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AUTOGENOUS BONE GRAFT IN ORAL AND MAXILLOFACIAL SURGERY
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Kumar Adarsh
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To begin with , I would like to thank Almighty God for showering me with His
blessings and for being my guiding light throughout the course of the journey. His
blessings have always helped me to fight through my difficulties and has given me
courage to do best in whatever I do.
I wish to express my great love and sincere thanks to my parents Shri. Shashi
Bhushan Verma and Smt. Jayshree Verma who has constantly showered me with
their blessings and word of encouragement both of them have been my inspiration and
continue to be, in my life. Without them it was not possible for me to reach at this
height of success.
I would also thank the pillars of Teerthanker Mahaveer University, Moradabad, Shri
Suresh Jain, chairman, Dr. R.K. Mudgal, Vice Chancellor for giving me opportunity
to be part of this esteemed university.
I am grateful to respected Dr. Mohan Gundappa, principal, Teerthanker Mahaveer

Dental College & Research Centre, Moradabad for his co-operation and support which
has always helped us to move in a right direction.
I would like to express my deeply gratitude to Dr. Lakshmi Gandi, Professor and
head, department of Oral And Maxillofacial Surgery, teerthanker mahaveer dental
college and research center. I sincerely want to thank mam, for showering her vast
knowledge, in valuable guidance, interpretating discussions and encouraging support
through the period of this dissertation.
I express the deepest appreciation to Dr. D.S. Gupta, Reader, Department of Oral and
Maxillofacial Surgery, Teerthanker Mahaveer Dental college and research centre for
constantly guiding me, sharing his knowledge with me .
I would also thank to Dr. Ravi Jain, Reader, Department of Oral and Maxillofacial
surgery, Teerthanker Mahaveer Dental College and Research Centre who has helped
me in making this dissertation complete. I am obliged to him for being a constant
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source of helpful guidance to me through this period of study, it is through his
continous encouragement and support that my dissertation is complete.
I would also thank to Dr. Mohsin Khan, senior lecturer, Department of Oral and
Maxillofacialo Surgery, Teerthankeer Mahaveer Dental College and Research Centre,
Moradabad for his guiding and supporting me.
I would also like to thank my close friends and my colleagues Dr. Aditya, Dr.
Saubhagya, Dr. Shivam, for their moral support, affection and willing cooperation.
I would also like to thank my dear friend Mr. Greesham Tripathi to give me strength
and support.
I would also like to express my thanks for my loving grand father, Shri Shanker
Prasad Verma and Smt. Shakuntala Rani for their motivation love and support.
I dedicate my Library Dissertation to my supportive Parents and my younger brother

Mr. Amit Verma.
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S.NO. TOPIC PAGE NO.

1. Introduction 1-4
2. History 5-6
3. Review of Literature 7 - 13
4. Anatomy of Bone 14 - 27
5. Bone Physiology & Healing 28 - 37
6. Classifications of Bone Graft 38 - 45

7. Applications of Autogenous Bone Graft in 46 - 61
Oral and Maxillofacial Surgery
8. Surgical Procedures & Harvesting Techniques 62 -
9. Indications For Various Techniques - 82
10. Complications 83 - 88
12. Conclusion 89
13. Bibliography 90 - 95
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Figure No. Title Page No.
1 Microscopic Structure of Bone 14

2 Bony Anatomy 15
3 Cancellous Bone 18
4 Compact Bone 18
5 Three ± dimentional diagram of a piece of 21
laminar bone showing parts of the vascular
network of two laminae.
6 Vessels in the Periosteum 21

7 Bone Cells 23
8 Ossification occur in the fibrous connective 24
tissue membrane
9 Bone matrix (osteoid) is secreted within the 25
fibrous membrane.
10 Woven bone and periosteum formation 25
11 Bone collar of compact bone form and red 26
marrow appears.
12 Stages of Endochondral Ossifiction 27
13 Utah paradigm of skeletal physiology 29
14 Osteoclast And Osteoblast 32
15 Showing osteocyte, osteoblast and osteoclast 33
16 Hematoma forms and the periosteum ruptures 34
partly
17 Cells migrate into the fracture hematoma 34
18 Fibrin fibers are formed and stabilize the 34
hematoma
19 Soft callus formation of cellular diffrentiation 35
20 Fibrocartilage replacing hematoma 36
21 Hard callus formation 36
22 Harvested bone graft 43
23 Growth factor 43
24 Mesenchymal stem cell 44
25 Platelet rich plasma 44
26 Calsium sulphate 44
LY
27 Lateral Skull radiography 47
28 Preparing the graft 47
29 Blocking graft 48
30 After removal of graft and shaping 48
31 Closing the donor site with cement 49
32 Pre operative 50
33 OPG showing horizontal bone loss between 51
maxillary right first and third molars, with thick
mucosa covering it
34 Incision marked for symphysis graft harvesting 52
35 Osteotomy done to harvest the graft 52
36 Corticocancellous symphysis graft harvested 53
37 Graft secured with 1.5x10 mm titanium screw 54
38 Recipient site closure 54
39 Pre-op probing 58
40 Pre-op lingual 58
41 Flap reflection 59
42 Defect probing 59
43 Lingual tori 60
44 Excised tori 60
45 Defect fill 61
46 Source of cancellous bone 62
47 Tibial graft 63
48 (A) ± Fibula can be harvested longitudinal bone; 64
(B) - tibial graft is shown: a large,
corticocancellous graft can be removed from the
proximal tibia on its anteromedial surface
49 This CT scan of the pelvis at the level of the 65
posterosuperior iliac spine illustratethe
thickness of the ilium posteriorly and the
amount of cancellous bone available;
50 The central section of the ilium at point A is 65
quite thin and is of no use in bone grafting
51 CT scan 3D, Anteroposterior ilium and CT scan 66
3D
52 Oblique posterior ilium with defect in iliac wall 66
after iliac bone is harvested
Y
53. The Iliac wall with defect 67
54 Incision line 68
55 Posterior iliac graft is shown 68
56 Thin bicortical cancellous grafts is harvested for 69

Congenital pseudarthrosisof the tibia
57 (a) Operative view showing the split rib grafts

reconstructing the bifrontal defect in the patient
with the interosseousmeningioma; (b) operative
view of the split rib graft reconstructing the
zygomaticomaxillary and pterygomaxillary
buttresses; (c)postoperative view of a patient
after maxillary reconstruction with an accepted
esthetic appearance; (d) postoperative 3DCT
scan of the
patient in (c) showing the survived bone grafts
58 Single-onlay cortical bone graft is shown for

humeral pseudarthrose.
59 Cortical cortical cancellous bone graft is
harvested from Ilium for scoliosis.
60 A sliding graft is used as a component of ankle
arthrodesis.
61 A sliding graft is used as a component of knee
arthrodesis.
62 Strut grafts for anterior spinal fusion.
63 Bone collectors
64 Bone driller
YL
Introduction
Introduction
Maxillofacial surgery deals with major surgery of jaw bone tumor, oral cancers, temporomandibular
joint, congenital facial defects, jaw bone fracture etc. [1]
Bone is classified as cortical bone and trabecular bone between the cortices. Cortical bone is made of
dense, compact bone containing series of haversian systems with lacunae housing osteocytes. Trabecular
bone fills the marrow space between the cortices. This bone consists of series of trabeculae and is also
known as spongy bone. Cells in the trabecular bone include osteoblasts, osteoclasts, and hematopoietic
cells. [2]
Bone grafting is a surgical procedure that replaces missing bone in order to bone fractures that are
extremely complex, pose a significant health risk to the patient, or fail to heal properly. Bone grafting is
a very old surgical procedure. The first recorded bone implant was performed in 1668. Bone grafts are
used to treat various disorders, including delayed union and nonunion of fractures, congenital
pseudoarthrosis, and osseous defects from trauma, infection, and tumors. Bone grafts are also used in
plastic and facial surgery for reconstruction. [3]
Bone generally has the ability to regenerate completely but requires a very small fracture space or some
sort of scaffold to do so. Bone grafts may be autoloJRXVERQHKDUYHVWHGIURPWKHSDWLHQW¶VRZQERG\
often from iliac crest), allograft (cadaveric bone usually obtained from a bone bank), or synthetic (often
made of hydroxyapatite or other naturally occurring and biocompatible substances) with similar
mechanical properties to bone. Most bone grafts are expected to be reabsorbed and replaced as the
natural bone heals over a few moQWK¶VWLPH
The principles, indications, and techniques of bone grafting procedures were well established before "the
metallurgic age" of orthopaedic surgery. Because of the necessity of using autogenous materials such as
bone pegs or, in some cases, using wire loops, fixation of grafts was rather crude. Lane and Sandhu
introduced internal fixation; Albee and Kushner, Henderson, Campbell, and others added osteogenesis
to this principle to develop bone grafting for nonunion into a practical procedure. [3]
WĂŐĞϭ
Introduction
The two principles, fixation and osteogenesis, were not, however, efficiently and simply combined until
surgeons began osseous fixation with inert metal screws. Then came the bone bank with its obvious
advantages. Much work, both clinical and experimental, is being done to improve the safety and results
of bone grafting: donors are being more carefully selected to prevent the transmission of HIV and other
diseases; tissue typing and the use of immunosuppressants are being tried; autologous bone marrow is
being added to autogenous and homogenous bone grafts to stimulate osteogenesis; and bone graft
substitutes have been developed.
Bone graft are involved in successful bone graft include osteoconduction (guiding the reparative growth
of the natural bone), osteoinduction (encouraging undifferentiated cells to become active osteoblast),
and osteogenesis (living bone cells in the graft material contribute to become remodeling). Osteogenesis
only occurs with autografts.
Bone grafts may be used for the following purposes:

1. To fill cavities or defects resulting from cysts, tumors, or other causes
2. To bridge joints and thereby provide arthrodesis
3. To bridge major defects or establish the continuity of a long bone
4. To provide bone blocks to limit joint motion (arthrorisis)
5. To establish union in a pseudarthrosis
6. To promote union or fill defects in delayed union, malunion, fresh fractures, or osteotomies.
7. To plastical arthrosis of acetabulum for Congenital Dislocation of the Hip and Perthes Disease. [3]
Basic knowledge of bone grafting

