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Osseous Grafts

2017.09.20
Review
1. Sheikh, Z., et al. (2017). “Natural graft tissues and synthetic biomaterials for
periodontal and alveolar bone reconstructive applications: a review.” Biomater
Res 21: 9.
 Mechanical properties, biological behavior & biodegradation mechanism vary for different
graft materials
2. AlGhamdi, A.S., O. Shibly, and S.G. Ciancio. (2010). “Osseous grafting part I:
autografts and allografts for periodontal regeneration--a literature review.” J
Int Acad Periodontol,. 12(2): 34-8.
 DFDBA is the only bone graft proven to result in periodontal regeneration in controlled human
histological studies (Bowers et al., 1989; Nasr et al., 1999)
 The addition of autograft or growth factors to allograft seems to enhance the regenerative potential
of these materials.
3. Sculean, A., et al. (2015). “Biomaterials for promoting periodontal regeneration
in human intrabony defects: a systematic review.” Periodontol 2000 68(1): 182-
216.
 autogenous bone: 80% of the defects ­ partial or complete regeneration
 allogeneic bone: 70% of the defects demonstrated signs of partial periodontal regeneration but
none reported complete regeneration
  alloplastic substitutes:  partial periodontal regeneration was observed in 73% of the defects,
but none showed complete regeneration.
4. Reynolds, M. A., M. E. Aichelmann-Reidy, et al. (2010). "Regeneration of periodontal
tissue: bone replacement grafts." Dent Clin North Am 54(1): 55-71.
 Controlled clinical trials provide strong evidence for the effectiveness of bone replacement 
grafts in the treatment of periodontal defects.
 Composite grafting materials, incorporating biomimetic and biologic components, have shown
great potential to enhance regenerative outcomes.

5. Reynolds, M. A., M. E. Aichelmann-Reidy, et al. (2003). "The efficacy of bone replacement


grafts in the treatment of periodontal osseous defects. A systematic review." Ann
Periodontol 8(1): 227-265.

Graft > OFD
Defect fill 1.04 mm*
Crestal resorption -0.37 mm*
CAL 0.55 mm*
Graft = OFD
PD 0.31 mm
Recession -0.12 mm

 Allograft (DFDBA,FDBA)= HA or ceramic: Defect fill, crestal resorption, CAL , PD, Recession

6. Rosen, P. S., M. A. Reynolds, et al. (2000). "The treatment of intrabony defects with bone
grafts." Periodontol 2000 22: 88-103.
 Patient selection: non-smoker
 Defect selection: predictabilityno. of remaining bone wall
 Pre-op preparation: plaque control, (splinting/ occlusal therapy), 0.12% CHX
 Flap design: sulcular incision (B&L), papilla preserve (proximal)
 Defect or root debridement: hand/ultrasonic/rotary, (tetracycline/citric acid), (decortication)
 Flap closure: passive, optional dressing without displacement of graft
 Post-op management: refrain from brushing surgical area for 4-6W, post-op supragingival
plaque removal, no probing prior 6-12M

Histology healing
I. Autograft

(1) Long junctional epithelium


7. Caton, J., S. Nyman, and H. Zander (1980).“Histometric evaluation of periodontal surgery. II.
Connective tissue attachment levels after four regenerative procedures.” J Clin Periodontol 7(3):
224-31. (2014-D-14)
 Monkey
 MWF + autogenous hip marrow  Long junctional epithelium only
8. Moskow, B. S., F. Karsh, et al. (1979). "Histological assessment of autogenous bone graft.
A case report and critical evaluation." J Periodontol 50(6): 291-300.
 presence of a downgrowing junctional epithelium between the root surface and the altered
graft bone
(2) New attachment apparatus
9. Hiatt, W. H., R. G. Schallhorn, et al. (1978). "The induction of new bone and cementum
formation. IV. Microscopic examination of the periodontium following human bone and
marrow allograft, autograft and nongraft periodontal regenerative procedures." J
Periodontol 49(10): 495-512.
 Graft procedures yielded new cementum formation in 66 of 79 sites evaluated while nongraft
approaches yielded new cementum formation in only 7 of 21 sites.
(3) Donor site healing
10. Evian, C. I., E. S. Rosenberg, et al. (1982). "The osteogenic activity of bone removed from
healing extraction sockets in humans." J Periodontol 53(2): 81-85. (2016-D-10)
 ideal time to harvest autograft from a healing extraction socket: 8-12
wks

