SCIENTIFIC FOUNDATION
Autogenous Bone Graft: Basic Science and
Clinical Implications
Gary F. Rogers, MD, JD, MBA, MPH* and Arin K. Greene, MD, MMScÞ
Abstract: No single biomaterial is optimum for every craniomax-
illofacial application. Instead, surgeons should consider the advan-
tages and disadvantages of each alternative in a given clinical
situation, and select the material with lowest overall cost and mor-
bidity, and the highest likelihood of success. Autogenous bone is
still considered the gold standard for most applications; it becomes
vascularized and osseointegrates with surrounding bone, thus min-
imizing the risk of infection, dislodgement, or break-down. Lim-
itations include added operative time for graft harvest, donor site
morbidity, graft resorption, molding challenges, and limited avail-
ability, especially in the pediatric population. Numerous alternatives
to bone graft have become available to address these limitations;
unfortunately, most of these products are expensive, do not
osseointegrate, and have unpredictable biologic activity. Under-
standing the physiologic behavior of autogenous bone graft can help
clarify the indications for its use and provide a conceptual frame-
work for achieving the best possible outcome when this alternative
is chosen.
Key Words: Autologous bone graft, craniofacial,
basic science, particulate
(J Craniofac Surg 2012;23: 323Y327)
A ugmentation or replacement of bone is one of the most com-
monly performed procedures in craniomaxillofacial surgery. A
number of biomaterials are available, and the choice depends on the
clinical situation, personal preference, availability, and cost. Some
experts dogmatically favor one biomaterial over another, but each
substance has advantages and disadvantages, and a more rational
approach is to choose the appropriate material for a given applica-
tion. For example, the preferred biomaterial to reconstruct a cranial
defect in a healthy 2-year-old would likely differ from what would
be indicated for a 71-year-old with major comorbidities. Similarly,
the material used for malar augmentation in a major metropolitan
From the *Division of Plastic and Reconstructive Surgery, Children’s
National Medical Center, Washington, District of Columbia; and
†Department of Plastic and Oral Surgery, Children’s Hospital Boston,
Boston, Massachusetts.
Received August 23, 2011.
Accepted for publication August 27, 2011.
Address correspondence and reprint requests to Gary F. Rogers, MD, JD,
MBA, MPH, Division of Plastic and Reconstructive Surgery, Children’s
National Medical Center, 111 Michigan Ave NW, Washington, DC
22102; E-mail: grogers@cnmc.org
The authors report no conflicts of interest.
Copyright * 2012 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e318241dcba
The Journal of Craniofacial Surgery & Volume 23, Number 1, January 2012
Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
craniofacial center in the United Kingdom may be considerably dif-
ferent than what might be available to a surgeon operating in a remote
hospital in Haiti. Thus, the wide range of clinical and socioeconomic
circumstances that one might encounter contravenes the idea that
there is a ‘‘best’’ biomaterial for all situations.
In general, materials for bone replacement or augmentation
fall into 3 categories: organic, synthetic organic, and inorganic.
Organic substances include autograft (from the same individual),
allograft (from another individual), and xenograft (from another
species). Synthetic organics include hydroxyapatite and osteoin-
ductive biologics such as bone morphogenic protein. Examples of
inorganic substances are methylmethacrylate, silicone, porous poly-
ethylene, titanium mesh, and bioactive glass.
Autogenous bone has been considered the criterion stan-
dard for osseous reconstruction and is still widely used.1,2 The most
common donor areas are the cranium, iliac bone, and ribs. Grafts
become vascularized and osseointegrate with surrounding bone,
minimizing infection, dislodgement, or breakdown. Nevertheless,
harvest requires added operative time and donor-site morbidity.
Autogenous bone has unpredictable resorption and can be difficult
to mold to meet the requirements of the craniofacial skeleton. In
addition, the supply of autogenous graft is limited, particularly in the
pediatric population.
