[Downloaded free from http://www.jicdro.org on Monday, November 18, 2019, IP: 182.66.13.

114]

Dynamics of bone graft healing around implants

Narayan Venkataraman, Sumidha Bansal1, Pankaj Bansal2, Sarita Narayan3
Department of Oral Pathology, Oxford Dental College, 3Department of Periodontics, Rajiv Gandhi Dental College, Banglore, Karnataka, 1Departments of
Periodontics and 2Oral and Maxillofacial Surgery, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India

ABSTRACT
Bone is a highly dynamic tissue undergoing constant adaptation to the mechanical and metabolic
demands of the body by bone regeneration and repair. In order to facilitate or promote bone healing, bone
grafting materials have been placed into bony defects. The advantages of using bone grafts are space
maintenance, inhibiting collapse of defect and acting (at least) as osteoconductive scaffold (though they
can be osteoinductive or osteogenic also). After their successful use around teeth afflicted by periodontal
disease, in ridge augmentations, and in socket preservations, we now look forward to their use around
implants during the osseointegration phase.
A few questions arise pertaining to the use of bone grafts along with implants are whether these are
successful in approximation with implant. Do they accelerate bone regeneration? Are all defects ultimately Access this article online
regenerated with new viable bone? Is the bone graft completely resorbed or integrated in new bone? Does Website: www.jicdro.org
the implant surface characteristic positively affect osseointegration when used with a bone graft? What DOI: 10.4103/2231-0754.172930
type of graft and implant surface can be used that will have a positive effect on the healing type and time? Quick Response Code:
Finally, what are the dynamics of bone graft healing around an implant? This review discusses the cellular
and molecular mechanisms of bone graft healing in general and in vicinity of another foreign, avascular
body, namely the implant surface, and further, the role of bone grafts in osseointegration and/or clinical
success of the implants.

Key words: Bone graft healing, endosseous dental implants, immediate implant placement,
osseointegration, sinus lift

INTRODUCTION The understanding of science of bone grafting is continuously

High success rates of dental rehabilitation with endosseous
implants have prompted its use in more challenging clinical
situations, the most common being insufficient bone volume
at recipient sites. These days implants are regularly being
accommodated in treatment plans, to be further placed in
extraction sockets as a part of immediate implant placement,
or in areas requiring sinus lift to increase the local bone stock.
Similarly, the loading schedule of implants is increasingly
getting shortened to weeks, days or even hours.[1] These
changes have been possible though evolution of knowledge
in different fields such as surgical procedures related to
implants, implant surface and design characteristics, and
the concepts and mechanisms of periimplant bone healing.
developing with the principles of cellular and molecular
biology being incorporated in osseous healing. With the
increased demand of use of bone grafting in implantology,
a review of biologic events of healing of various bone grafts
around implant surface seems essential.
The first documented xenograft was done by Job van Mee’kren
in 1600.[2] Allografting was introduced by Sir William MacEwen
This is an open access article distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 3.0
License, which allows others to remix, tweak, and build upon the
work non-commercially, as long as the author is credited and the
new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

Address for correspondence:

Dr. Sumidha Bansal, Cite this article as: Venkataraman N, Bansal S, Bansal P, Narayan S.
363, Sector 19, Faridabad, Haryana, India. Dynamics of bone graft healing around implants. J Int Clin Dent Res Organ
2015;7:40-7.
E-mail: sumidhabansal@yahoo.in

S40 © 2015 Journal of the International Clinical Dental Research Organization | Published by Wolters Kluwer - Medknow
[Downloaded free from http://www.jicdro.org on Monday, November 18, 2019, IP: 182.66.13.114]
Narayan, et al.: Healing of bone grafts around implants
in 1879.[3] The physiological properties of osteogenesis,
osteoconduction, and osteoinduction possessed by bone
grafts is one of the most important factors that affect the
dynamics of bone graft healing. While osteogenesis is the
ability of graft to produce new bone owing to the presence
of viable osteoprogenitor/osteogenic precursor cells,
osteoinduction is the ability of the graft to induce stem cells
to differentiate into mature bone cells owing to the presence
of bone growth factors. Osteoconduction is just a physical
property that enables a graft to serve as a scaffold and allow
the ingrowth of neovasculature and infiltration of osteogenic
precursor cells into the graft site.[4]
Several local factors that influence graft incorporation
positively are good vascular supply at graft site, large surface
area, mechanical stability and loading, growth factors, and
electrical stimulation; while radiation, bone disease, infection,
mechanical instability, and denervation affect it negatively.[5]
A major factor when considering a bone graft material is the
aim of the surgeon regarding repair or regeneration. Repair
is the replacement of a part with something that is physically
but not biologically or physiologically similar to the original
structure, and regeneration is natural renewal of a structure,
produced by growth and differentiation of new cells and
intercellular substances to form new tissues or parts in all
ways identical to what was lost.[6]
Concept of osseointegration
Endosseous wound healing comprises of stages of hematoma
formation, clot resolution, and osteogenic cell migration,
which lead to the formation of new bone. The osseous healing
phase consists of:
1. Osteoconduction that relies on recruitment and migration
of osteogenic cells to implant surface.