II. Autograft/Allograft

 Long junctional epithelium


11. Listgarten, M. A. and M. M. Rosenberg (1979). "Histological study of repair following new
attachment procedures in human periodontal lesions." J Periodontol 50(7): 333-344.
(2006-94)
 Autograft: tuberosity, Allograft: iliac crest  fresh-frozen
 Tooth blocks from human: anterior teeth, premolars
 Epithelium: 52-85% of distance from alveolar crest to bottom of original defect

III. Allograft/Alloplast

(1) Long junctional epithelium


12. Dragoo, M. R. and W. B. Kaldahl (1983). "Clinical and histological evaluation of alloplasts
and allografts in regenerative periodontal surgery in humans." Int J Periodontics
Restorative Dent 3(2): 8-29.
 Alloplasts: Dyhydrotachysterol, potassium permanganate, ferric
chloride
 Allografts: sclera, decalcified dentin, FDBA, DFDBA
 None inhibited the apical migration of epithelium
(2) New attachment apparatus
13. Bowers, G. M., B. Chadroff, et al. (1989). "Histologic evaluation of new attachment
apparatus formation in humans. Part I." J Periodontol 60(12): 664-674.
 non-submerged (22): no new attachment apparatus
Submerged (25): 1 form new attachment apparatus
14. Bowers, G. M., B. Chadroff, et al. (1989). "Histologic evaluation of new attachment
apparatus formation in humans. Part II." J Periodontol 60(12): 675-682.
 DFDBA (30 defects) vs. non-grafted (13 defects)
 New attachment & bone: grafted> non-grafted
15. Bowers, G. M., B. Chadroff, et al. (1989). "Histologic evaluation of new attachment
apparatus formation in humans. Part III." J Periodontol 60(12): 683-693.
 FGG + DFDBA (32) vs. FGG + non-grafted (25)
 New attachment apparatus, cementum, CT, bone: grafted> non-
grafted
 FGG didn’t enhance regeneration
16. Mellonig, J.T. (2006). “Histologic and clinical evaluation of an allogeneic
bone matrix for the treatment of periodontal osseous defects.” Int J
Periodontics Restorative Dent 26(6): 561-9.
 (Graftonz) Demineralized bone matrix + glycerol
 6M post-OP  en bloc (3 teeth)  2 teeth: regeneration
17. Koylass, J.M., P. Valderrama, and J.T. Mellonig. (2012). “Histologic evaluation of an
allogeneic mineralized bone matrix in the treatment of periodontal osseous defects.” Int J
Periodontics Restorative Dent 32(4): 405-11.
 Puros mineralized human can- cellous bone allograft (MCBA)
 6M post-OP  en bloc (4 teeth)
 2 teeth: regeneration, 1 tooth: new connective tissue attachment, 1
tooth: junction epi.
(3) Tissue banking
18. (2001). "Tissue banking of bone allografts used in periodontal regeneration." J Periodontol
72(6): 834-838.
 wide variability exists in the ability of commercial preparations of
DFDBA to induce new bone  age of the donor, content of bone-
inductive factors in donor bone
19. Schwartz, Z., A. Somers, et al. (1998). "Ability of commercial demineralized freeze-dried
bone allograft to induce new bone formation is dependent on donor age but not gender." J
Periodontol 69(4): 470-478. (2014-D-23)
 Ability of DFDBA to induce new bone formation  age-dependent