Many alternatives to autogenous bone graft have become
available and share 2 advantages: (1) the supply is limitless, and (2) a
donor site is not required. Some materials can be molded or cus-
tom manufactured to fit the deformity. Although nonautogenous
products offer certain advantages, these substances are not osteo-
genic (capable of new bone formation). Bone morphogenic pro-
tein and demineralized bone matrix are osteoinductive (able to
induce transformation of undifferentiated mesenchymal cells to
osteoblasts), but the absence of structural integrity limits their ap-
plicability. The remaining substrates either are osteoconductive
and provide a scaffold for bony ingrowth (eg, allograft, hydroxy-
apatite, ceramics) or have no biologic activity (eg, methylmetha-
crylate, titanium, porous polyethylene). These compounds undergo
incomplete revascularization and osseointegration and are suscep-
tible to latent infection, foreign body reaction, displacement, and
breakage.3Y8 Consequently, the use of alloplastic materials in grow-
ing children generally is not recommended. With the exception of
methylmethacrylate, the high cost of these materials renders them
unavailable in all but the wealthiest parts of the world. In an era of
increasing scrutiny of health care costs, the arguments for consider-
ing autogenous bone graft for most craniofacial application seem
even more compelling.
Unfortunately, academic interest in autogenous bone graft
has waned recently as researchers and clinicians have clamored to
study and use more sophisticated biomaterials. The majority of the
literature regarding the biology and outcomes of autogenous bone
graft predates this millennium. Certainly, some of this trend can
be rightly attributed to a genuine desire on the part of surgeons to
overcome perceived limitations of autogenous bone graft. How-
ever, an equally potent and more insidious force is the aggressive
product marketing tactics by the biotechnology industry. It is no
323
Rogers and Greene The Journal of Craniofacial Surgery
surprise that our journals are inundated with advertisements and
industry-sponsored research, touting the virtues of the latest bio-
material to replace bone.
AUTOGENOUS BONE GRAFT: FACTORS
AFFECTING VOLUME RETENTION AND
CLINICAL OUTCOME
The 2 most important clinical outcomes after transfer of
an autogenous bone graft are volume retention and the biologic
behavior of the graft. The final volume of bone graft that remains
after implantation is the net effect of osteolysis (caused by revas-
cularization and remodeling) and osteogenesis in and around the
graft. If the former process exceeds the latter, the graft will lose
volume. Conversely, if the rate of osteogenesis exceeds the rate of
resorption, graft volume will increase. The biologic behavior of a
graft includes its ability to heal and integrate with surrounding bone,
resist infection, and tolerate mechanical load. These characteristics
of any osseous graft are largely related to the survival of bone-
producing cells after transfer. Failure to identify and compensate
for variables that can adversely influence the volume retention
and survival of a bone graft will result in a suboptimal clinical
outcome.
Osteocyte and Osteoblast Survival
Living bone contains viable bone-producing cells (ie, osteo-
cytes and osteoblasts). Although osteocytes are capable of only
limited bone formation, they are very important in orchestrating
and regulating the activity of bone-producing osteoblasts and bone
healing.9,10 The ability to initiate new bone growth is one of the
greatest advantages of autologous bone graft over other substrates,
and surgeons should strive to protect these cells. Furthermore, os-
teocyte death may promote bone resorption through induction of
osteoclastic activity.11 Thus, survival of these cells is an important
determinant of graft retention and biologic activity after transfer.
Osteocyte and osteoblast survival in a nonvascularized graft
depends on their ability to obtain metabolites from the recipient bed
during the first few days after transplantation. Eventually, angio-
genesis from the recipient site provides critical substrates to the
graft. Vessel penetration is relatively slow and cannot be relied on
to prevent cellular demise; osteocyte/osteoblast death occurs after
25 hours of ischemia.12 The diffusion of nutrients and oxygen from
the environment favors the cells on the surface of the graft. Thick
or large cortical grafts have a greater percentage of cells on their
interior that do not survive. Only viable surface osteocytes and
osteoblasts participate in bone healing, but the nonviable interior
remains osteoconductive and serves as a scaffold for new bone
growth. It will gradually be replaced with viable bone by the rela-
tively slow process of creeping substitution. Until this exchange is
complete, the dead bone remains more susceptible to infection and
structural damage.
Although surface osteocytes are most likely to survive trans-
plantation, they may be compromised during harvest and storage.
Thermal injury can result from power instruments used to harvest
or contour the graft. Limiting the use of power tools and irrigating
the graft with cold water when such instruments are used can miti-
gate heat damage. Desiccation or osmotic damage to the cells can
occur while the graft is stored outside the body; the best media is a
blood-soaked sponge.
