate type has been of particular interest because of the close chemical and crystal resemblance of some of these materials to bone mineral. Commonly used calcium phosphate ceramics for periodontal regeneration are essentially of two types: The relatively nonresorbable HA (Ca10(PO4)6(OH)2) or the resorbable tricalcium phosphates (Ca3(PO4)2).
| Hydroxyapatite|| |
The HA products used in periodontology are of two forms: A particulate nonresorbable ceramic form and a particulate resorbable nonceramic form. In controlled clinical studies, grafting of intrabony periodontal lesions with HA resulted in an attachment level gain of 1.1–3.3 mm which was greater as compared with nongrafted surgically debrided controls by Galgut et al. in 1992.
| Tricalcium Phosphate|| |
Tricalcium phosphate has been shown to stimulate bone formation, and is comparable or in most cases superior in this regard to HA as described by Fetner et al. in 1994. It has been shown to stimulate bone formation to a greater extent than HA, but to a much lesser extent than bioglass as described by Wilson and Low in 1992. Cultured human fibroblasts have been demonstrated to attach readily to the surface of calcium phosphate ceramics. HA acts as an amphoteric ion exchanger. Selective accumulation of calcium and phosphate ion occurs as a consequence of the negative charges on the HA surface. This leads to the formation of more apatite and stimulates the formation of new bone.
| Plaster of Paris|| |
Plaster of Paris is biocompatible and porous, thereby allowing fluid exchange, which prevents flap necrosis. Plaster of Paris resorbs completely in 1 or 2 weeks. Its usefulness in human cases has not been proven.
| Hard Tissue Replacement Polymer|| |
HTR polymer is a nonresorbable, microporous biocompatible composite of poly-methylmethacrylate and polyhydroxyethylmethacrylate, a resorbable polylactic acid polymer. This material has been used in the fabrication of contact lenses, lens transplants, and prosthetic heart valves over many years. The polymer does not produce an inflammatory or immune response in contact with bone or soft tissue as described by Yukna in 1990.
| Bio-Active Glasses and Ceramics|| |
Bioglasses are composed of Si-CaO-Na2O-P2O5 and are resorbable or not resorbable depending on the relative proportion of these components. When bioglasses are exposed to tissue fluids, a double layer of silica gel and calcium phosphate is formed on their surface. Through this layer, the material promotes absorption and concentration of proteins used by osteoblasts to form an extracellular bone matrix which may theoretically promote bone formation as described by Hench et al. in 1972. They have been extensively used in conjunction with medical and dental implants because they develop a layer of hydroxy-carbonate-apatite on their surface following exposure to body fluids. When used on the surface of metal implants, this layer incorporates collagen fibrils and in this way produces a mechanically strong bond between implant and the adjacent bone surface as described by Hench and West in 1996.
| Nonbone Graft Materials|| |
In addition to bone graft materials, many nonbone graft materials have been tried to restore the periodontium. Among them are sclera, dura, cartilage, cementum, dentin, and coral-derived materials.
| New Innovations|| |
It is a bone grafting material used to fill periodontal osseous defects that is composed of anorganic bovine-derived HA bone matrix combined with a synthetic cell-binding peptide.
Growth factor-enhanced matrix 21S
Growth factor-enhanced matrix (GEM) 21S is a synthetic grafting system for bone and periodontal regeneration composed of a purified recombinant growth factor and a synthetic calcium phosphate matrix.
GEM 21S is supplied in a single-use kit. Each GEM 21S kit consists of the following:
- One cup containing 0.5cc of beta-tricalcium phosphate particles (0.25–1.0 mm)
- One syringe containing a solution of 0.5 ml recombinant human platelet-derived growth factor-BB (0.3 mg/ml).
| Biodegradable Composite Scaffolds|| |
Researchers are working hard to develop a strategy to modulate stem cell behavior by developing biodegradable composite scaffolds. Research activities on biological applications and, in particular, on stem cell interaction of a biodegradable nanocomposite have started only recently. We expect that biodegradable polymeric nanocomposites will most likely become one of the widely used substrates for bio-applications. There is a great necessity for the development of these multifunctional nanocomposite scaffolds, but there are some difficulties and challenges to overcome in their fabrication.