IV. Xenograft

 New attachment apparatus


20. Nevins, M. L., M. Camelo, et al. (2003). "Evaluation of periodontal regeneration following
grafting intrabony defects with bio-oss collagen: a human histologic report." Int J
Periodontics Restorative Dent 23(1): 9-17.
 Bio-Oss Collagen alone; Bio-Oss Collagen & Bio-Gide
 En bloc resection post-op 9M  complete new attachment apparatus
21. Camelo, M., M. L. Nevins, et al. (1998). "Clinical, radiographic, and histologic evaluation of
human periodontal defects treated with Bio-Oss and Bio-Gide." Int J Periodontics
Restorative Dent 18(4): 321-331.
 Bio-Oss Collagen alone; Bio-Oss Collagen & Bio-Gide
 En bloc resection post-op 6-9M  new bone & cementum with inserting collagen fibers
V. Alloplast

 Long junctional epithelium


(1) BG
22. Nevins, M. L., M. Camelo, et al. (2000). "Human histologic evaluation of bioactive ceramic
in the treatment of periodontal osseous defects." Int J Periodontics Restorative Dent 20(5):
458-467.
 PerioGlas, Block biopsies post-op 7M or 12M (5 cases)
 long junctional epithelium with minimal new connective tissue
attachment
(2) HA
23. Horvath, A., et al. (2013). “Histological evaluation of human intrabony
periodontal defects treated with an unsintered nanocrystalline hydroxyapatite
paste.” Clin Oral Investig 17(2): 423-30.
 Nano-HA, 6 teeth
 7M  predominantly epithelial downgrowth
24. Sapkos, S. W. (1986). "The use of Periograf in periodontal defects. Histologic findings." J
Periodontol 57(1): 7-13.
 Block sections post-op 12M  Fibroblasts& collagen fibers // tooth
long axis
(3) TCP
25. Bowers, G. M., J. W. Vargo, et al. (1986). "Histologic observations following the placement
of tricalcium phosphate implants in human intrabony defects." J Periodontol 57(5): 286-
287.
 Re-entry surgery
 Bone and osteoid formation was observed around graft particles

Intrabony defect
I. Flap vs. graft only

(1) Autograft
 Auto > OFD
26. Froum, S. J., M. Ortiz, et al. (1976). "Osseous autografts. III. Comparison of osseous
coagulum-bone blend implants with open curetage." J Periodontol 47(5): 287-294.
 Auto  bone fill: 2.98* mm, re-entry depth: 0.76* mm
 OFD  bone fill: 0.66 mm, re-entry depth: 1.51 mm
 Auto = OFD
27. Renvert, S., S. Garrett, et al. (1985). "Healing after treatment of periodontal intraosseous
defects. III. Effect of osseous grafting and citric acid conditioning." J Clin Periodontol
12(6): 441-455.
 Citric acid conditioning only vs. Citric acid conditioning + autograft
 both 1mm CAL↑& PBL↑
(2) Allograft
 Allo > OFD
28. Flemmig, T. F., B. Ehmke, et al. (1998). "Long-term maintenance of alveolar bone gain
after implantation of autolyzed, antigen-extracted, allogenic bone in periodontal
intraosseous defects." J Periodontol 69(1): 47-53.
 DFDBA > OFD in CAL and PBL↑(SS.)
29. Laurell, L., J. Gottlow, et al. (1998). "Treatment of intrabony defects by different surgical
procedures. A literature review." J Periodontol 69(3): 303-313.
  NS. correlation btw IBD depth & CAL  ↑by OFD;  but significant correlation btw bone 
fill & defect depth.
  Significant correlation btw IBD depth & CAL↑ , bone fill 
   by OFD + bone & GTR.
  IBD depth ≧ 4mm benefit from GTR
(3) Xenograft
 Xeno (Bio Oss) = OFD
30. Slotte, C., B. Asklow, et al. (2012). "A randomized study of open-flap surgery of 32
intrabony defects with and without adjunct bovine bone mineral treatment." J Periodontol
83(8): 999-1007. (2015-73)/(2014-71)
 Post-OP 12M  improved periodontal conditions
 Gingival recession, probing depth reduction, gain in CAL, probing bone level: N.S.
 Radiographic defect depth change: BBM (3.4 – 2.3 mm) > OF (1.9 – 1.7 mm)*