2. de novo bone formation.
3. Bone remodeling.
Osseointegration was defined by Brånemark[7] as a direct
structural and functional connection between ordered living
bone and the surface of a load-carrying implant. Osborn and
Newesley[8] proposed the concept of contact or distance
osteogenesis. While the former involves de novo bone formation
directly on the implant surface, the latter is formation of new
bone on the surfaces of existing periimplant bone. Immediately
after implantation serum proteins adhere, and during the first
three days mesenchymal cells attach and proliferate. Osteoid
formation and matrix calcification occur by 6 days and 14 days
respectively. Remodeling starts by 3 weeks.[9]
Rationale of using bone graft with implants
Bone grafts are used along with implants in procedures such
as sinus lift, immediate implant placement in extraction
sockets, and ridge augmentation. Bone grafts serve as
Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
support for the sinus membrane to prevent its collapse and
hence maintain space, and may at the same time promote
bone formation.[10]
According to Schmitz and Hollinger,[11] a critical-size defect
does not heal spontaneously without placement of the
graft during the healing period. Thus bone augmentation
is recommended in the gaps wider than 2 mm left between
the socket wall and the coronal neck of the implant during
immediate implant placement. All grafts have their unique
properties owing to which they are usable in different
conditions. Autogenous grafts, although the gold standard
in reconstructive surgery, have the disadvantages of donor
site morbidity and limited available bone volume. Dense,
crystalline hydroxyapatite (HA) is used in the denture
support region to maintain contour and volume and not in
socket preservation as it is almost thrice as hard as bone
and nonresorbable. While β-tricalcium phosphate (β-TCP) is
considered useful in a contained type defect owing to the
favorable substitution rate in a standardized bone defect,
its usefulness in onlay grafting and as volume expander
around autogenous onlay blocks is questionable due to
the same reason. Anorganic bovine bone (ABB) shows
osseous integration in mature bone but without evidence
of substitution of graft particles, thus showing partial
nonresorbability.[12] Hence the choice of graft material is
based on its application and macromolecular and biochemical
profile.
Structure and biochemical properties of different
grafts
Autografts
These contain properties of osteoinductivity [due to bone
morphogenetic protein (BMP)], osteoconductivity (bone
mineral and collagen), and osteogenicity (osteoblastic
cells, preosteoblastic precursor cells). Insufficient amount,
morbidity, and cost are the drawbacks. Autografts can be of
three types: bone marrow, cancellous, and cortical.[5]
Allografts
These are the graft materials harvested from different
individuals of the same species and require processing in
order to lessen antigenicity and disease transfer. They are
osteoconductive and osteoinductive. Immunogenicity is
decreased when grafts are deep-frozen and even more when
freeze-dried.[5]
Xenografts
These are obtained from the bone of individuals of other
species, their composition and biomechanical properties
being almost similar to bone. Two illustrations of xenografts
used in dentistry are i) coral-derived bone substitutes
having geometry similar to that of human cancellous
S41
[Downloaded free from http://www.jicdro.org on Monday, November 18, 2019, IP: 182.66.13.114]
Narayan, et al.: Healing of bone grafts around implants
bone interconnected macropores (200-600 µm) and ii)
demineralized bovine bone grafts, biocompatible and
osteoconductive. There are two types of demineralization:
a. High temperatures and
b. Chemical extraction of calcium and other minerals.[13]
Alloplastic materials
Calcium phosphates
These are synthetic osteoconductive materials with composition
similar to bone. They are HA (calcium/phosphate: 1.67) and
β-TCP: (calcium/phosphate: 1.5). Due to this biochemical
difference in the composition, β-TCP resorbs faster and is
generally replaced by natural bone in a 3-24 month period
depending on the type of bone. HA resorption is slow/very slow
(years, decades). Calcium phosphates are available as porous
blocks or granules. The molecular mechanism of action in vivo
is not yet defined. Regulation of bioactivity is based only on the
HA/TCP ratio. The mechanism of resorption involves chemical
dissolution and osteoclastic resorption.[14]
Bioactive glasses
Bioactive glasses are a group of synthetic silica-based
bioactive materials with unique bone-bonding properties
first discovered by Hench.[15] They are composed of calcium
and phosphates along with sodium and silicon salts that
promote bone mineralization. They are available as granules
or sintered porous blocks, fibers, and woven structures;
they are osteopromotive and form chemical bonding with
ongrowing new bone. They induce high local bone turnover.