| Conclusion|| |
Bone grafting is one of the most commonly used options to treat large bone defects in periodontal regenerative therapy. Although not all bone grafting materials support the formation of a new periodontal attachment apparatus, there is conclusive evidence that periodontal regeneration is achievable with bone replacement grafts in humans. Autografts remain the gold standard since they provide osteogenic cells, osteoinductive growth factors, and an osteoconductive scaffold, all essential for new bone growth, but carry the limitations of morbidity at the harvesting site and limited availability. Allografts, xenografts, and tissue-engineered grafts all have shortcomings. New strategies such as gene therapy, polytherapy by using scaffolds, healing promotive factors and stem cells, and finally three-dimensional printing are in their preliminary stages, but may open new insights shortly.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sukumar S, Drízhal I. Bone grafts in periodontal therapy. Acta Medica (Hradec Kralove) 2008;51:203-7.
Glossary of Periodontic Terms. American academy of Periodontology; 2001.
Elsalanty ME, Genecov DG. Bone grafts in craniofacial surgery. Craniomaxillofac Trauma Reconstr 2009;2:125-34.
Schallhorn RG, Hiatt WH, Boyce W. Iliac transplants in periodontal therapy. J Periodontol 1970;41:566-80.
Hyatt GW, Butler MC. The procurement, storage, and clinical use of bone homografts. Instr Course Lect 1957;14:343-73.
Carranaza FA, Newman MG. Reconstructive Osseous Surgery. In: Clinical Periodontology. Philadelphia, USA: WB Saunders Company; 1999;8:622-39.
Hegedus Z. The rebuilding of the alveolar process by bone transplantation. Dent Cosmos 1923; 65:736.
Nabers CL, O'leary TJ. Autogenous bone transplants in the treatment of osseous defects. J Periodontol 1965;36:5-14.
Robinson E. Osseous coagulum for bone induction. J Periodontol 1969;40:503-10.
Mellonig JT, Bowers GM, Cotton WR. Comparison of bone graft materials. Part II. New bone formation with autografts and allografts: A histological evaluation. J Periodontol 1981;52:297-302.
Meffert RM, Thomas JR, Hamilton KM, Brownstein CN. Hydroxylapatite as an alloplastic graft in the treatment of human periodontal osseous defects. J Periodontol 1985;56:63-73.
Yukna RA. HTR polymer grafts in human periodontal osseous defects. I 6-month clinical results. J Periodontol 1990;61:633-42.
Richardson CR, Mellonig JT, Brunsvold MA, McDonnell HT, Cochran DL. Clinical evaluation of Bio-Oss: A bovine-derived xenograft for the treatment of periodontal osseous defects in humans. J Clin Periodontol 1999;26:421-8.
Urist MR. Bone: Formation by autoinduction. Science 1965;150:893-9.
Araújo M, Linder E, Wennström J, Lindhe J. The influence of Bio-Oss Collagen on healing of an extraction socket: An experimental study in the dog. Int J Periodontics Restorative Dent 2008;28:123-35.
Galgut PN, Waite IM, Brookshaw JD, Kingston CP. A 4-year controlled clinical study into the use of a ceramic hydroxylapatite implant material for the treatment of periodontal bone defects. J Clin Periodontol 1992;19:570-7.
Fetner E, Martigan MS, Low SB. Periodontal repair using PerioGlas in non-human primates: Clinical and histologic observations. Compend Contin Educ Dent 1994;12:932-9.
Wilson J, Low SB. Bioactive ceramics for periodontal treatment: Comparative studies in the Patus monkey. J Appl Biomater 1992;3:123-9.
Yukna RA. HTR polymer grafts in human periodontal osseous defects. I 6-month clinical results. J Periodontol 1990;61:633-42.
Hench LL, Splinter RJ, Allen WC, Greenlee TK Jr. Bonding mechanism at the interface of ceramics prosthetic materials. J Biomed Mater Res Symp 1972;2:117-41.
Hench LL, West JK. Biological applications of bioactive glasses. Life Chem Rep 1996;13:187-241.
Schallhorn RG. Present status of osseous grafting procedures. J Periodontol 1977;48:570-6.
Armentano I, Fortunati E, Mattioli S, Rescignano N, Kenny JM. Biodegradable composite scaffolds: A strategy to modulate stem cell behaviour. Recent Pat Drug Deliv Formul 2013;7:9-17.