In cancellous bone grafts, the necrotic tissue in marrow spaces and haversian canals is removed by
macrophages. Granulation tissue, preceded by the advance of capillaries, invades the areas of resorption.
Pluripotential mesenchymal cells differentiate into osteoblasts, which begin to lay seems of osteoid
along the dead trabeculae of the bone graft.
Osteoclasts resorb the necrotic bone, and eventually most of the bone graft is replaced by new host bone.
Finally, the old marrow space is filled by new marrow cells. In cortical bone, the process of
incorporation is similar but much slower, because invasion of the graft must be through the haversian
WĂŐĞϮ
Introduction
canals of the transplant. Osteoclasts resorb the surface of the canals, creating larger spaces into which
granulation tissue grows. As these granulation tissue penetrates the center of the cortical graft, new bone
is laid throughout the graft along enlarged haversian canals. Depending on the size of the graft, complete
replacement may take many months to a year or more. [3]
Types of Bone Grafts

Grafts and implant substances are classified according to their immunological basis:
(1) Autogenous bone grafts - Autograft is composed of tissue taken from the same individual or from the
host himself.
(2) Allogenic bone grafts - Composed of tissue taken from an individual of the same species who is not
genetically related to the patient.
(3) Isogenic bone grafts or Isograft or Homograft or Syngenesioplastic graft - Where tissue is taken
from an individual of the same species who is genetically related to the patient.
(4) Heterografts or Xenogenic graft ± It means tissue taken from a donor of another species eg. animal
bone grafts to man cortical bone cancellous bone or mixed cortical cancellous slabs may be used. Such
grafts can be applied as chips, flakes or shaped blocks.
Conditions for success in bone grafting

There are certain factors which are very important to achieve, successful bone grafting. Poor nutritional
condition, improper stabilization of bone may affect the success of bone grafting. Besides absence of
infection is essential to prevent the graft become infected before it has been revascularised and to
constitute sequestrum. For this reason bone grafts can be inserted through skin incision rather than the
mucous membrane of the mouth avoidance of wound contamination and antibiotic therapy. So the tissue
should be free from infection, healthy and vascular. The recipient site should have an adequate blood
supply to ensure rapid invasion of the graft by granulation tissue and its adequate nourishment,
otherwise the graft will fail.
WĂŐĞϯ
Introduction
Autogenous bone grafts taken from iliac crest or ribs have become a common practice to reconstruct
mandible, maxilla, nasal bridge, Temporomandibular joint with variable degree of success.
Microvascular surgery using soft tissue and bone anastomosing with vessels may be a better method,
[3]
however, it needs special skills & expensive equipment.
WĂŐĞϰ
History

History
Grafting of a bone fragment or transplanting a limb from one human being to another has
preoccupied mankind for thousands of years. In 2000 BC, this was inhabited by a prehistoric
people known as the Khurits. In the first skull the prehistoric surgeons had inserted a piece of
[4]
animal bone into a 7-mm defect caused by injury.
The Egyptians were also advanced in dental surgery and bone surgery in general. There are
accounts of orthopedic operations performed on various segments of the human body and
radiographic tests of the mummy of the priest User-montu, which is preserved at San José
museum in California and belonged to the 26th dynasty (656±525 BC), revealed that the left leg
around the knee had a 23-cm prosthesis. This had been inserted by a complex surgical procedure.
In the seventeenth and eighteenth centuries orthopedic surgeons focused their attention on the
structure of bone, which was described for the first time in 1674 by Antoni Van Leeuwenhoek in
Philosophical Transactions, concerning what would become known as Haversian canals. The
concepts of bone callus, implant and resorption began to beoutlined. Most operations requiring
bone resection were for nonunion, which was often treated by amputating the limb. A technique
caOOHG³VXE-SHULRVWHDOUHVHFWLRQ´EDVHGRQ'XKDPHO¶VWKHRU\RIWKHLPSRUWDQFHRIWKHSHULRVWHXP
in bone regeneration was widespread until halfway through the nineteenth century, and it was
used by many surgeons for the treatment of nonunion. [4]
In 1820, the first autologous graft was performed in Germany by the surgeon Philips Von
Walter, who replaced a fragment of cranium after trepanation. More recently, a surgeon from
Lyon, Leopold Ollier, studied the phenomenon of bone regeneration and in 1861 he published
³7UDLWpGHODUpJpQpration GHVRV´DGRFXPHQWGHVFULELQJWKHWHUP ERQHJUDIW³JUHIIHRVVHXVH´
for the first time. The grafts used by Ollier and his contemporaries, around 1860, were of
autologous origin. Non-autologous grafts were not taken into consideration for many years.
3XWWLVDLGRIKHWHURSODVWLFJUDIWV³H[SHULHQFHKDVVKRZQWKDWLWFDQQRWFRPSDUHWRDXWRSODVWLFDQG
KRPRSODVWLFERQH´DQGKHZHQWRQWRFLWHFDVHVLQZKLFKsome contemporary surgeons used fresh
calf, rabbit femur, and lamb tibia bone grafts.
WĂŐĞϱ

History

The same theorLHV ZHUH VXSSRUWHG E\ 3KHPLVWHU¶s experiments, who (in 1914) reported studies
on dogs in which fragments of autologous bone had been grafted. The author VWDWHGWKDW³LWKDV
been sufficiently demonstrated that bone from animals of the same species behaves in the same
way as if it had come from the same animal, but with slightly reduced powers, and that a graft
from a different species acts in the same way as dead bRQH RU D IRUHLJQ ERG\´ (Phemister
1914).[4]

WĂŐĞϲ

Review of Literature

James A. Goulet et .al (1997) ± Conducted a study to assess the effect of iliac crest bone
grafting on patient there functional outcomes and their complications.
Lawrence G. Rasiz (1999) ± Conducted a study and describe about the bone remodelling cycle
and its pathophysiology of bone that involves a complex series of sequential steps that are
highly regulated with their local factors are implicated in the pathogenesis of the skeletal changes
associated with immobilization.
W.S.S. Jee (2000) ± Conducted a study to view that non-mechanical agents dominate control of
osteoblasts and osteoclasts and thus postnatal changes in bone strength and mass (agent effector
cells disease) is obsolete. Non-mechanical agents include hormones, calcium, vitamin D,
cytokines, gender, genetics, etc. This paradigm overlooks all tissue level features, biomechanics
and relationships found after 1960.
Molla MR et al (2001) ± Conducted a study to describe about the principles and types of bone
grafting and their success.
Iain H. Kalfas (2001) ± Conducted a study and described the understanding of bone healing has
evolved due to knowledge gleaned from a continuous interaction between basic laboratory
investigations and clinical observations following procedures to augment healing of fractures,
osseous defects, and unstable joints. The stages of bone healing parallel the early stages of bone
development. The bone healing process is greatly influenced by a variety of systemic and local
factors.
Alexander R. Vaccaro (2002) ± Autogenous bone is regarded as a gold standard for bone graft
material. It provides three elements necessary to generate and maintain bone: scaffolding for
osteoconduction, growth factors for osteoinduction, and progenitor cells for osteogenesis bone
grafting are progressing with the evolution of biomaterials that permit the incorporation of
osteoinductive and osteogenic proteins into osteoconductive composite scaffolds.
WĂŐĞϳ


Alberto Blay et al (2003) ± Evaluated the use of autogenous bone graft is the best choice for
reconstructive surgery. The purpose of this study is to consider the use of bone collectors as an
alternative method for obtaining material to fill small bone imperfections, such as fenestrations
and dehiscences. Thirty samples were obtained and These samples were fixed in 10% neutral
formaldehyde for 24 hours and subjected to histological preparation, Bacterial growth evaluation
was made by using six different culture media. The results show that, if proper care is taken to
prevent saliva contamination during the surgical procedure, this method of collecting autogenous
bone may be useful in situations where small amounts of bone are required.
Marshall M. Freilich, George K.B. Sandor (2006) ± Evaluated and describe two minimally
invasive techniques for in-office iliac crest bone harvesting. The increasingly limited access to
hospital operating rooms and the increased need for bone grafting to facilitate dental implant-
related reconstructions have been the major impetuses behind relocating some of these surgeries
to the out-of-hospital, in-office setting.
Filippo Graziani et al (2007) ± Conducted a study of bone grafting procedure during implant
surgery. The objective of this study was to systematically review the use of bone collectors in
implant dentistry, focusing on the quantity, quality, and bacterial contamination of the bone
collected. Bone collectors amassing small amount of bone, the vitality of bone is consistently
demonstrated and collected debris was contaminated by bacteria. The bone debris amassed in
bone collectors is not ideal grafting material and should be utilized with caution.
Ferhan Yaman et al (2007) ± Conducted a study to investigate the methods of removing

pathogenic microorganisms from bone grafts that have been contaminated during surgery.
Solutions such as povidone-iodine, neomycin, cephazolin sodium, and rifamycin were found to
be effective decontaminants. These solutions did not damage the bone structure. Among these
solutions, only rifamycin was effective against all bacteria used in this study to contaminate
bone grafts. Rifamycin seems to be the most suitable agent for the elimination of contamination
introduced into bone grafts during surgery.
WĂŐĞϴ