Bioactive glasses have different rates of bioactivity and
resorption rates, which can be regulated by modifying the
chemical composition. The most rapid bonding is achieved
with bioactive glasses containing 45-52% in weight of SiO2
(silicon dioxide). They are found to be superior to calcium
phosphates owing to the relatively quick rate of reaction with
host cells, ability to bond to collagen found in connective
tissue, and ability to bond to hard and soft tissue. The
mechanism of resorption is through chemical dissolution.
They are also known to inhibit bacterial growth in vitro,
depending on chemical composition.[14]
Hard tissue replacement (HTR) polymer
It is a microporous composite with calcium hydroxide graft
surface. It is slow-resorbing, healing by osteoconduction.[16]
Cellular and molecular events after bone grafting
Autograft
An autograft is very osteogenic, easily revascularized, and
rapidly incorporated. It lacks mechanical strength, but
this is balanced by early production of new bone. Active
bone formation and resorption occurs by 4 weeks of graft
placement. In the secondary phase, osteoblasts lay down
seams of the osteoid that surrounds the core of dead
S42 Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
bone. The most important difference between cortical and
cancellous grafts is in the rate of vascularization and degree of
osteoinduction, which is less in the former due to the dense
architecture and lower number of endosteal cells.
For osseointegration of the graft to proceed successfully,
the host tissue must have sufficient vascularity to diffuse
nutrients to the cells before revascularization occurs and bud
new capillaries into the graft to create a more permanent
vascular network. Osteogenesis is activated by surgical
trauma, which releases a large quantity of cytokines with
osteogenic effects, such as BMP-2, platelet-derived growth
factor (PDGF), tumor growth factor-β (TGF-β), and vascular
endothelial growth factor (VEGF). This repair reaction with
the formation of woven bone originates from the bone
walls subjected to trauma, which stimulates the osteoblastic
precursors, due to exposure of the bone matrix, and also acts
as a solid wall for attachment of the osteoblasts. Placement of
the graft with autogenous endosteal osteoblasts embedded
within creates a biochemical environment at the recipient
site that is hypoxic (O2 tension of 3-10 mmHg), acidotic (pH
4.0-6.0), and rich in lactate. Osteoblasts survive the first
3-5 days after transplant to the host site because of their
surface positioning and ability to absorb nutrients from
recipient sites. The platelets trapped in the clot degranulate
within hours and release the PDGF depending on the oxygen
gradient of the graft incorporated, with mitogenesis of
osteocompetent cells and angiogenesis of the capillaries
at the recipient site. By 3 days, budding capillaries are seen
outside the surface of the graft, which penetrate the graft
and form a vascular network by 10-14 days. PDGF is then
replaced by macrophage-derived growth factor (MDGF) and
other mesenchymal tissue stimulators from the TGF-β family.
During the initial week of graft placement only minimal
osteoid deposition is noted, but after established vascular
network formation, due to abundant oxygen and nutrient
availability, acceleration in bone healing is noticeably seen.
Consolidation of the graft during the first 3-4 weeks by
the chemical and cellular phase activity of bone healing
enables formation of a scaffold framework for initiation
of the osteoconductive phase of healing. This phase of
bone healing with cellular regeneration is referred to as
phase-I bone regeneration, where disorganized woven bone
similar to fracture callus is formed. The addition of certain
growth factors to the material, such as PDGF, recombinant
human BMP (rhBMP), TGF-β, and insulin growth factor (IGF),
increases the speed and quantity of bone regeneration.
Phase-I bone undergoes resorption and remodeling until its
eventually replacement by less cellular, more mineralized and
structurally organized phase-II bone forms. Phase-II bone is
initiated by osteoclasts that arrive at the graft site through
the newly developed vascular network. This bone forms as in
[Downloaded free from http://www.jicdro.org on Monday, November 18, 2019, IP: 182.66.13.114]
Narayan, et al.: Healing of bone grafts around implants
response to demands placed by the jaw and graft working in
function. This bone develops into mature Haversian systems
and lamellar bone that can withstand normal shear forces
from the jaw and impact compressive forces that are typical
of dentures and implant-supported prostheses.[16]
Allograft
Cancellous allograft is a poor promoter of bone healing
compared to autograft. Allografts are incorporated faster
than their cortical counterparts. They act as a scaffold onto
which host bone is laid. They are never completely resorbed
and thus remain entrapped in the host bone.[5]
Bone formation starts from the defect walls and progresses
toward the center. Along the interface, spots of apparent
mineral deposition arise between the mineralized woven bone
and the demineralized matrix [demineralized freeze-dried
bone allografts (DFDBA)], which are spherical and cylindrical
precipitates having diameters 3-5 pm at around 4 weeks, as
seen in an animal study on minipigs.[17] Recalcification of DFDBA
is restricted to areas where new mineralizing bone matrix is
deposited on their surface. Sites where the particle surface
faces the marrow tissue stay nonmineralized. At 12 weeks, bone
formation spreads over the whole defect area, but it still includes
a considerable amount of the grafted material and represents
a composite of partially recalcified DFDBA, woven bone, and
most superficially, lamellar bone deposits. Remodeling starts
and osteoclastic resorption extends along bony surfaces as well
as on recalcified DFDBA particles [Figure 1a and b].