Bone cell survival also can be reduced if the recipient bed
is impaired. A recipient site complicated by infection, hematoma,
radiation, and/or scar will limit the transfusion of nutrients to and
neovascularization of the graft. When a large graft is required, or
324
Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
& Volume 23, Number 1, January 2012
the recipient bed is suboptimal, vascularized bone graft is a more
reliable option. Rapid and predictable revascularization of the bone
results in a high rate of osteocyte survival. The living bone maintains
its inherent properties: rapid healing, osseointegration, resistance to
infection, and adaptation to mechanical forces. Over the last decade,
vascularized bone grafts have become more widely used in cra-
niofacial reconstruction.
Graft Type and Microarchitecture
Many sources of autogenous bone graft exist, but there are
only a few sites where bone can be removed without causing a
significant functional or aesthetic deficit. The most common areas
are the cranium, ribs, or iliac crest. Donor-site morbidity for rib graft
includes possible contour irregularity, pleuritic pain, and pneumo-
thorax.13 Iliac harvest causes discomfort and risks injury to the
lateral femoral cutaneous nerve. In young children, overzealous iliac
bone harvest may damage the apophysis.
In contrast to iliac or rib donor sites, which require a second
incision, the cranium is often exposed in most craniomaxillofacial
procedures. The cranial donor site causes minor discomfort, and the
scar is well concealed. Cranial bone can be harvested full thickness,
partial (split) thickness, or as particulate corticocancellous graft.
Although full-thickness bone is excellent for structural purposes, it
leaves a donor defect that must be repaired. Consequently, most
surgeons use split cranial bone graft through the diploic space to
obtain 2 pieces of mostly cortical boneVone to perform the re-
construction and the other to repair the donor site. Limitations of
split cranial bone grafting include (1) the segments over the donor
and recipient sites do not heal to a normal thickness over time, and
(2) the technique requires a well-developed diploic space, which
rarely occurs in children younger than 5 years.
An attribute of cranial bone compared with other autoge-
nous bone sources is its superior volume retention when used to
augment existing bone. Historically, this phenomenon was at-
tributed to the embryologic origin of the grafts (endochondral vs
membranous).14,15 Nevertheless, subsequent studies demonstrated
that volume retention of onlay grafts depends primarily on its cor-
tical-cancellous composition.16Y18 Grafts that are mostly cortical,
such as cranial bone, resorb less than grafts that have a greater can-
cellous composition, such as rib or iliac crest.17,19Y21
This difference has been largely attributed to revasculariza-
tion.18,21,22 Although revascularization is generally considered de-
sirable for bone cell survival, it proceeds by osteolysis and works to
deplete volume. Osteoclasts carve out small channels, termed cut-
ting cones, which becomes the conduit for vessel growth. New bone
gradually fills the defect as the cutting cone extends deeper into the
graft. The rate of revascularization and graft replacement de-
pends strongly on the graft microarchitecture, specifically the sur-
face areaYtoYvolume ratio.21,23,24 This ratio is much higher in
cancellous than cortical grafts. Consequently, the rate of revascu-
larization is much higher in the former than in the latter tissue. Thus,
graft revascularization depends on bone microarchitecture and not
whether the graft is from a cortical or cancellous source per se.17
We recently reported that onlay particulate cranial graft, which is
derived principally from cortical bone, undergoes resorption simi-
lar to cancellous graft.25 In the orthopedic literature, Tagil et al26
showed that impacting morselized bone graft to make it more cor-
tical decreased revascularization and replacement.
Although the high surface-to-volume relationship of can-
cellous bone promotes greater revascularization, it also can have a
positive effect relative to the potential for graft osteoinductive and
osteogenic. These biologic processes are more active in the heal-
ing of cancellous grafts than cortical grafts for 2 reasons. First, the
relatively large surface areaYvolume relationship of cancellous grafts
* 2012 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery & Volume 23, Number 1, January 2012
means that a high proportion of osteoblasts and osteocytes will sur-
vive transfer and contribute to new bone formation. This is not the
case for cortical grafts, especially if they are large or thick. Second,
rapid revascularization of cancellous grafts releases osteoinductive
mediators, such as bone morphogenic protein, into the recipient
environment and promotes differentiation of bone-producing cells
around the graft. Bone microarchitecture can explain much, but not
all, of the clinical behavior of an autogenous graft. The remaining
piece of the puzzle is the interaction of the graft with tissues in the
recipient bed.