Somsak Sittitavornwong, Rajesh Gutta (2010) ± Evaluated the Bone grafts and are widely
used in the reconstruction of osseous defects in the oral and maxillofacial region. Autogenous
bone grafts are generally obtained from the ilium, the rib, and the calvarium. These grafts can be
easily obtained from these donor sites, but each site has associated morbidity.
Kenneth J. Zouhary (2010) ± Conduted a study on bone graft harvesting from distant sites has a
very low incidence of complications. A thorough understanding of the relevant anatomy, various
harvesting techniques, and potential morbidity associated with each harvest site will aid the
surgeon in selecting the optimal bone graft source.
R. David Roden Jr ± (2010) ± Evaluated the principles of bone grafting, with all of the available
methods and materials, a clear understanding of these basic principles will assist in the selection
of a technique for each individual patient.
Teresa Mao, Kamakshi V (2010) ± Conducted a study of bone resorption is a natural

phenomenon and can occur due to old age, loss of teeth, prolonged denture wear or as a result of
systemic conditions, and describe the use of human bone material (Allografts), synthetic
materials (Alloplasts) and blood components as successful grafting materials. Their use has
shown an effective amount of bone formation and proliferation in the defective sites and proves
to be a beneficial choice in bringing the back lost bone.
Gustavo Davi Rabelo et al (2010) ± Conducted a retrospective study was to evaluate morbidity
and possible complications in augmentation procedures before implant placement. Alveolar
reconstruction using autogenous bone followed by implant placement is a reliable treatment for
patients with insufficient bone. Complications and morbidity were frequently observed.
Ogunlade S. O et al (2010) ± Evaluated the mandible resection and subsequent defect created
lead to aesthetic and functional abnormalities. The technique of harvesting iliac crest graft is
highlighted in this prospective study involving 37 iliac crest grafts for mandibular defect
reconstruction between 1999 and 2006. Graft site infection was the most complication with
overall incidence of 27.0 percent. Most of the infections were superficial and responded to
WĂŐĞϵ


antibiotic use and local wound care. The use of autogenous iliac bone graft for reconstruction of
mandibular bone defect in our environment.
Cassiano Costa Silva Pereira et al (2011) ± Conducted a study for Maxillomandibular

reconstructions are traditionally performed by means of autogenous bone grafts collected from
intraoral donor areas and extraoral donor areas such as clavicle, iliac bone, rib, and tibia. The
calvarial bone has been studied as an alternative donor area, with a low incidence of
complications and minimal postoperative morbidity. Complications such as dural lacerations
associated with cerebrospinal fluid leakage and extradural and subdural bleeding were
minimized due to the use of surgical trepan, allowing the diploiclayer delimitation before the
osteotomy, preserving the internal calvarial cortical. Suggested a new technique for the
obtainment of calvarial bone grafts with surgical trepan.
Arun Kumar Singh et al (2011) ± Evaluated the Primary bone grafting of craniofacial skeletal
injuries provides an opportunity for one stage correction of bony defects. Functional and
aesthetic assessment of each of patients, managed with primary bone grafting revealed a low rate
of disabilities and high percentage of satisfaction in this study.
Gerry M. Raghoebar et al (2011) ± Conducted a study to assess whether elevation of the sinus
mucosal lining combined with applying an autologous bone graft as a ceiling and placement of a
short implant would allow for bone formation around the implant thus surpassing the need for
applying augmentation materials around the installed implants. All implants were stable and no
implants were lost. There were no complications after harvesting the bone graft.
Nymphea Pandit et al (2012) ± Conducted a study to evaluate the efficacy of autogenous block
is used to evaluate the efficacy of autogenous bone block in the regeneration of bone, for saving
teeth with a hopeless prognosis. This method is considered to be very viable alternative to
extraction and replacement by costly implant.
Brion Benninger et al (2012) ± Conducted a study to evaluate the iliac crest is the standard site
for harvesting bone and demonstrates that the use of the proximal tibia led to shorter hospital
WĂŐĞϭϬ


stays, lower morbidity rates, and a shorter learning curve for the surgeon and to analyze the
clinical anatomy of a proximal tibial bone harvest graft to provide the anatomical architecture
supporting a safe suggests that the medial proximal tibial bone harvest approach would have
IHZHU VHULRXV VWUXFWXUHV LQ KDUP¶V ZD\ FRPSDUHG WR WKH ODWHUDO KRZever, the lateral approach
may be preferred for a subgroup.
Sung-Min Park et al (2012) ± Conducted a study to evaluate the Auto-tooth bone graft material,
it consists of 55% inorganic hydroxyapatite (HA) and 45% organic substances. The organic
substances include bone morphogenetic protein and proteins which have osteoinduction capacity,
as well as the type I collagen identical to that found in alveolar bone. Auto-tooth bone graft
material is useful as it supports excellent bone regeneration capacity and minimizes the
possibility of foreign body reaction, genetic diseases. Based on these results, they concluded that
auto-tooth bone graft material should be researched further as a good bone graft material with
osteoconduction and osteoinduction capacities to replace autogenous bone, which has many
limitations.
Mansi Pabari et al (2012) ± Conducted a study to evaluate the sufficient width and height of
maxillary or mandibular alveolar ridge is a must for implant placement. Surgical reconstruction
of such alveolar ridge using autologous bone grafts allows implant fixation in an esthetic and
functional manner. For repair of most localized alveolar defects, block bone grafts from the
symphysis offer advantages over iliac crest grafts, like close proximity of donor and recipient
sites, convenient surgical access, decreased donor site morbidity, decreased cost and hidden scar,
deficient alveolar height in the maxillary posterior region which was reconstructed with intraoral
symphysis graft from the mandible before implant placement in patient.
Giacomo De Riu et al (2012) ± Conducted a study to evaluate the results of mandibular

augmentation with coronoid process bone grafts for dental implant insertion and grafted alveolar
ridges showed mean transverse and vertical augmentations of 3.07 and 2.80 mm, respectively. At
24 months after implant surgery, the cumulative implant survival rate was 95% and mean
marginal bone loss was plus, minus 1.6 to 0.18 mm. Coronoid process bone grafts can be used
WĂŐĞϭϭ


to reconstruct moderate defects in edentulous alveolar processes. The insertion of the graft with
minimal access in a tunneled fashion minimizes the risk of infection.
Lee EG et al (2013) ± Conducted a study to evaluate the extraction site has insufficient bone
height or volume for an implantation, an autogenous tooth bone block for a socket reconstruction
and bone graft can be implemented. In the case studies, we obtained outstanding treatment
outcomes using autogenous tooth bone block reconstructing extracted socket and ridge
augmentation. This study presents its clinical and radiological findings.
Sherin.A.Khalam et al (2014) ± Conducted a study to evaluate the secondary alveolar bone

grafting is a well established technique in the management of patients with cleft lip and alveolus,
bone grafting determine the selection of grafting material such as cortical or cancellous,
membranous or endochondral, success depends on panoply of variables including the
physiologic and mechanical properties of the graft material and the biology of recipient site. The
case of secondary alveolar bone grafting using autogenous mandibular bone graft from
symphysis.
Muthukumar Santhanakrishnan et al (2014) ± Conducted a study to evaluate the need for an

extra surgical site is the tori/exostoses. Bone grafting was planned for this patient as there were
angular bone loss present between 35ǡ36 and 36ǡ37. The use of mandibular tori as a source of
autogenous bone graft should be considered whenever a patient requires bone grafting procedure
to be done and presents with a tori.
K Harshakumar et al (2014) ± Conducted a study to evaluate the placement of endosteal

implants requires adequate bone volume for successful osseointegration. When the morphology
of the bone does not allow proper implant placement. The mandibular ramus can act as an
excellent source of autogenous bone for augmentation of alveolar ridge deficiencies. Describes a
case of localized alveolar ridge augmentation using block bone autografts harvested from the
mandibular ramus prior to implant.
WĂŐĞϭϮ


Pokhrel P K et al (2015) ± Conducted a study to evaluate the autologous bones are used as graft
for reconstruction of the alveolar ridges for the preparation of complete denture or implant
supported prosthesis, procedure to graft calvarial bone graft is no longer outreach from the
Maxillofacial Surgeons of for the functional and esthetic rehabilitation of the patients.
Davide Donati, et al (2016) ± Conducted a study and concluded as follows:

a) The uniformity of bone graft integration processes, and a marked reduction in integration
capacity in heteroplastic grafts.
b) The osteogenetic incapability of the graft as opposed to the osteogenetic capability of the
periosteum.
c) Marked reduction in the biological capability of bone that has been treated with preservatives,
boiled, or macerated.
d) The importance of the quality of the tissues in which the bone graft is inserted, including the
mechanical characteristics of the graft and its fixation.
e) The importance of asepsis.
f) The importance of functional exercise.
WĂŐĞϭϯ

Anatomy of Bone

Anatomy of Bone
Bone is the main component of the skeleton in the adult human. Like cartilage, bone is a specialised form
of dense connective tissue. Bone gives the skeleton the necessary rigidity to function as attachment and
lever for muscles and supports the body against gravity. ΀ϱ΁
Bones provide a hard framework that supports the body. Bones provide protection to internal
organs. The cranium protects the brain, the vertebrae protect the spinal cord, the rib cage protects
the thoracic cavity organs, and the hip bones protect pelvic cavity organs. Skeletal muscle uses
the bones as levers for movement.
Fig : 1 Microscopic Structure of Bone
WĂŐĞϭϰ

Anatomy of Bone

Two types of bone can be distinguished macroscopically:
Trabecular bone (also called cancellous or spongy bone) consists of delicate bars and sheets of
bone, trabeculae, which branch and intersect to form a sponge like network. The ends of long
bones (or epiphyses) consist mainly of trabecular bone. [5]
Compact bone does not have any spaces or hollows in the bone matrix that are visible to the eye.
Compact bone forms the thick-walled tube of the shaft (or diaphysis) of long bones, which
surrounds the marrow cavity (or medullary cavity). A thin layer of compact bone also covers the
epiphyses of long bones. [5]
Bone is, again like cartilage, surrounded by a layer of dense connective tissue, the periosteum. A
thin layer of cell-rich connective tissue, the endosteum, lines the surface of the bone facing the
marrow cavity. Both the periosteum and the endosteum possess osteogenic potency. Following
injury, cells in these layers may differentiate into osteoblasts (bone forming cells) which become
involved in the repair of damage to the bone. [5]
\
Fig : 2 Bony Anatomy
WĂŐĞϭϱ

Anatomy of Bone

Function of Bones
Support ± form the framework that supports the body and cradles soft organs.
Protection ± provide a protective case for the brain, spinal cord, and vital organs.
Movement ± provide levers for muscles.
Mineral storage ± reservoir for minerals, especially calcium and phosphorus.
Blood cell formation ± hematopoiesis occurs within the marrow cavities of bones.
Bone Markings
Bulges, depressions, and holes that serve as:

Sites of attachment for muscles, ligaments, and tendons
Joint surfaces, conducts for blood vessels and nerves .
Mechanical Loads on the Human Body.