Xenograft
Coral-derived HA
According to the study on minipigs mentioned above,[17] at
4 weeks the rather compact coral-derived HA granules are
evenly dispersed in the defect sites and are invaded by dense
fibrous tissue and bony trabeculae. Thin layers of woven
bone cover the outer surface of the granules as well as the
a b
Figure 1: (a) histologic sections of grafted bone 9 months after grafting with
alloplast graft material. graft particles (GP) are surrounded by vital newly formed
bone (NB) and bone marrow (BM). lining osteoblasts (OB) are clearly observed at
the interface (hematoxylin and eosin stain; original magnification, 40×) (b) image
processing of the biopsy in identifies new bone (red), graft particles (blue), and
connective tissue (yellow)[37]
Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
lining of their pores. At 12 weeks, the bony filling of pores
and interspaces becomes much denser. Half of the newly
formed bone still consists of woven bone, reinforced by
parallel-fibered and lamellar bone. The overall remodeling
activity, however, is low. At 24 weeks, the composite of
coralline filler and bony regenerate seems the same except
for the maturity of the bone structure. Enhanced remodeling
replaces much of woven bone with lamellar bone but is
restricted to the bone compartment, not extending into the
adjacent coralline material [Figure 2a and b].
ABB
Defects grafted with ABB show newly formed bone, although
smaller and less mature than with autograft, at 4 weeks in
minipigs.[12] The stark difference when compared to other grafts is
its stability and resistance to resorption. At 8 weeks, too, it shows
osseous integration that creates a dense, hard tissue network,
which provides biological support to loaded dental implants that
is comparable to or even in excess of native bone.[18]
Alloplast
Calcium phosphate-based graft materials
Several calcium phosphate parameters can affect cellular
activity: dissolution, composition, topography, surface
energy. After colonization of the substrate by monocytes/
macrophages that are recruited during the inflammatory
reaction following surgery, osteoclasts are responsible for
bone resorption. They degrade calcium phosphate ceramics
in a similar way to bone mineral: osteoclasts attach firmly
to the substrate-sealing zone. In the center of this sealing
zone, they secrete H+ leading to a local pH = 4-5. In vivo,
osteoclasts participate partially in the degradation of calcium
phosphate ceramics into the minerals available for the bone
regeneration by providing the space required for bone
formation.[19] Defects grafted with β-TCP in minipigs showed
newly formed bone throughout the defects at 4 weeks,
but the amount and maturity was less than that seen with
autograft. Graft particles had almost disappeared, also, and
were substituted by bone. At 8 weeks complete trabecular
bone filling is seen, with β-TCP almost resorbed by dissolution
rather than cellular resorption.[12]
a b
Figure 2: image showing μCT in which the substitute material HA (grey) is
completely surrounded by bone (green)[36]
S43
[Downloaded free from http://www.jicdro.org on Monday, November 18, 2019, IP: 182.66.13.114]
Narayan, et al.: Healing of bone grafts around implants
Bioactive glasses
Undifferentiated mesenchymal tissue surrounds the bioactive
glass microspheres during the first 2 weeks of primary bone
response and differentiate into an immature woven-bone
structure. Histomorphometric analysis has revealed that
bioactive glass filling induces a constant time-related increase
of new bone. Formation of the silicon-rich layer is known to
be a crucial stage in bone bonding as it acts as a template for
calcium phosphate precipitation. The calcium phosphate layer
then directs new bone formation together with absorbing
proteins. The extracellular proteins attract macrophages,
and mesenchymal stem cells and osteoprogenitor cells with
generation and further crystallization of matrix.[14] The results
of a study by Mahesh et al.[20] suggest that ridge preservation
using a putty calcium phosphosilicate alloplastic (CPS) bone
substitute demonstrates more timely graft substitution and
increased bone regeneration when compared to an ABB
xenograft. Moreover, implant stability seems to be higher
in sockets grafted with CPS, as determined by periotest,
compared to nongrafted sites, which suggests enhancement
in bone quality for implant placement[21] [Figure 3a and b].
Effects of various bone grafts on osseointegration
The type of bone graft used does not seem to be associated
with success of the procedure as well as implant survival
according to a systematic review pertaining to the
determination of any advantage of using autogenous graft
over bone substitutes in sinus floor augmentation. The
results of this review are not changed even by considering
length of the healing period, simultaneous or staged implant
placement, sinusitis or graft loss.[22]
In a human randomized control trial (RCT),[23] comparing
alloplast (synthetic biphasic calcium phosphate, i.e., BCP)
and xenograft (deproteinized bovine bone, i.e., DBB),
new bone formation, and bone-to-implant contact around
microimplants with sand-blasted, acid-etched surface was
found to be equivalent between sinuses augmented with
either material.