Recipient Bed: Inlay Versus Onlay
The interplay between the recipient bed and bone graft leads
to interesting and seemingly enigmatic, biologic questions. For ex-
ample, onlay cancellous grafts undergo significant resorption. How-
ever, when placed over dura, their volume increases. Rosenthal and
Buchman27 found that both cortical and cancellous inlay grafts in-
crease in volume after placement, but the cancellous bone was found
to have a greater volume increase. However, each graft type undergoes
some resorption when used to onlay bone. We have noted similar
behavior with particulate cranial bone graft.25,28 Although mechani-
cal theories have been proposed to explain this apparent dichot-
omy, they are too simplistic. One study found that isolating bone
graft from the pericranium with a double-layer collagen membrane
actually improved graft retention.29 Although this affected revascu-
larization, it minimally influenced forces applied to the graft from
the overlying tissues.
The principal difference in the environment between inlay
and onlay grafts used on the cranium is contact with the dura, be-
cause both are typically covered by pericranium. Although most
surgeons consider pericranium critical for cranial graft healing, it
is considerably less important than the dura.30Y33 The contribution
of pericranium to inlay graft healing is limited to the graft surface,
whereas osteogenesis from the dura extends throughout the graft.32
Isolation of inlay bone graft from the overlying pericranium has
minimal effect on graft survival or volume retention, whereas iso-
lation from the dura causes a significant decrease in volume.33
Some investigators have noted improved onlay graft survival when
the bone is rigidly fixed and the periosteum is included with the
graft.34Y38 Others have found that periosteum does not effect graft
survival39 or may even promote revascularization and resorption.29
This is particularly true in areas of the craniofacial skeleton that
exhibit ‘‘resorptive’’ tendencies.40
Overall, the impact of dural-mediated osteogenesis super-
sedes the osteolytic byproduct of revascularization for inlay graft
and typically leads to a gain in volume. For onlay grafts, the more
attenuated osteogenic role of the pericranium does not keep pace
with bone resorption consequent to revascularization, and there is
a net loss of bone. The loss of onlay graft volume is more pro-
nounced for cancellous bone because it is more readily revascular-
FIGURE 1. Adult, New Zealand white rabbit with 17  17-mm critical-size parietal defect filled with particulate graft harvested from the frontal bone using
a hand-driven brace and bit. Sixteen weeks later, the defect has ossified; the bone is as thick as the surrounding cranium and contains a diploic space.
Note that the partial thickness donor sites have healed and can be used again to harvest additional particulate graft.
* 2012 Mutaz B. Habal, MD
Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Autogenous Bone Graft
ized than cortical bone. Thus, rapid vascularization of an onlay graft
is detrimental to volume retention. In support of this tenet, we re-
cently demonstrated that abrading the cortical surface under onlay
cranial graft leads to greater bone resorption through increased re-
vascularization and osteoclast activity. The osteogenic potential of
the recipient bed largely explains the disparate behavior of identi-
cal autogenous materials in different environments and should be
considered when choosing a graft.
CLINICAL APPLICATIONS
The biology of autogenous bone graft discussed above forms
the groundwork for its clinical use:
(1) Bone viability should be ensured throughout the harvest, stor-
age, and placement of the graft. Dead bone has no osteogenic
potential, has limited osteoinductive capacity, and heals pri-
marily by creeping substitution. Clinically, this can lead to delay
in graft healing, a reduced capacity to withstand mechanical
stresses, and an increased potential for resorption and infection.
The viability of nonvascularized bone depends on the size and
thickness of the graft, as well as the angiogenic/osteogenic po-
tential of the recipient bed. Vascularized bone may be superior
for situations where bone viability is critical (eg, load bearing)
or when the recipient bed is significantly compromised.
(2) Autogenous bone, regardless of its cortical/cancellous compo-
sition, generally will retain volume when placed over normal
dura (inlay). In the inlay position, the balance between osteo-
genesis and resorption is weighted toward osteogenesis. Be-
cause the dura is important for osteogenesis, graft survival
should be expected to decrease if the dura is scarred. Cancellous
grafts tend to increase in volume more than cortical grafts and
hence may have a slight advantage over cortical bone for inlay
applications.
(3) Bone grafts placed over intact bone (onlay) tend to resorb. For
onlay grafts, the balance between osteogenesis and resorption
favors resorption. Because cortical bone revascularizes more
slowly than cancellous bone, the former graft material generally
has better volume retention than the latter. Abrading the re-
cipient site increases revascularization and causes greater, not
less, graft resorption.
Cranial bone is our preferred grafting material because (1)
a remote donor site is not required; (2) there is less donor-site
morbidity compared with harvesting rib or iliac bone; and (3) cra-
nial graft has better volume maintenance than rib or iliac bone.