1. Types of loading
Compression: pressing or squeezing force directed axially through a body.

Tension: pulling or stretching force directed axially through a body.
Shear: force directed parallel to a surface.
Bending: asymmetric loading that produces tension on one side of a body's longitudinal axis and
compression on the other.
Torsion: load causing twisting of a body around its longitudinal axis.
Combined loading: combination of different types of loading.
2. Effects of loading
Deformation: change in shape
Acute vs. Repetitive: likelihood of injury: load magnitude vs frequency.
3. Mechanical Stress and Strain

Mechanical stress: distribution of force inside of a solid body (lumbar vs. thoracic vertebrae)
Strain: deformation due to stress.
WĂŐĞϭϲ

Anatomy of Bone

Load-deformation curve (stress-strain curve)
Yield point (elastic limit): permanent deformation
Failure point: loss of mechanical continuity.
Composition and Structure of Bone

Stiffness - ratio of stress to strain in a loaded material (stress divided by the relative amount of
change in structure's shape)
Compressive strength - ability to resist pressing or squeezing force.
Building Blocks of Bone
Minerals (calcium carbonate and calcium phosphate ~ 60-70% of bone weight) source of
stiffness and compressive strength
Collagen (protein) ~ 10% source of flexibility and tensile strength aging causes decrease in
collagen and, as a result, increase in fragility.
Water ~ 25-30% important contributor to bone strength.
Cortical Bone (compact mineralized tissue with low porosity)
Trabecular Bone (less compact with high porosity. [5]
WĂŐĞϭϳ

Anatomy of Bone

Histological Organisation of Bone
Fig : 3 Cancellous Bone
Fig : 4 Compact Bone
WĂŐĞϭϴ

Anatomy of Bone

Compact Bone
Compact bone consists almost entirely of extracellular substance, the matrix.

Osteoblasts deposit the matrix in the form of thin sheets which are called lamellae.
Lamellae are microscopical structures. Collagen fibres within each lamella run parallel to each
other.
Collagen fibres which belong to adjacent lamellae run at oblique angles to each other. Fibre
density seems lower at the border between adjacent lamellae, which gives rise to the lamellar
appearance of the tissue.
Bone which is composed by lamellae when viewed under the microscope is also called lamellar
bone. In the process of the deposition of the matrix, osteoblasts become encased in small hollows
within the matrix and the lacunae.
Unlike chondrocytes, osteocytes have several thin processes, which extend from the lacunae into
small channels within the bone matrix, the canaliculi. Canaliculi arising from one lacuna may
anastomose with those of other lacunae and, eventually, with larger, vessel-containing canals
within the bone. Canaliculi provide the means for the osteocytes to communicate with each other
and to exchange substances by diffusion.
In mature compact bone most of the individual lamellae form concentric rings around larger
ORQJLWXGLQDO FDQDOV DSSUR[ȝPLQGLDPHWHU ZLWKLQWKH ERQH WLVVXH7KHVHFDQDls are called
Haversian canals. Haversian canals typically run parallel to the surface and along the long axis of
the bone. The canals and the surrounding lamellae (8-15) are called a Haversian system or an
osteon. A Haversian canal generally contains one or two capillaries and nerve fibres.
Irregular areas of interstitial lamellae, which apparently do not belong to any Haversian system,
are found in between the Haversian systems.
Immediately beneath the periosteum and endosteum a few lamella are found which run parallel
to the inner and outer surfaces of the bone. They are the circumferential lamellae and endosteal
WĂŐĞϭϵ

Anatomy of Bone

lamellae. A second system of canals, called Volkmann's canals, penetrates the bone more or
less perpendicular to its surface.
These canals establish connections of the Haversian canals with the inner and outer surfaces of
the bone. Vessels in Volkmann's canals communicate with vessels in the Haversian canals on the
[5]
one hand and vessels in the endosteum on the other.
Vascular supply of bone
Lamellar bone, the lamellarer Schalenknochen of German histologists, is usually replacement,

that is, secondary bone; the fibres show a high degree of orientation and it consists of very thin
lamellae (about 5/x thick).
The periosteum, lying outside a layer of woven bone, has blood-vessels on the inner surface of
the fibrous layer, lying on the sub-periosteal surface of the bone.
A large amount of woven bone is formed very quickly. The new layer of bone is supported, and
held clear of the old sub-periosteal surface, by an occasional bridge of woven bone.
The blood-vessels that previously lay on the sub-periosteal surface of the bone are now enclosed
in spaces completely surrounded by woven bone.
Lamellar bone begins to form on the endosteal side of the cavity in which the blood-vessels lie,
the osteoblasts probably coming from part of the original periosteum, left behind and enclosed in
the cavity in the woven bone.
WĂŐĞϮϬ

Anatomy of Bone
Fig : 5 Three ± dimentional diagram of a piece of laminar bone showing parts of the vascular network of
two laminae.
Lamellar bone begins to form on the endosteal side of the cavity in which the blood-vessels lie,
the osteoblasts probably coming from part of the original periosteum, left behind and enclosed in
the cavity in the woven bone.
The spaces round the blood-vessels get smaller as more lamellar bone is laid down on the walls
of the cavity.
WĂŐĞϮϭ

Anatomy of Bone

A few communications also exist with vessels in the periosteum.
Fig : 6 Vessels in the Periosteum
Trabecular Bone
The matrix of trabecular bone is also deposited in the form of lamellae. In mature bones,
trabecular bone will also be lamellar bone.
+RZHYHUODPHOODHLQWUDEHFXODUERQHGRQRWIRUP+DYHUVLDQV\VWHPV
/DPHOODH RI WUDEHFXODU ERQH DUH GHSRVLWHG RQ SUHH[LVWLQJ WUDEHFXODH GHSHQGLQJ RQ WKH Oocal
demands on bone rigidity.
2VWHRF\WHVODFXQDHDQGFDQDOLFXOLLQWUDEHFXODUERQHUHVHPEOHWKRVHLQFRPSDFWERQH.
Bone Matrix and Bone cells
Bone Matrix Collagen fibres (about 90% of the organic substance) and ground substance.
Collagen type I is the dominant collagen form in bone.
The hardness of the matrix is due to its content of inorganic salts (hydroxyapatite; about 75%
of the dry weight of bone), which become deposited between collagen fibres.
WĂŐĞϮϮ

Anatomy of Bone

Bone Cells
Osteoblast: Bone forming cells
Osteocytes: Mature bone cells.
Osteoclast: Large cell that resorb or break the bone matrix.
Osteoid: Unmineralised bone matrix composed of proteoglycan, glycoprotein, and collagen.
Osteoprogenitor cells (or stem cells of bone) are located in the periosteum and
endosteum.
They are very difficult to distinguish from the surrounding connective tissue cells.
They differentiate into :
Osteoblasts (or bone forming cells)
Osteoblasts may form a low columnar "epitheloid layer" at sites of bone deposition.
They contain plenty of rough endoplasmatic reticulum (collagen synthesis) and a large Golgi
apparatus.
As they become trapped in the forming bone they differentiate into:
Osteocytes.
Osteocytes contain less endoplasmatic reticulum and are somewhat smaller than osteoblasts
Osteoclasts
These DUHYHU\ODUJHXSWRȝPPXOWL-nucleated (about 5-10 visible in a histological section,
but up to 50 in the actual cell) bone-resorbing cells. They arise by the fusion of monocytes
(macrophage precursors in the blood) or macrophages. Osteoclasts attach themselves to the bone
matrix and form a tight seal at the rim of the attachment site. The cell membrane opposite the
matrix has deep invaginations forming a ruffled border. Osteoclasts empty the contents of
lysosomes into the extracellular space between the ruffled border and the bone matrix. The
released enzymes break down the collagen fibres of the matrix. [5]
WĂŐĞϮϯ

Anatomy of Bone
Fig : 7 Bone Cells
Formation of Bone
Bones are formed by two mechanisms:
Intramembranous ossification
Endochondral Ossification
Intramembranous ossification
It results in the formation of cranial bones of the skull (frontal, parietal, occipital, and temporal
bones) and the clavicles.
All bones formed this way are flat bones.
An ossification center appears in the fibrous connective tissue membrane.
Bone matrix is secreted within the fibrous membrane.
Woven bone and periosteum form. Bone collar of compact bone forms, and red marrow appears.
WĂŐĞϮϰ

Anatomy of Bone
Stages of intramembranous ossification
1. Ossification occur in the fibrous connective tissue membrane.
Fig : 8
2. Bone matrix (osteoid) is secreted within the fibrous membrane.
Fig : 9
WĂŐĞϮϱ

Anatomy of Bone
3. Woven bone and periosteum formation.
Fig : 10
4. Bone collar of compact bone form and red marrow appears.
Fig : 11
WĂŐĞϮϲ

Anatomy of Bone

Endochondral Ossification
It results in the formation of all of the rest of the bones:
Begins in the second month of development.
8VHVK\DOLQHFDUWLODJH³ERQHV´DVPRGHOVIRUERQHFRQVWUXFWLRQ
Requires breakdown of hyaline cartilage prior to ossification.
Formation begins at the primary ossification center. [6]
Stages of Endochondral Ossification
Fig : 12
WĂŐĞϮϳ