Figure 3: image showing immunohistochemical technique for studying bone
healing. immuno-labeled proteins (arrows) such as (osteoprotegerin) OPG;
receptor activator of nuclear factor kB (RANKL); alkaline phosphatase (ALP);
osteopontin (OPN); vascular endothelial growth factor (VEGF); tartrate-resistant
acid phosphatase (TRAP); type 1 collagen (COL I); and osteocalcin (OC)[38]
S44
Nortan et al.[24] have studied the 3-year clinical outcome
of implants placed in bioactive glass-grafted sites. They
concluded that although a long healing time is required to
achieve even a small amount of new bone incorporation
into the graft histologically, there is still a high rate of
osseointegration that is achieved, resulting in implant
success. It is likely that initial integration comes from native
bone in contact but also that the graft material does not
prohibit osseointegration and does conduct new bone
growth, though quite slowly.
Polyzois et al.[25] studied the effect of gap width and graft
placement on bone healing around implants in dogs and
concluded that wider gaps (≥2.37 mm) around implants
without bone graft give less favorable histological results at
short time intervals (4 months) than do gaps grafted with
xenograft (ABB), which showed more bone implant contact
(BIC) and more bone inside the threads. Choo et al.[26] in
their 4-week animal (sheep) study using resorbable barrier
membrane, examining the effect of β-TCP with recombinant
human platelet-derived growth factor BB (rhPDGF-BB)
(300 μg/mL) and β-TCP alone in circumferential critical size
(3.25 mm) defects on bone healing, found out that the
former enhanced bone regeneration almost twice as much,
while the latter, although maintaining space and preventing
collapse of soft tissue, showed inhibition in bone healing at
the end of the study. Moreover, it was also suggested that the
rate of resorption of β-TCP was retarded in the presence of
rhPGDD-BB and that a greater amount of new bone formation,
both from the bottom of the defect as well as the lateral walls
(that too in contact with implant surface) was seen when a
combination graft was used.
Role of implant surface in osseointegration
Among the implant-related factors, importance is given to
material, shape, surface topography, and chemistry.[27]
Topography
This is achieved by additive (plasma spraying, HA coating,
magnetron sputter, calcium phosphate coatings, biologic
molecules) and subtractive methods (abrasion through
blasting, grit or sandblasting with aluminous oxides, blasting
and etching with hydrogen sulfate or chloride). Other
treatments are anodizing, cold working, and sintering and
bead compaction. Surface energy, topography, composition,
and roughness are supposed to be important factors
governing bone formation and apposition.
Chemistry
Charge affects the hydrophilic and hydrophobic properties
of a surface. A hydrophilic surface is assumed to be more
favorable in the initial stages of osseointegration. Topography
also alters its chemistry. Turned surfaces are found to have
Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
[Downloaded free from http://www.jicdro.org on Monday, November 18, 2019, IP: 182.66.13.114]
Narayan, et al.: Healing of bone grafts around implants
more carbon and less titanium than roughened ones and acid
etching removes most of the carbon contaminant.
Both iliac bone marrow-grafting and demineralized bone
matrix (DBM) have been shown to enhance biological fixation
in porous implants. Among different pore sizes, pore size
above 80 μm is associated with improved bone ingrowth in
both HA and tricalcium phosphate materials. Bone allograft,
bone graft substitutes, and biological coatings have been used
to induce osseointegration.[28] Calcium phosphate ceramics not
only increase implant surface but also favor platelet adhesion
activation and fibrin binding by increasing protein adsorption.
Several growth factors such as BMPs, including BMP-2 and BMP-7
[also known as osteogenic protein-1 (OP-1)], PDGF, insulin-like
growth factor 1 (IGF-1), and other biologic coatings such as
collagen and extracellular matrix proteins, including fibronectin
and vitronectin, have been used to enhance osseointegration.
Rough surface implants yield higher survival rates than
machined surface implants when placed in grafted sinuses.[29]
Telleman et al. compared nanotite (dual acid-etched surface
modified with nanometer-sized calcium phosphate) and
osseotite (dual acid-etched surface) implant surfaces in
humans and demonstrated that endosseous healing in the
former was superior to that in the latter in native bone,
suggesting that the more complex nanotopography and/or
CaP deposits may lead to a better osteogenic process but
not in the autograft area, which they attributed to slower
remodeling process of graft and the shorter study period
of 3 months.[30] Menicucci et al. presented similar results in
his 12-month human study with ABB graft, the result being
ascribed to clot detachment from an inflexible implant surface
in the grafted area.[31] Moreover, strain signals responsible
for biomineral formation were missing in this area. Schuler
et al.[32] described in their 4-week dog study maximum
bone-to-implant BIC in 1-mm marginal defects (5 mm deep)
around AO implants (i.e., porous oxide surface prepared by
anodic oxidation) with autograft as compared to T implants
(turned surface) with autograft and even surpassed the
effect of AO surface alone. The highest point of the first BIC
was also seen in the AO + autograft group. This shows that
the effect of the surface can be enhanced by bone grafting.