(4) Alloplast
 BG > OFD
31. Sohrabi, K., V. Saraiya, et al. (2012). "An evaluation of bioactive glass in the treatment of
periodontal defects: a meta-analysis of randomized controlled clinical trials." J Periodontol
83(4): 453-464.
 15 studies: 12 for intrabony, 2 for furcation, 1 for intrabony & furcation
PD: 252 pts., 426 teeth; CAL: 264 pts., 438 teeth
BG vs. control: PD 0.52 mm*, CAL 0.60 mm*
BG vs. control limited to intrabony: PD 0.40 mm*, CAL 0.54 mm*
BG vs. OFD: PD 0.72 mm*, CAL 1.18 mm*
 BG is efficacious in the repair of periodontal intrabony defects
32. Park, J. S., J. J. Suh, et al. (2001). "Effects of pretreatment clinical parameters on
bioactive glass implantation in intrabony periodontal defects." J Periodontol 72(6): 730-
740.
 BG>OFD: PAL↑, BPD↓ (SS.)
33. Zamet, J.S., et al. (1997). “Particulate bioglass as a grafting material in the
treatment of periodontal intrabony defects.” J Clin Periodontol 24(6): 410-8.
 BG (Perioglas) vs. OFD
 Radiographic density & volume of defects treated: BG > OFD (SS.)
 PD↓, PAL↑  BG > OFD (NS)
34. Froum, S. J., M. A. Weinberg, et al. (1998). "Comparison of bioactive glass synthetic bone
graft particles and open debridement in the treatment of human periodontal defects. A
clinical study." J Periodontol 69(6): 698-709.
 BG vs. OFD: PD↓, CAL↑, Defect fill, Defect depth↓ (SS.)
 BG = OFD
35. Ong, M. M., R. M. Eber, et al. (1998). "Evaluation of a bioactive glass alloplast in treating
periodontal intrabony defects." J Periodontol 69(12): 1346-1354.
 OFD+BG vs. OFD  NS.
 OFD+BG vs. baseline: PD↓CAL↑, Defect fill (SS.)
 OFD vs. baseline: Defect fill (SS.)
 HA > OFD
36. Kenney, E. B., V. Lekovic, et al. (1985). "The use of a porous hydroxylapatite implant in
periodontal defects. I. Clinical results after six months." J Periodontol 56(2): 82-88.
 OFD + HA vs. OFD: PD↓, CAL↑, Defect depth↓(SS.)
37. Meffert, R. M., J. R. Thomas, et al. (1985). "Hydroxylapatite as an alloplastic graft in the
treatment of human periodontal osseous defects." J Periodontol 56(2): 63-73.
 Defect fill  OFD+HA: 66.89%*, OFD: 9.91%
II. Graft comparison

 DFDBA = FDBA
38. Rummelhart, J. M., J. T. Mellonig, et al. (1989). "A comparison of freeze-dried bone
allograft and demineralized freeze-dried bone allograft in human periodontal osseous
defects." J Periodontol 60(12): 655-663. (2014-D-6)
 6 M post-OP
 Osseous repair: DFDBA  1.7 mm (59%), FDBA 2.4 mm (66%)
 Mean clinical attachment gain: DFDBA  1.7 mm, FDBA  2.0 mm
39. Gothi, R., et al. (2015) “A comparative evaluation of freeze dried bone
allograft and decalcified freeze dried bone allograft in the treatment of
intrabony defects: A clinical and radiographic study.” J Indian Soc
Periodontol 19(4): 411-5.
 3M, 6M post-OP
 PD↓, RAL↑, defect area 
40. Ogihara, S. and D.P. Tarnow. (2014). “Efficacy of enamel matrix derivative with freeze-
dried bone allograft or demineralized freeze-dried bone allograft in intrabony defects: a
randomized trial.” J Periodontol 85(10): 1351-60.
 PD↓, CAL↑  EMD + FDBA ≒ EMD + DFDBA
 Allo (DFDBA) = Xeno (Bio Oss)
41. Richardson, C. R., J. T. Mellonig, et al. (1999). "Clinical evaluation of Bio-Oss: a bovine-
derived xenograft for the treatment of periodontal osseous defects in humans." J Clin
Periodontol 26(7): 421-428.
 Both ss. Improvement of PD, AL, bone fill, defect repair comparing to baseline
 Allo (FDBA) = Alloplast (HA)
42. Barnett, J. D., J. T. Mellonig, et al. (1989). "Comparison of freeze-dried bone allograft and
porous hydroxylapatite in human periodontal defects." J Periodontol 60(5): 231-237.
 FDBA > HA in PD↓, CAL↑, but ns in bone fill
 Allo (DFDBA) = Alloplast (HA)
43. Bowen, J. A., J. T. Mellonig, et al. (1989). "Comparison of decalcified freeze-dried bone
allograft and porous particulate hydroxyapatite in human periodontal osseous defects." J
Periodontol 60(12): 647-654.
 6M re-entry
 2.2 mm of bone repair with DFDBA and 2.1 mm with HA NS.
 Allo (DFDBA) = Alloplast (BG)
44. Lovelace, T. B., J. T. Mellonig, et al. (1998). "Clinical evaluation of bioactive glass in the
treatment of periodontal osseous defects in humans." J Periodontol 69(9): 1027-1035.
 6M re-entry
 DFDBA: PD 7.2mm; bot-crest 4.53mm, BG: PD 7.07mm; bot-crest
4.53mm  NS.
 Allo (FDBA) + Auto > Allo (FDBA)
45. Sanders, J. J., W. W. Sepe, et al. (1983). "Clinical evaluation of freeze-dried bone
allografts in periodontal osseous defects. Part III. Composite freeze-dried bone allografts
with and without autogenous bone grafts." J Periodontol 54(1): 1-8.
 FDBA/ABGs appear to offer significantly improved results in both
osseous regeneration and pocket reduction.