Bone phsiology and healing

Bone physiology and healing
Bone physiology
The Mechanostat is a model describing bone growth and bone loss. It was promoted by Harold
Frost and described extensively in the Utah Paradigm of Skeletal Physiology in the 1960s.
In the 1960 paradigm of bone physiology that many still hold, the main role of osteoblasts and
osteoclasts is to determine bone health and diseases. Bone status depended on those cells and
their being influenced by non-mechanical agents like hormones, calcium, vitamin D, cytokines,
gender, genetics, etc. This paradigm overlooks all tissue level features, biomechanics and
relationships found after 1960. This more recent information led to the Utah paradigm of skeletal
physiology, proposed by Harold Frost in 1995. Non-mechanical agents could help or hinder the
influence of the mechanical factors but could not replace them. [7]
The ever-evolving Utah Paradigm of skeletal physiology for load-bearing bones is a legacy of 50
years of study by Harold M. Frost. It replaces the 1960 paradigm of skeletal physiology in which
effector cells (chondroblasts, fibroblasts, osteoblasts, osteoclasts, etc.) regulated by non-
mechanical agents determined the architecture, strength and health of bones. [8]
The mechanostat deals mainly with load bearing bones. Postnatally, there are two kinds of bones
after birth - the load-bearing bones which implies muscles forces and the others with different
needs like the cranial vault, cribiform plates of the ethmoid, nasal bones, turbinates, etc.
Nevertheless, all are subject to gravity forces. [7]
Briefly, the mechanostat consists of 4 major components:

(1) the genetically determined baseline conditions;
(2) loads generating signals (mechano WUDQVGXFHUV WKDW WKDW WXUQ µRQ¶ RU µRII¶ tissue-level
biologic mechanisms highways or pathways;
(3) genetically determined minimum effective strain (MES) general biomechanical relations
MES remodeling < E adaptation < MES modeling >> MES pathology >> FX fracture; and
feedback loops of above features.
WĂŐĞϮϴ

Fig : 13 Utah paradigm of skeletal physiology
Pathophysiology of Bone Remodeling

Abnormalities of bone remodeling can produce a variety of skeletal disorders. Inflammatory
bone loss in periodontal disease and arthritis is probably the combined result of stimulation of
resorption and inhibition of formation by cytokines and prostaglandins. Interleukin 1 (IL-1), IL-
6, and tumor necrosis factor as well as growth factors have been implicated in pathologic
responses in the skeleton, particularly in osteoporosis associated with estrogen deficiency,
hyperparathyroidism, and Paget disease. [9]
WĂŐĞϮϵ


Bone Healing
Bone healing can be sub classified into primary and secondary healing. As with soft tissue
healing, primary healing of bone implies direct contact or a gap of less than 1 mm between bone
fragments. This process of healing occurs by osteoclasts working in groups to create a cutting
cone. Following this cutting cone of osteoclasts are osteoblasts secreting osteoid for future
mineralization. [10]
Secondary bone healing occurs through formation of a callus within which osteoid is produced
and mineralization occurs. This type of bone healing can be divided into three major phases. The
first phase is the inflammatory phase, which occurs immediately. There is formation of a
hematoma, which eventually becomes granulation tissue. The repair stage then begins as
inflammatory cells and fibroblasts invade the tissue. These cells cause differentiation and
recruitment of osteoblasts and provide a scaffold for further vascular in growth. The osteoblasts
lay down osteoid and form the soft callus. This callus eventually is ossified. The final stage of
healing occurs with remodeling. This phase occurs over months to years and restores the bone to
its original shape and near its original strength. [10]
The principles of primary and secondary bone healing can be applied to bone graft healing. The
[10]
type of graft material used, block versus particulate, dictates which healing process occurs.
Cortical block bone grafts heal by a process called creeping substitution. This process is similar
to primary bone healing. Once the non-vascularized graft material is transferred to the defect,
osteoclasts begin to resorb the graft material, allowing for fibroblast ingrowth and the creation of
a matrix for vascularization of the graft. The osteoclasts create voids in the graft material that are
filled with osteoid from osteoblasts. These osteoid then becomes mineralized. Once the graft
material is resorbed, the newly formed bone undergoes remodeling and maturation. Ideally, the
grafted bone would be completely resorbed, and new bone would be formed. The cortical block
graft is never fully resorbed and replaced by new bone. The grafted bone remains as necrotic
centers mixed with the newly formed bone. [10]
WĂŐĞϯϬ


Particulate, cortical, or cancellous, bone grafts begin the healing process by apposition of bone.
They provide the necessary scaffold for ingrowth of osteoblasts and precursor cells into the
defect. This apposition of bone is followed by resorption of the graft material. Ideally, there is
complete resorption of the graft material, which is replaced by mature bone. Because cancellous
grafts do not have to first undergo resorption before apposition, they revascularize faster than
cortical block grafts. There is a much higher percentage of newly formed bone and greater
resorption of the graft material when particulate grafts are used.
Autogenous cancellous marrow grafts undergo a well-documented and predictable healing

process. Transferred in the graft are osteocompetent marrow stem cells and osteoblasts. These
cells initially survive at the grafted site through plasmatic diffusion of oxygen and nutrients.
During week 1, platelets degranulate and release growth factors that are chemotactic, mitogenic,
and angiogenic. [10]
These growth factors include:

PDGFaa (Platelet derived growth factor)
PDGFbb
PDGFab
TGF-b1 (Transforming growth factor)
TGF-b2
VEGF (Vascular endothelial growth factor)
EGF (Epidermal growth factor)
Bone remodeling
All bone is in a state of constant turn over. Bone is constantly being removed and replaced. This
is an essential component of the body's metabolism. The removal of the bone liberates calcium
into the blood stream.
The cells that remove bone are called osteoclasts. New bone is formed by specialized cells called
osteoblasts. Osteoblasts are derived from mesenchymal precursors and have receptors for the
WĂŐĞϯϭ


parathyroid hormone, prostaglandins, vitamin D, and certain cytokines. They synthesize bone
[11]
matrix and regulate its mineralization by capturing calcium ions from the blood stream.
Fig : 14 Osteoclast and Osteoblast
Furthermore, osteoblasts mature into osteocytes, which are the cells of mature bone tissue. The
FRRUGLQDWHGDFWLRQV RI WKH RVWHRFODVWVDQG RVWHREODVWVWDNHSODFHDV FXWWHU FRQHV³GULOO´WKURXJK
old bone and lay down concentric lamellae of new bone to form new osteons. This is revisited in
detail later under the topic "direct bone healing". Whether a cutter cone is taking part in the
continuous process of bone turnover, or in bone healing, it functions similarly. Indeed, direct
bone healing is accelerated bone remodeling. [11]
WĂŐĞϯϮ

Fig : 15 Showing osteocyte, osteoblast and osteoclast
Phases of bone healing (indirect)

The phases of indirect bone healing are
,QIODPPDWLRQ
6RIWFDOOXVIRUPDWLRQ
+DUGFDOOXVIRUPDWLRQ
5HPRGHOLQJ. [11]
Inflammation (1±7 days post fracture)

The fracture results in:
6RIW-tissue damage
'LVUXSWLRQRIEORRGYHVVHOVLQERQH
6HSDUDWLRQRIVPDOOERQ\IUDJPHQWV [11]
WĂŐĞϯϯ

Fig : 16 Hematoma forms and the periosteum ruptures partly
Fig : 17 Cells migrate into the fracture hematoma
Fig : 18 Fibrin fibers are formed and stabilize the hematoma (hematoma callus).
(Coagulation starts)
WĂŐĞϯϰ

Soft callus formation (2±3 weeks post fracture)

Once injury occurs, the natural process of bone healing begins with the creation of soft callus a
cascade of cellular differentiation occurs. [11]
Fig : 19 Soft callus formation of cellular differentiation
Phase 1:
New blood vessels invade the organizing Hematoma. Decrease of pain and swelling.
Phase 2:
Fibroblasts, derived from periosteum, invade and colonize the hematoma.
Phase 3:
Fibroblasts produce collagen fibers (granulation tissue).
Phase 4:
Collagen fibers are loosely linked to the bone fragments.
Phase 5:
The cells of the granulation tissue gradually differentiate to form fibrous tissue and subsequently
fibrocartilage (replacing hematoma). [11]
WĂŐĞϯϱ

Fig : 20 Fibrocartilage replacing hematoma
Hard callus formation (3±12 weeks post fracture)

Endochondral ossification converts the soft callus to woven bone starting at the periphery and
moving towards the center, further stiffening the healing tissue. This continues until there is no
more inter-fragmentary movement.
Fig : 21 Hard callus formation
WĂŐĞϯϲ

Remodeling (Process taking months to years)

The remodeling stage:
conversion of woven bone into lamellar bone through surface erosion and osteonal remodeling
once interfragmentary movement ceases. Fracture healing becomes complete with remodeling of
the medullary canal and removal of parts of the external callus. [11]
WĂŐĞϯϳ

Classifications of bone graft

Structure of grafts
Cortical bone grafts are used primarily for structural support, and cancellous bone grafts for
osteogenesis. Structural support and osteogenesis may be combined; this is one of the prime
advantages of using bone graft. [12]
These two factors, however, vary with the structure of the bone. Probably all or most of the
cellular elements in grafts (particularly cortical grafts) die and are slowly replaced by creeping
substitution, the graft merely acting as a scaffold for the formation of new bone. [12]
In hard cortical bone this process of replacement is considerably slower than in spongy or
cancellous bone. Although cancellous bone is more osteogenic, it is not strong enough to provide
efficient structural support. When selecting the graft or combination of grafts, the surgeon must
be aware of these two fundamental differences in bone structure. Once a graft has united with the
host and is strong enough to permit unprotected use of the part, remodeling of the bone structure
takes place commensurate with functional demands. [12]
Bone grafts may be cortical, cancellous, or corticocancellous. If structural strength is required,

cortical bone grafts must be used. However, the process of replacement produces resorption as
early as 6 weeks after implantation; in dogs, it may take up to 1 year before the graft begins to
regain its original mechanical strength. Drilling holes in the graft does not appear to accelerate
the process of repair, but it may lead to the early formation of biologic pegs that enhance graft
union to host bone. [12]
Sources of grafts
For most applications, autogenous bone graft is indicated. Other types of bone grafts are
indicated only if autogenous bone graft is unavailable or if it is insufficient and must be
augmented. Another exception is when structural whole or partial bones, with or without joint
articular surfaces, are needed for reconstruction of massive whole or partial bone defects.
WĂŐĞϯϴ