Histologically the researchers showed the presence of new
formed bone surrounding the nonvital bone graft particles
and these (nonvital bone) particles were never found in
contact with the implant surface. Apart from histological
determination of BIC, cytodetachment technology might
represent a new parameter to judge implant surface
properties as it calculates the force required to detach
osteoblasts from different implant surfaces.[33]
Thus it may be concluded that surfaces considered superior
Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
for osseointegration show conflicting results in terms of
osseointegration in the presence of a bone graft.
Study methods of bone healing
Histological and histomorphometric analysis
of graft healing
Histological analysis gives the qualitative data regarding the
bone healing, while histomorphometric analysis focuses on the
quantitative data. Hockers et al.[34] performed a histological and
histomorphometric analysis of new bone formation in large
bone defects (4 mm apicocronally, 6 mm both mesiodistally
and buccolingually) around implants in beagle dogs using
bioresorbable membrane along with xenograft or autograft.
After 4 months they concluded that both the graft materials
appeared to be integrated equally well in regenerating bone,
with no clinically or statistically significant differences in terms
of vertical bone regeneration, new bone-to-implant contact,
area density of bone near the graft, and bone-to-graft contact.
No contact was seen between grafts and implant surface,
and only a minimal part of regenerated bone was in contact
with implant. In another, 8-week-long study by Jensen et al.[12]
on minipigs, it was seen that both ABB and β-TCP seem to
decelerate bone regeneration as compared to autograft in
the early healing phase, but finally all defects regenerate with
newly formed bone and developing bone marrow.
Radiographic
Technetium-99 scan
99m
Tc-labeled diphosphonates [technetium-99m-methyl
diphosphonate ( 99m Tc-MDP) and technetium-99m-
hydroxymethylene diphosphonate ( 99m Tc-HMDP)] and
fluorine-18 sodium fluoride ( 18 F-NaF) are essentially
markers of both bone perfusion and bone turnover. After
intravenous administration, the principal uptake mechanism
of bone-seeking radiotracers involves adsorption onto or into
the crystalline structure of HA. 99mTc-MDP undergoes protein
binding in blood, which increases over time from around 25%
at injection to about 50% at 4 h after injection. Only unbound
tracer will be available for bone uptake. The mechanism of
binding of extravascular 99mTc diphosphonates to bone is
due to physicochemical adsorption (chemisorption) to the
HA structure of bone tissue.[35]
Microcomputed tomography (μCT)
μCT is a nondestructive radiographic procedure that provides
three-dimensional (3D) radiographs of hard tissues with a
spatial resolution of up to 6 × 6 × 6 μm2. As μCT has been
used successfully to characterize the 3D structure of bone
with morphometric precision comparable to that of classic
histomorphometry, μCT is also suitable for evaluation of the
remodeling of bone substitute material after healing in the
human jaw.[36]
S45
[Downloaded free from http://www.jicdro.org on Monday, November 18, 2019, IP: 182.66.13.114]
Narayan, et al.: Healing of bone grafts around implants
Immunohistochemical staining
Immunohistochemistry (IHC) is a widely used biological
technique that combines anatomy, physiology, immunology,
and biochemistry. Developed from the antigen-antibody binding
reaction, HC can be considered as a method that visualizes
distribution and localization of specific antigen or cellular
components in separated tissues, or tissue sections.
Major components in a complete IHC experiment:
1. Primary antibody binds to specific antigen;
2. The antibody-antigen complex is formed by incubation
with a secondary, enzyme-conjugated antibody;
3. With presence of substrate and chromogen, the enzyme
catalyzes to generate colored deposits at the sites of
antibody-antigen binding.
In graft healing analysis, antibodies generated against
growth factors in the bone and specific cell receptors for
bone remodeling are impregnated into the core sample of
the bone to be analyzed. Later, these antibodies combine
with their specific antigen and form a complex that can be
illustrated under the microscope with the help of chromogen
impregnated in the antibody.[37]
CONCLUSION
Perusal of the literature reveals many limitations pertaining to
the subject being reviewed. According to long-term studies on
implants (staged placement) in grafted bone, incorporation
of nonvital, non- or slow-resorbing particles may not make a
difference in their clinical success, although studies done on
fully resorbable materials support earlier placement of dental
implants. As far as immediate implant placement is concerned,
most of the results are from animal studies, which have to be
applied with caution to human beings. These studies do provide
histological and histomorphometric evidence of new bone
formation, but do not render any information about the strength
of shear forces between implant and new bone containing
different graft materials. Moreover, turnover rates of various graft
materials such as DBB mineral and autogenic transplanted bone
are presently not known and need to be determined in future
studies. Furthermore, the biologic responses to the physical
nature of different implant surfaces may affect grafting materials
differently. Histologic studies describing bone graft healing in
the vicinity of immediately placed as well as immediately loaded
implants are also lacking. More studies are required comparing
different implant surfaces with the same graft materials to see
the actual effect of surface on bone graft healing.