III. Membrane vs. graft

 Resorbable membrane = BG
46. Mengel, R., D. Schreiber, et al. (2006). "Bioabsorbable membrane and bioactive glass in
the treatment of intrabony defects in patients with generalized aggressive periodontitis:
results of a 5-year clinical and radiological study." J Periodontol 77(10): 1781-1787.
 Bone fill  BG > Resorbable memb.
 PD↓,CAL↑,Rec,crest↓  BG = Resorbable memb.
IV. Membrane + graft vs. graft

 Resorbable membrane
47. Hartman, G. A., R. M. Arnold, et al. (2004). "Clinical and histologic evaluation of anorganic
bovine bone collagen with or without a collagen barrier." Int J Periodontics Restorative
Dent 24(2): 127-135.
 PD↓, CAL↑, Recession  Bio-Oss collagen ≒ Bio-Oss collagen +
memb.
48. Yadav, V.S., et al. (2011) “Clinical evaluation of guided tissue regeneration combined with
autogenous bone or autogenous bone mixed with bioactive glass in intrabony defects.” J Oral Sci
53(4): 481-8.
 Collagen membrane + AG ≒ Collagen membrane +AG+BG > Collagen
membrane
 PD↓, CAL↑, Defect resolution
49. Chen, C.C., et al. (1995.) “Evaluation of a collagen membrane with and without bone
grafts in treating periodontal intrabony defects.” J Periodontol 66(10): 838-47.
 PD, AL, GR, defect fill, crestal bone resorption, GI, PI, mobility
 Collagen membrane + DFDBA ≒ Collagen membrane
50. Camelo, M., M. L. Nevins, et al. (1998). "Clinical, radiographic, and histologic evaluation of
human periodontal defects treated with Bio-Oss and Bio-Gide." Int J Periodontics
Restorative Dent 18(4): 321-331.
 Bio-Oss+Bio-Gide vs. Bio-Oss
 Bio-Oss+Bio-Gide  Regenerative effect more pronounced
 Non-resorbable membrane
51. Guillemin, M. R., J. T. Mellonig, et al. (1993). "Healing in periodontal defects treated by
decalcified freeze-dried bone allografts in combination with ePTFE membranes (I). Clinical
and scanning electron microscope analysis." J Clin Periodontol 20(7): 528-536.
 Bone fill: DFDBA + membrane (71%) > DFDBA(58%) (NS.)
 REC & KG loss: DFDBA + membrane > DFDBA (58%) (SS.)
52. Kilic, A. R., E. Efeoglu, et al. (1997). "Guided tissue regeneration in conjunction with
hydroxyapatite-collagen grafts for intrabony defects. A clinical and radiological evaluation."
J Clin Periodontol 24(6): 372-383
 PD↓, CAL↑, BL↑  e-PTFE memb.+ HAC > HAC alone (NS.)
53. Kim, C. K., E. J. Choi, et al. (1996). "Periodontal repair in intrabony defects treated with a
calcium carbonate implant and guided tissue regeneration." J Periodontol 67(12): 1301-
1306.
 PD↓, CAL↑, BL↑  Improvement in GTR with or without CC (SS.)