Autogenous grafts, when the bone grafts come from the patient, the grafts usually are removed
from the tibia, fibula, or ilium. These three bones provide cortical grafts, whole bone transplants,
and cancellous bone, respectively. [12]
TYPES OF BONE GRAFT

Autograft
Autologous (or autogenous) bone grafting involves utilizing bone obtained from the same
individual receiving the graft. When a block graft will be performed, autogenous bone is the
most preferred because there is less risk of the graft rejection because the graft originated from
the patient's own body such a graft would be osteoinductive and osteogenic, as well as
osteoconductive. A negative aspect of autologous grafts is that an additional surgical site is
required, in effect adding another potential location for post-operative pain. [12]
All bone requires a blood supply in the transplanted site. Depending on where the transplant site
and the size of the graft, an additional blood supply may be required. For these types of grafts,
extraction of the part of the periosteum and accompanying blood vessels along with donor bone
is required. This kind of graft is known as a vital bone graft. [12]
Allografts
Allograft bone, like autogenous bone, is derived from humans; the difference is that allograft is
harvested from an individual other than the one receiving the graft. Allograft bone is taken from
cadavers that have donated their bone so that it can be used for living people who are in need of
it; it is typically sourced from a bone bank. [12]
In small children the usual donor sites do not provide cortical grafts large enough to bridge
defects, or the available cancellous bone may not be enough to fill a large cavity or cyst;
furthermore, the possibility of injuring a physis must be considered. Therefore grafts for small
[12]
children usually were removed from the father or mother.
WĂŐĞϯϵ


Heterogeneous Grafts
The undesirable features of autogenous and allogenic bone grafting, heterogenous bone, that is,
bone from another species, was tried early in the development of bone grafting and was found to
be almost always unsatisfactory. These grafts often incited an undesirable foreign body reaction.
Consistently satisfactory heterogenous graft material still is not commercially available, and its
use is not recommended.
Cancellous Bone Substitutes

Hydroxyapatite and tricalcium phosphate, synthetic and naturally occurring materials, are now
being used as substitutes for cancellous bone grafts in certain circumstances. These porous
materials are invaded by blood vessels and osteogenic cells, provide a scaffold for new bone
formation, and are, in theory, eventually replaced by bone.
There primary usefulness is in filling cancellous defects in areas where graft strength is not
important. Bucholz et al. found hydroxyapatite and tricalcium phosphate materials to be effective
alternatives to autogenous cancellous grafts for grafting tibial plateau fractures. A synthetic bone
graft substitute composed of biphasic ceramic (60% hydroxyapatite and 40% tricalcium
phosphate) plus type I bovine collagen and marketed as Collagraft has recently undergone
clinical trials. [12]
Synthetic variants
Artificial bone can be created from ceramics such as calcium phosphates (e.g. hydroxyapatite
and tricalcium phosphate), Bioglass and calcium sulphate; all of which are biologically active to
different degrees depending on solubility in the physiological environment.
These materials can be doped with growth factors, ions such as strontium or mixed with bone
marrow aspirate to increase biological activity. Some authors believe this method is inferior to
autogenous bone grafting, however infection and rejection of the graft is much less of a risk, the
mechanical properties such as Young's modulus are comparable to bone .[12]
WĂŐĞϰϬ


Xenografts
Xenograft bone substitute has its origin from a species other than human, such as bovine.
Xenografts are usually only distributed as a calcified matrix. In January 2010 Italian scientists
announced a breakthrough in the use of wood as a bone substitute, though this technique is not
expected to be used for humans until at the earliest. [12]
Alloplastic grafts
Alloplastic grafts may be made from hydroxyl apatite, a naturally occurring mineral that is also
the main mineral component of bone. They may be made from bioactive glass. Hydroxyl apetite
is a Synthetic Bone Graft, which is the most used now among other synthetic due to its
osteoconduction, hardness and acceptability by bone. Some synthetic bone grafts are made of
calcium carbonate, which start to decrease in usage because it is completely resorbable in short
time which make the bone easy to break again. Finally used is the tricalcium phosphate which
now used in combination with hydroxyl apatite thus give both effect osteoconduction and
resorbability.[12]
Bone bank
It is used to preserved allogenic bone. Allografts are indicated in small children, aged persons,
patients who are poor operative risks, and patients from whom enough acceptable autogenous
bone is not available. Autogenous cancellous bone can be mixed in small amounts with allograft
bone as "seed" to provide osteogenic potential. Mixed bone grafts of this type will incorporate
more rapidly than allograft bone alone. [12]
To efficiently provide safe and useful allograft material, a bone banking system is required that
uses thorough donor screening, rapid procurement, and safe, sterile processing.
Standards outlined by the American Association of Tissue Banks must be followed. Donors must
be screened for bacterial, viral (including HIV and hepatitis), and fungal infection. Malignancy
(except basal cell carcinoma of the skin), collagen-vascular disease, metabolic bone disease, and
the presence of toxins are all contraindications to donation.
WĂŐĞϰϭ


Nearly one third of all bone grafts used in North America are allografts. Allografts have
osteoconductive proprieties and can serve as substitutes for autografts but carry the risk of
disease transmission. The risk for transmission of human immunodeficiency virus (HIV) is
1:1,500,000; for hepatitis C, the risk is 1:60,000; and for hepatitis B, it is 1:100,000.
The U.S. Food and Drug Administration (FDA) requires testing for HIV-1, HIV-2, and hepatitis
C; many states require additional testing for hepatitis B core antibody. The American
Association of Tissue Banks additionally tests for antibodies to human T-cell lymphotrophic
virus. [12]
Growth factors
Growth Factor enhanced grafts are produced using recombinant DNA technology. They consist
of either Human Growth Factors or Morphogens (Bone Morphogenic Proteins in conjunction
with a carrier medium, such as collagen). [12]
Classification of Bone graft

Several categories of bone graft and graft substitutes are available and include a variety of
materials, with different sources and origins. In spite of the availability of wide range of choices,
DXWRORJRXV ERQH VWLOO UHPDLQV WKH ³JROG VWDQGDUG´ IRU VWLPXODWLQJ ERQH UHSDLU DQG UHJHQHUDWLRQ
but its availability may be limited and the procedure to harvest the material is associated with
many complications. [13]
Bone-graft substitutes can either substitute autologous bone graft or expand an existing amount
of autologous bone graft.
Classification of grafts and graft substitutes could be modified as follows:

A. Harvested bone grafts and graft substitutes:
These include bone grafts, endogenous or exogenous, that are essential to provide support and
enhance biologic repair of skeletal defects due to traumatic or non-traumatic origin.
WĂŐĞϰϮ

Fig : 22 Harvested bone graft
B. Growth factor-based bone graft substitutes:

These are natural and recombinant growth factors used alone or in blend with other materials
such as transforming growth factor-beta (TGF-beta), platelet-derived growth factor (PDGF),
fibroblast growth factor (FGF), and bone morphogenetic protein (BMP).
Growth factors bind to receptors on cell surfaces stimulating the formation of proteins to be used
inside the cell or externally (e.g. formation of extracellular matrices like bone tissue). [13]
Fig : 23 Growth factor
WĂŐĞϰϯ


C. Cell-based bone graft substitutes:
These use cells to generate new tissue alone or are seeded onto a support matrix (e.g.,
mesenchymal stem cells). [13]
Fig : 24 Mesenchymal stem cell Fig : 25 Platelet rich plasma
D. Ceramic-based bone graft substitutes:

These include calcium phosphate, calcium sulfate, and bio glass used alone or in combination.[13]
Fig : 26 Calcium sulphate
WĂŐĞϰϰ


E. Polymer-based bone graft substitutes:
Degradable and non-degradable polymers are used alone or in combination with other materials
(e.g., Cortoss [Orthovita, Inc, Malvern, Pa], open porosity polylactic acid polymer [OPLA],
Immix [Osteobiologics, Inc, San Antonio, Tex]).
F. Miscellaneous:
Various unconventional marine biomaterials are also used as bone graft substitutes which include
coral, chitosan, and sponge skeleton. [13]
WĂŐĞϰϱ

Applications of Autogenous Bone Graft in Oral and Maxillofacial Surgery

Calvarian bone graft for Pre Prosthetic Surgery
The calvarium is composed of two parallel layers of cortical bone separated by a thin layer of
cancellous bone. The skull reaches 75% of its thickness by the age of 5 years and adult thickness
by 17 years. The mean thickness of the adult skull ranges from 6.80 mm to 7.72 mm but can also
deviate 3 mm and 12 mm. [14]
The autogenous Calvarial bone (CBG) were described as osteocutaneous vascularized flaps in
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was suggested that Calvarial membranous bone was superior to Endochondral bone as bone graft
material for head and neck surgery. Calvarial bone embryonal derivation (membranous)
compactness and wider availability when compared with other extra oral sites makes it preferred
choice in preprosthetic surgery. Cranial bone has excellent mechanical strength due to its larger
cortical component. Calvarial donor site causes less discomfort to the patient compared with rib
or iliac. [14]
Procedure/Technique
There are different procedures for harvesting the graft, procedure outlined by Christian metes et
al is described below Donor site ± Skull Radiographs to determine the thickness and density of
parietal bone, non-dominant hemishphere right handed patient right side is preferred. The length
of the incision depends on the quantity of bone needed and good visibility on the donor site.
Mark the midline, a distance of at least 3 cm from the median line to avoid the contact with the
superior sagittal sinus. Split Calvarial bone grafts from outer cortex, desired dimensions of the
graft block outlined with round burs under constant irrigation. The bur should reach the
cancellous bone, indicated by bleeding, but should not penetrate the inner side of the cortical
bone, preventing contact to the meninges. The block grafts than segmented in smaller grafts. To
facilitate harvesting and are removed using curved chisels. Donor site the cranial defect is closed
with Bicalcium Phosphate cement or Tricalcium Phosphate cement. Inner layer closed by
continuous suture with vicryl and outer layer stapled or sutured with silk. [14]
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Fig : 27 A Lateral Skull radiograph
Fig : 28 Preparing the graft
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Fig : 29 Blocking graft
Fig : 30 After removal of graft and shaping
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Fig : 31 Closing the donor site with cement
Advantages and Disadvantages of Calvarial bone graft