A better understanding of the complex biological events
occurring at the bone/implant interface continues to develop
and will lead to improved, biologically driven strategies for
endosseous implants.
S46 Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Davies JE. Understanding peri-implant endosseous healing. J Dent
Educ 2003;67:932-49.
2. Meek’ren JJ. Observations Medico Chirurgicae. Amsterdam, The
Netherlands: H and T Boon; 1632. p. 6.
3. Macewen W. Observation concerning transplantation of bone:
Illustrated by a case of interhuman osseous transplantation
whereby over two thirds of the shaft of a humerus was restored.
Proc R Soc London 1881;32:232-47.
4. Kalfas IH. Principles of bone healing. Nuerosurg Focus 2001;10:1-4.
5. Khan SN, Cammisa FP Jr, Sandhu HS, Diwan AD, Giradi FP, Lane JM.
The biology of bone grafting. J Am Acad Orthop Surg 2005;13:77-86.
6. Horowitz RA, Leventis MD, Rohrer MD, Prasad HS. Bone grafting:
History, rationale, and selection of materials and techniques.
Compend Contin Educ Dent 2014;35(Suppl):1-7.
7. Branemark PI, Zarb GA, Albrektsson T. Tissue Integrated
Prostheses: Osseointegration in Clinical Dentistry. Chicago:
Quintessence; 1985. p. 11.
8. Osborn JF, Newesly H. Dynamics aspects of the implant-bone
interface. In: Heimke G, editor. Dental Implants-Materials and
Systems. Munich: Carl Hanser; 1980. p. 111-23.
9. Schwartz Z, Boyan BD. Underlying mechanisms at the bone-
biomaterial interface. J Cell Biochem 1994;56:340-7.
10. Pettinicchio M, Sammons R, Caputi S, Piattelli A, Traini T. Bone
regeneration in sinus augmentation procedures with calcium
sulphate. Microsturcture and microanalytical investigations. Aust
Dent J 2012;57:200-6.
11. Schmitz JP, Hollinger JO. The critical size defect as an experimental
model for craniofacial nonunions. Clin Orthop Rel Res 1986;299-308.
12. Jensen SS, Broggini N, Hjørting-Hansen E, Schenk R, Buser D.
Bone healing and graft resroption of autograft, anorganic
bovine bone and beta-tricalcium phosphate. A histologic and
histomorphometric study in the mandibles of minipigs. Clin Oral
Implants Res 2006;17:237-43.
13. Jensen SS, Bosshardt DD, Buser D. Bone grafts and bone
substitute materials. In: Buser D, editor. 20 Years of Guided
Bone Regeneration in Implant Dentistry. Chicago: Quintessence
Publishing; 2009. p. 1-96.
14. Välimäki VV, Aro HT. Molecular basis for action of bioactive
glasses as bone graft substitute. Scand J Surg 2006;95:95-102.
15. Hench LL, Splinter RJ, Allen WC, Greenlee TK. Bonding
mechanisms at the interface of ceramic prosthetic materials.
J Biomed Mater Res Symp 1971;2:117-41.
16. Garg AK, Bone Biology, Harvesting, and Grafting for Dental
Implants: Rationale and Clinical Applications. Quintessence
Publishing (IL), 2004. ISBN 10: 0867154411/ISBN 13: 9780867154412,
p. 87.
17. Buser D, Hoffmann B, Bernard JP. Lussi A, Mettler D, Schenk RK.
Evaluation of filling materials in membrane-protected bone
defects. A comparative histomorphometric study in the mandible
of miniature pigs. Clin Oral Implants Res 1998:9;137-50.
18. Haas R, Mailath G, Dörtbudak O, Watzek G. Bovine hydroxyapatite
for maxillary sinus augmentation: Analysis of interfacial
bond strength of dental implants using pull-out tests. Clin
Oral Implants Res 1998;9:117-22.
19. Barrère F, van Blitterswijk CA, de Groot K. Bone regeneration:
Molecular and cellular interactions with calcium phosphate
[Downloaded free from http://www.jicdro.org on Monday, November 18, 2019, IP: 182.66.13.114]
Narayan, et al.: Healing of bone grafts around implants
ceramics. Int J Nanomedicine 2006;1:317-32.