One misconception regarding cranial bone is that there is a limited
amount that can be harvested, particularly in young children. This
perception is one reason why endochondral bone and/or alloplas-
tic materials are often used for craniofacial reconstruction. Re-
cently described techniques using cranial particulate bone graft,
however, allow the expansion of the cranial donor site. Almost all
inlay defects, in patients of any age, may now be reconstructed with
autologous cranial graft.
325
Rogers and Greene The Journal of Craniofacial Surgery
FIGURE 2. A 24-month-old girl with a cranial defect following resection of a venous malformation. The area was filled with particulate bone graft harvested
from the adjacent ectocortex. The defect was clinically healed in 6 weeks; computed tomography at that time showing healing particulate graft without resorption.
The uses and advantages of particulate corticocancellous cra-
nial bone graft have been extensively described (Figs. 1 and 2).41Y44
For cranial procedures, the donor site is already in the operative
field so there is no additional operative morbidity. The graft can
be harvested from the outer table of the cranium or from the inner
table of any bone segment using a hand-driven Hudson brace and
D’Errico craniotomy bit (Codman & Shurtleff, Inc, Raynham, MA).
The use of a manual drill prevents thermal injury and ensures
maximal graft viability. The diameter and pitch of the cutting bit
also can affect the graft survival. If the particles are too small, they
will be digested by macrophages; if they are too large, the osteo-
genic and osteoinductive potential of the graft may be reduced. We
recently have shown that bone ‘‘dust’’ produced with a high-speed
drill resorbs when used as inlay graft because of osteonecrosis and
diminutive particle size.25
Because the donor defects created during harvest of par-
ticulate graft are partial thickness and less than critical size, they
fill over time. Consequently, unlike split cranial bone, the donor sites
return to normal thickness and can be used in the future to harvest
additional bone graft. For bone harvested from the ectocortical
surface, there is no need for neurosurgical assistance because the
inner table remains intact. Particulate graft can be harvested from
areas of the cranium (eg, temporal, greater sphenoid wing, occiput)
that would be difficult to split or in children without a diploic
space. The lattice of full-thickness bone between the donor-site
FIGURE 3. A, Temporal defect in a 22-year-old following craniectomy for
tumor accessVthe bone window gradually resorbed postoperatively.
B, Full-thickness bone graft harvested from contralateral parietal regions using
template. C, Particulate bone graft (PBG) harvested from endocortical surface
of graft and the ectocortex of the intact cranium. D, PBG and full-thickness
graft after harvest was completed. E, Full-thickness graft in temporal recipient
site. F, PBG in donor-site defect. Both areas were solid by palpation at
3 months postoperatively.
326
Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
& Volume 23, Number 1, January 2012
defects allows the area to maintain greater strength compared with
split cranial bone.
Particulate graft is best used to reconstruct inlay defects.
Similar to other types of cancellous grafts, the bone mass remaining
after healing is equal to or greater than the mass that was originally
placed into the defect. Over time, the graft becomes indistinguish-
able from the surrounding bone and can even form a diploic space.
This observation implies that the graft induces regional osteogenesis
from the adjacent dura and pericranium. We refer to this process as
reparative osteogenesis, because the body responds to the graft as if
it were repairing a fracture. This is analogous to the mechanism of
bone ‘‘generation’’ used through distraction osteogenesis.
Because the dura is critical in this process, we have largely
refrained from placing the particulate graft over scarred dura. In-
stead, we have used the technique of exchange cranioplasty in these
situations (Fig. 3).44 A full-thickness piece of bone is harvested
from the intact calvaria. We have limited harvest to areas behind
the hairline to avoid any possible contour irregularities. The donor
defect is then back-filled with particulate graft derived from the
endocortex of the full-thickness segment or the ectocortex of the
surrounding intact cranium. This technique can also be used to
harvest large segments of full-thickness bone for use as an onlay
or in other areas of the craniofacial skeleton. Virtually any area of
intact cranium can be removed and replaced with particulate graft
harvested from the endocortical surface of the graft. In the unusual
situation where additional particulate graft is needed to fill the do-
nor site, it can be obtained from the ectocortex of the surround-
ing cranium. Because the thickness and integrity of the particulate
bone after healing are comparable to the surrounding native bone, it
can be harvested in the future as particulate, split, or full-thickness
donor bone. Thus, through cycles of harvest and healing, the cra-
niofacial surgeon can access a nearly endless supply of autogenous
cranial bone.
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