V. EMD

54. Leknes, K.N. (2009). “Enamel matrix derivative versus bioactive ceramic filler in the
treatment of intrabony defects: 12-month results.” J Periodontol 80(2): 219-27.
 Proximal CAL↑: BCF > EMD (SS.)
55. Yilmaz, S., et al. (2010). “Healing of two and three wall intrabony
periodontal defects following treatment with an enamel matrix
derivative combined with autogenous bone.” J Clin Periodontol 37(6):
544-50.
 1Y post-OP
 EMD+AB > EMD: PPD↓, RAL↑, PBL↑ (SS.)
56. Aspriello, S.D., et al. (2011). “Comparative study of DFDBA in combination
with enamel matrix derivative versus DFDBA alone for treatment of
periodontal intrabony defects at 12 months post-surgery.” Clin Oral
Investig, 2011. 15(2): 225-32.
 1Y post-OP
 EMD + DFDBA > DFDBA: PD↓, CAL↑, Bone fill (SS.)

VI. PRP + graft vs. graft

57. Garg, K., et al. (2017). “Clinical evaluation of platelet rich plasma when
combined with an alloplastic bone graft material in the treatment of intrabony
periodontal defects.” Saudi Journal of Oral Sciences 4(1): 33
 PD↓, CAL↑, defect fill  PRP + HA/β-TCP > saline + HA/β-TCP
58. Demir, B., D. Sengun, and A. Berberoglu (2007). “Clinical evaluation of
platelet-rich plasma and bioactive glass in the treatment of intra-bony
defects. “J Clin Periodontol 34(8): 709-15.
 Unigraft®
 PRP + BG  no additional benefit in PD↓,, CAL↑ & defect fill.

Particle size

 No related
(1) DFDBA
59. Fucini, S. E., G. Quintero, et al. (1993). "Small versus large particles of demineralized
freeze-dried bone allografts in human intrabony periodontal defects." J Periodontol 64(9):
844-847. (2015-72)/ (2014-67)/ (2013-86)
 250-500μ vs. 850-1000μ: bony fill  NS.
(2) TCP
60. Jung, U. W., S. Y. Choi, et al. (2006). "The effect of varying the particle size of beta
tricalcium phosphate carrier of recombinant human bone morphogenetic protein-4 on
bone formation in rat calvarial defects." J Periodontol 77(5): 765-772.
 50-150 µm vs. 150-500 µm: defect closure, new bone area, augmented
area  NS.
 Related
(1) Autograft
61. Zaner, D. J. and R. A. Yukna (1984). "Particle size of periodontal bone grafting materials."
J Periodontol 55(7): 406-409.
 Bone blend: 100 x 200 µm, hand chisel: 780 x 1560 µm, high speed: 200 x 350 µm,
low speed: 300 x 530 µm
(2) FDBA
62. Schepers, E. J. and P. Ducheyne (1997). "Bioactive glass particles of narrow size range
for the treatment of oral bone defects: a 1-24 month experiment with several materials and
particle sizes and size ranges." J Oral Rehabil 24(3): 171-181.
 425-800 µm, 300-355 µm, 212-300 µm, 100-710 µm
 300-355 µm BG  superior response
(3) BG
63. Felipe, M. E., P. F. Andrade, et al. (2009). "Potential of bioactive glass particles of different
size ranges to affect bone formation in interproximal periodontal defects in dogs." J
Periodontol 80(5): 808-815.
 300-350 µm vs. 90-710 µm
 Smaller particle faster resorption & substitution by new bone