20. Mahesh L, Venkataraman N, Shukla S, Prasad H, Kotsakis GA.
Alveolar ridge preservation with the socket-plug technique utilizing
an alloplastic putty bone substitute or a particulate xenograft: A
histological pilot study. J Oral Implantol 2015;41:178-83.
21. Mahesh L, Narayan T, Kostakis G, Shukla S. Periotest values of
implants placed in sockets augmented with Calcium phosphosilicate
putty graft: A comparative analysis against implants placed in
naturally healed sockets. J Contemp Dental Pract 2014;15:181-5.
22. Nkenke E, Stelzle F. Clinical outcomes of sinus floor augmentation
for implant placement using autogenous bone or bone substitutes: A
systematic review. Clin Oral Implants Res 2009;20(Suppl 4):124-33.
23. Lindgren C, Sennerby L, Mordenfeld A, Hallman M. Clinical
histology of microimplants placed in two different biomaterials.
Int J Oral Maxillofac Implants 2009;24:1093-100.
24. Norton MR, Wilson J. Dental implants placed in extraction sites
implanted with bioactive glass: Human histology and clinical
outcome. Int J Oral Maxillofac Implants 2002;17:249-57.
25. Polyzois I, Renvert S, Bosshardt DD, Lang NP, Claffey N. Effect
of Bio-Oss on osseointegration of dental implants surrounded
by circumferential bone defects of different dimensions: An
experimental study in the dog. Clin Oral Implants Res 2007;18:304-10.
26. Choo T, Marino V, Bartold PM. Effect of PDGF-BB and beta-tricalcium
phosphate (β-TCP) on bone formation around dental implants: A
pilot study in sheep. Clin Oral Implants Res 2013;24:158-66.
27. Raghavendra S, Wood MC, Taylor TD. Early wound healing
around endosseous implant: A review of literature. Int J Oral
Maxillofac Implants 2005;20:425-31.
28. Mavrogenis AF, Dimitriou R, Parvizi J, Babis GC. Biology of
implant osseointegration. J Musculoskeletal Nueronal Interact
2009;9:61-71.
29. Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic
review of the success of sinus floor elevation and survival of
implants inserted in combination with sinus floor elevation. J Clin
Periodontol 2008;35(Suppl):216-40.
30. Telleman G, Albrektsson T, Hoffman M, Johansson CB,
Journal of the International Clinical Dental Research Organization | Supplement 1 | Vol 7 | 2015
Vissink A, Meijer HJ, et al. Peri-implant endosseous
healing properties of dual acid-etched mini-implants with
a nanometer-sized deposition of CaP: A histological and
histomorphometric human study. Clin Implant Dent Relat
Res 2010;12:153-60.
31. Menicucci G, Mussano F, Schierano G, Rizzati A, Aimetti  M,
Gassino G, et al. Healing properties of implants inserted
concomitantly with anorganic bovine bone. A histomorphometric
human study. Aust Dent J 2013;58:57-66.
32. Schuler RF, Janakievski J, Hacker BM, O’Neil RB, Roberts FA.
Effect of implant surface and grafting on implants placed into
simulated extraction sockets: A histologic study in dogs. Int J Oral
Maxillofac Implants 2010;25:893-900.
33. Bhatavadekar NB, Hu J, Keys K, Ofek G, Athanasiou KA. Novel
application of cytodetachment technology to the analysis
of dental implant surfaces. Int J Oral Maxillofac Implants
2011;26:985-90.
34. Hockers T, Abensur D, Valentini P, Legrand R, Hammerle CH.
The combined use of bioresorbable membranes and xenografts
or autografts in the treatment of bone defects around implants. A
study in beagle dogs. Clin Oral Implants Res 1999;10:487-98.
35. Wong KK, Piert M. Dynamic bone imaging with 99mTc-labeled
diphosphonates and 18F-NaF: Mechanisms and applications.
J Nucl Med 2013;54:590-9.
36. Figure 2: (courtesy) Kühl S, Götz H, Hansen T, Kreisler M, Behneke
A, Heil U, et al. Three-dimensional analysis of bone formation
after maxillary sinus augmentation by means of microcomputed
tomography: A pilot study. Int J Oral Maxillofac Implants. 2010
Sep-Oct:25(5):930-8.
37. Figure 1: (courtesy) Kolerman R et al. Histomorphometric analysis
of maxillary sinus augmentation using an alloplast bone substitute.
J Oral Maxillofac Surg 2012;70:1835-43.
38. Figure 3: (courtesy) Pedrosa Jr WF, Okamoto R, Faria PEP, Arnez
MFM, Xavier SP, Salata LA. Immunohistochemical, tomographic
and histological study on onlay bone grafts remodeling. Part II:
Calvarial bone. Clin Oral Impl Res 2009;20:1254-64.
S47