Advantages
The main advantage of Calvarial bone graft is good integration, absence of pain and no visible
scar. The skull is well known donor site.
Disadvantages
The outer table of the Calvarial bone, limit of this surgery is thin Calvarial bone less than 5mm,
because the risk of dural or cerebral wound is accentuated. Calvarial bone grafts are not indicated
if there is extensive sagittal misrelationship between maxilla and mandible. [14]
Complication
Limited use of electrocoagulation to avoid destruction of hair follicles.
Sagittal sinus lacerations in cases of thin calvaria. [14]
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Block Grafting in the Preparation of Site for an Implant

Alveolar ridge resorption after tooth loss is a common phenomenon. After a tooth is extracted the
alveolar ridge decreases in width and height very rapidly, with as much as 50% loss in width
during the first year, two-thirds of which occurs in the initial 3 months. Restorations supported
by dental implants are currently a widely accepted and successful treatment modality for the
treatment of partial and complete edentulism. [15]

The availability of adequate bone volume for dental implant placement is often diminished by
trauma, pathology, periodontal disease, and tooth loss. The placement of titanium implants in
sites that are deficient of alveolar ridge width has always been unpredictable due to the lack of
bone around the implant. Autogenous bone grafts have been used for many years for ridge
augmentation and are still considered the gold standard for jaw reconstruction. Preparation of
deficient alveolar ridge for the placement of implants with autogenous block graft namely,
symphysis. [15]
Fig : 32 Pre operative
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Procedure/Technique
Full thickness mucoperiosteal flap was raised and labial surface of mandibular symphysis was
exposed till the lower border of mandible. Size of defect previously recorded was marked on the
symphysis, 5 mm away from apices of mandibular anteriors, mental foramina & 4 mm from
lower border of mandible.
Postage stamp method was adopted and holes were drilled with no.702 bur. Depth of the holes
were limited till the medullary bone. Holes were joined & corticocancellous block graft was
harvested using straight and curved osteotomes. [15]
Fig : 33 OPG showing horizontal bone loss between maxillary right first and third molars, with thick
mucosa covering it.
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Fig : 34 Incision marked for symphysis graft harvesting
Fig : 35 Osteotomy done to harvest the graft
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Fig : 36 Corticocancellous symphysis graft harvested
The recipient site and donor site were prepared following standard aseptic technique. Local
anaesthesia was administered at the recipient and the donor site via bilateral inferior alveolar
nerve blocks and right posterior superior alveolar nerve block and greater palatine nerve block.
Crestal incision was given on the recipient site, and releasing incision was given anteriorly. A
full thickness mucoperiosteal flap was reflected. The defect was measured clinically and was 5
mm buccolingually and 6 mm anteroposteriorly. Defect was decorticated with no.702 straight
fissure bur. The defect was packed with gauze. A vestibular degloving incision was given from
cuspid to contralateral cuspid, 5 mm away from the mucogingival junction leaving adequate
tissue for bone was curetted out from same donor site. Hemostasis was achieved and closure of
the donor site was done. Harvested corticocancellous block was checked for fit over the recipient
site. Any irregularities on undersurface of the graft were trimmed to achieve maximum graft-
recepient site contact. Corticocancellous block graft was stabilised over the recipient site by
means of 1.5 mm titanium screws of 10 mm length. Margins of the graft were smoothened. [15]

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Fig : 37 Graft secured with 1.5x10 mm titanium screw
Fig : 38 Recipient site closure
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The average symphysis graft has been found to be composed of 65% cortical bone and 36%
cancellous bone, as opposed to the mandibular ramus, which is nearly 100% cortical in nature.[15]
Mandibular Tori: A source of autogenous bone graft

Bone has been harvested successfully from the local areas of the mandible and maxilla and
distant sites, such as the ilium, tibia, scapula, clavicle and calvarium. Due to the location and
complexity of the harvesting procedure, most of these techniques require a comprehensive
surgical protocol. Grafts from the local sites provide advantages that may include an in office
outpatient procedure, reduced operative period and decreased morbidity for the patient.
Intraorally mandibular donor bone is preferred over maxillary bone.
The tori
It is defined as a congenital bony protuberance with benign characteristics, leading to the
overworking of osteoblasts and bone to be deposited along the line of fusion of the palate or on
the hemimandibular bodies.
Mandibular tori are usually symmetrical and bilateral, but can also be unilateral, located on the
lingual side of the mandible, above the mylohyoid line, and at the level of premolars, but it may
extend distally to the third molar and mesially to the lateral incisor. [16]
Etiology
The etiology of the mandibular torus has not been determined clearly, though both genetic
factors and environmental factors such as diet, presence of teeth and occlusal load are thought to
be involved. [16]
Some studies have suggested that genetic predisposition to mandibular torus may be inherited in
a dominant manner. In relation to the role of environmental factors, one study suggested a
correlation between the number of existing teeth and incidence of mandibular torus, as the
number of existing teeth was significantly higher in patients with mandibular torus than in those
without mandibular torus. [16]
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The following reasons have been attributed for the occurrence of tori:
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The size of the tori may vary from few mm to few cm in diameter. The size of the tori may
fluctuate throughout life, and in some cases the tori can be large enough to touch each other in
the midline of mouth. As a result of this, it is believed that mandibular tori are the result of local
stresses and not solely of genetic influences.
Two classification systems are followed based on the size of the tori Haguen et al.
Small <2 mm
Medium 2Ǧ4 mm
Large >4 mm
Reichart et al.
Grade 1 ± small up to 3 mm
Grade 2 ± moderate up to 6 mm
Grade 3 ± marked above 6 mm
Mandibular tori are usually a clinical finding with no treatment necessary until there is complaint
of pain, speech defect. Ulcers can form on the area of the tori due to trauma. The tori may also
complicate the fabrication of dentures. [16]
Removal of the tori can be considered during the following conditions.
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In cases were the tori excision is indicated, surgery can be done to reduce the amount of bone,
but chances of recurrence is more in cases where adjacent teeth still receive local stresses. When
excision is planned, the tori may be either removed with a chisel or via bone bur by smoothening
through the base of the bony tori. [16]

Surgical technique
Conservative incisions were done to provide soft tissue cover over the graft material at the end of
the procedure. The soft tissue cover prevents the material from being washed away. Full
thickness flap reflection was done to expose the recipient area. A relatively thick flap was
preferred over a thin flap to prevent tissue necrosis and possible washing away of the graft
material. Full thickness flap was reflected on the lingual side to expose the mandibular tori which
extended from distal aspect of the canine to the mesial aspect of second premolar. The defect
between 35ǡ36 and 36ǡ37 were prepared by soft tissue debridement by using a combination of
hand curettes and ultrasonic scalers. Root conditioning was done with tetracycline hydrochloride
to decontaminate the root surface and increase the compatibility of the root surface with cell
attachment. As the defect was lined by a cortical wall of bone, which can limit blood flow to the
graft area, intra marrow penetrations were done using a micromotor hand piece with a round bur
to encourage blood supply from the underlying cancellous bone, and provide graft with sufficient
nutrients for survival. [16]
The tori from the lingual side was excised with rotary instruments, chisel and mallet and placed
in a sterile dappen dish with saline. The graft material was condensed in the defect area tightly.
Care was taken for grafts not to be overfilled to avoid exposure due to soft tissue shortage. The
flap margins were coated and sutured. The longcone paralleling technique was used to take all
the radiographs.

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Fig : 39 Pre-op probing
Fig : 40 Pre-op lingual
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Fig : 41Flap reflection
Fig : 42 Defect probing
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Fig : 43 Lingual tori
Fig : 44 Excised tori
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Fig : 45 Defect fill
Intraoral autogenous bone graft material are ideal for periodontal regeneration. The choice of
autogenous donor site is markedly influenced by two important considerations namely, the
quantity of bone required at the recipient site and the biologic qualities of the donor bone. [16]
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Surgical Procedures & Harvesting Techniques


Position of bone grafting is harvested
Sources of cancellous bone
In treating small bone defects secondary to trauma or small tumors, it may be most convenient to
harvest the graft from the ipsilateral extremity undergoing operation. The graft can often be
taken through the same incision or through a small, separate incision. Most of these sites can be
harvested through a small, 2.5 to 5.0 cm longitudinal incision placed over the subcutaneous
surface of the end. [17]
Fig : 46 Source of cancellous bone
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Removal of tibial graft
Make a slightly curved longitudinal incision over the anteromedial surface of the tibia, placing it
so as to prevent a painful scar over the crest. Because of the shape of the tibia, the graft is usually
wider at the proximal end than at the distal. The periosteum over the tibia is relatively thick in
children and can usually be sutured as a separate layer. In adults however, it is often thin, and
closure may be unsatisfactory; suturing the periosteum and the deep portion of the subcutaneous
tissues as a single layer is usually wise. [17]
Fig : 47 Tibial graft
Removal of fibular graft
In the removal of a fibular graft three points should receive consideration:

(1) the peroneal nerve must not be damaged;
(2) the distal fourth of the bone must be left to maintain a stable ankle; and
(3) the peroneal muscles should not be cut. [17]
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The entire proximal two thirds of the fibula may be removed without materially disabling the leg.
However, a study by Gore et al. indicates that most patients have complaints and mild muscular
weakness after removal of a portion of the fibula. The configuration of the proximal end of the
fibula is an advantage: the proximal end has a rounded prominence, which is partially covered by
hyaline cartilage, and thus forms a satisfactory transplant to replace the distal third of the radius
or the distal third of the fibula. [17]
The middle one third of the fibula also can be used as a vascularized free autograft based on the
peroneal artery and vein pedicle using microvascular technique. This graft is recommended by
Simonis, Shirall, and Mayou for the treatment of large defects in congenital pseudarthrosis of the
tibia. Portions of iliac crest also can be used as free vascularized autograft. The use of free
vascularized autografts has limited indications, requires expert microvascular technique, and is
not without donor site morbidity. [17]
Fig : 48 (A) ± Fibula can be harvested longitudinal bone; (B) - tibial graft is shown: a large,
corticocancellous graft can be removed from the proximal tibia on its anteromedial surface.
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Removal of iliac bone graft
The iliac crest is an ideal source of bone graft because it is relatively subcutaneous, has natural
curvatures that are useful in fashioning grafts, has ample cancellous bone, and has cortical bone
of varying thickness. Removal of the bone carries minimal risk and usually there is no significant
residual disability. The posterior third of the ilium is thickest, and this is confirmed by computer
tomography (CT) scans. [17]
Fig : 49 Fig : 50
Fig : 49 This CT scan of the pelvis at the level of the posterosuperior iliac spine illustrate the thickness of
the ilium posteriorly and the amount of cancellous bone available; Fig : 50 The central section of the
ilium at point A is quite thin and is of no use in bone grafting.
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µ
Cancellous grafts
Unless considerable strength is required, the cancellous graft fulfills almost any requirement.
Regardless of whether the cells in the graft remain viable, clinical results indicate that cancellous
grafts incorporate with the host bone more rapidly than do cortical grafts. Large cancellous and
corticocancellous grafts may be obtained from the anterosuperior iliac crest and the posterior
iliac crest. Small cancellous grafts may be obtained from the greater trochanter of the femur,
femoral condyle, proximal tibial metaphysis, medial malleolus of the tibia, olecranon, and distal
radius. At least 2 cm of subchondral bone must remain to avoid collapse of the articular
surface.[17]
Removal of iliac bone graft
When removing a cortical graft from the outer table, first outline the area with an osteotome or
power saw. Then peel the graft up by slight prying motions with a broad osteotome. Wedge
grafts or full-thickness grafts may be removed more easily with a power saw; this technique also
is less traumatic than when an osteotome and mallet are used. For this purpose an oscillating saw
or an air-powered cutting drill is satisfactory. Avoid excessive heat by irrigating with saline at
room temperature. Avoid removing too much of the crest anteriorly and leaving an unsightly
deformity posteriorly.
Fig : 51 Fig : 52
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Fig : 53
Fig : 51 CT scan 3D, Anteroposterior ilium and CT scan 3D, Fig : 52 Oblique posterior ilium with defect
in iliac wall after iliac bone is harvested and Fig : 53 The Iliac wall with defect.
Posterior iliac grafts

The region of the posterosuperior iliac spine is the best source of cancellous bone.
- Make a straight vertical incision directly over the posterosuperior iliac spine or a curvilinear
incision that parallels the iliac crest. To prevent injury to the cluneal nerves, avoid straight
transverse incisions and try not to carry incisions too far laterally. A transverse incision is more
likely to result in dehiscence and can be painful if it lies along the belt line.
- Identify the origin and fascia of the gluteus maximus insertion on the crest. With a cautery
knife, incise the origin of the gluteus maximus and dissect it free from the crest subperiosteally.
If the entire posterior iliac area is to be harvested, take down the gluteus from approximately 2.5
cm superior to the posterosuperior iliac spine and inferior as far as the posteroinferior spine. [17]
- The outer wall of the ilium is removed by first outlining the area to be harvested by cutting
through the outer table of the ilium with a sharp osteotome. If an onlay cancellous bone graft is
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to be performed, harvest corticocancellous strips with a curved gouge. Remove all underlying
cancellous bone down to the inner table of the ilium with a curved gouge and currette of an
appropriate size.
Fig : 54 Incision line Fig 55 : Posterior iliac graft is shown.
Anterior iliac grafts

Large grafts of cancellous and corticocancellous bone can be harvested from the anterior ilium.
Incise with a cautery knife along the iliac crest, avoiding muscle. Subperiosteally, dissect the
[17]
abdominal musculature and, subsequently, the iliacus from the inner wall of the ilium.
-Outline the area to be harvested with straight and curved osteotomes. Cut the strips, which will
be removed. The middle ilium is paper thin, but the anterior column just above the acetabulum is
quite thick.
- Harvest the corticocancellous strips with a gouge.
- Remove additional cancellous bone with gouges and currette. Do not broach the outer table.
Bicortical grafts
Full-thickness bicortical grafts may be necessary for spinal fusion or for replacement of major
bone defects in metaphyseal regions, such as in nonunions of the distal humerus or in opening
wedge osteotomies. [17]
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Fig : 56
Fig : 56 Thin bicortical cancellous grafts is harvested for Congenital pseudarthrosis of the tibia (From
Author - Hung NN. .
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Rib graft
The use of different rib components in grafting is an established and basic modality in nasal,
auricular, cricotracheal, cranial and mandibular reconstruction. The rib grafts were used in
reconstructing deformities or defects in the cranio maxillofacial skeleton and trachea.
Graft harvesting, set, and fixation

The right sixth rib was harvested, osseous only or chondroosseous (costochondral), for
mandibular, maxillary and cranial reconstruction. The periostium was sharply incised along the
anterior surface of the rib and carefully dissected in a circumferential manner from both surfaces
by curved and Doyn elevators taking care not to injure the underlying pleura. The bone was
sharply separated from the chondral junction and cut posteriorly with bone cutting forceps.
When a costochondral graft (CCG) was desired for reconstructing the mandibular ramus, the
perichondrium on the anterior surface was preserved in continuity with a small strip of
periostium. If another graft was desired the fourth one was harvested. The right ninth costal
cartilage was the source of cartilage grafts used in reconstructing nasal dorsal saddling, tracheal
stenosis, and auricular deformities. A subcostal skin incision was used and dissection was
continued as previously described strictly in a circumferential subperichondrial fashion..
During harvesting, continuous palpation of the underlying rib is essential to avoid pleural injury.
The wound was then infiltrated with 5±10 ml of 2% xylocaine and closed in layers after
application of a suction drain. The rib grafts used to reconstruct the mandible (split rib, onlay
whole rib, CCGs) were fixed by 0.5 mm stainless steel wire or 13 mm long titanium self tabbing
mini screws preceded by maxillomandibular fixation that was released 1±3 weeks
postoperatively.
The CCGs (Costochondral graft) were used to reconstruct the mandibular ramus after
condylectomy in patients with Temporomandibular joint ankylosis (four bilateral and six
unilateral). In such cases the graft was proved to have the advantages of restoring the shortened
posterior face height, correcting the facial disfigurement in the form of symmetric and non-
symmetric retrognathia, preventing recurrence of the ankylosis, and providing a potential for
growth in children.
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Graft loss because of infection seems to be the major disadvantage of the use of Costochondral
graft. The perioperative administration of systemic antibiotics and the temporary storage of the
graft in an antibiotic/saline solution are considered to limit the incidence of such infection.
Fig : 58 (a) Operative view showing the split rib grafts reconstructing the bifrontal defect in the patient
with the interosseous meningioma; (b) operative view of the split rib graft reconstructing the
zygomaticomaxillary and pterygomaxillary buttresses; (c) postoperative view of a patient after maxillary
reconstruction with an accepted esthetic appearance; (d) postoperative 3DCT scan of the patient, (e)
showing the survived bone grafts.
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Bone grafting fundamentals
Bone grafting refers to a wide variety of surgical methods augmenting or stimulating the
formation of new bone where it is needed.
There are five broad clinical situations in which bone grafting is performed:
1. To stimulate healing of fractures either fresh fractures or fractures that have failed to heal after
an initial treatment attempt.
2. To stimulate healing between two bones across a diseased joint. This situation is called
³DUWKURGHVLV´RU³IXVLRQ´
3. To regenerate bone which is lost or missing as a result of trauma, infection, or disease.
Settings requiring reconstruction or repair of missing bone can vary from filling small cavities to
replacing large segments of bone 12 or more inches in length.
4. To improve the bone healing response and regeneration of bone tissue around surgically
implanted devices, such as artificial joints replacements (e.g. total hip replacement or total knee
replacement) or plates and screws used to hold bone alignment.
5. To plastical arthrosis of acetabulum (Congenital Dislocation of the Hip or Perthes disease). [17]
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Indications For Various Techniques
Single Onlay Cortical Grafts.
Until relatively inert metals became available, the onlay bone graft was the simplest and most
effective treatment for most ununited diaphyseal fractures. Usually the cortical graft was
supplemented by cancellous bone for osteogenesis. The onlay graft is still applicable to a limited
group of fresh, malunited, and ununited fractures and after osteotomies. [17]
Cortical grafts also are used when bridging joints to produce arthrodesis, not only for
osteogenesis but also for fixation. Fixation as a rule is best furnished by internal or external
metallic devices. Only in an extremely unusual situation would a cortical onlay graft be indicated
for fixation, and then only in small bones and when little stress is expected. For osteogenesis the
thick cortical graft has largely been replaced by thin cortical and cancellous bone from the ilium.
The single-onlay cortical bone graft was used most commonly before the development of good
quality internal fixation and was employed for both osteogenesis and fixation in the treatment of
nonunions. [17]
Dual Onlay Grafts.
Dual onlay bone grafts are useful when treating difficult and unusual nonunions or for the
bridging of massive defects. The treatment of a nonunion near a joint is difficult, since the
fragment nearest the joint is usually small, osteoporotic, and largely cancellous, having only a
thin cortex. It is often so small and soft that fixation with a single graft is impossible because
screws tend to pull out of it and wire sutures cut through it. Dual grafts provide stability because
they grip the small fragment like forceps. [17]
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The advantages of dual grafts for bridging defects are as follows:
(1) Mechanical fixation is better than fixation by a single onlay bone graft.
(2) The two grafts adds strength and stability.
(3) The grafts form a trough into which cancellous bone may be packed.
(4) During healing the dual grafts, unlike a single graft, prevent contracting fibrous tissue
from compromising transplanted cancellous bone. [17]
Fig : 59 Single-onlay cortical bone graft is shown for humeral pseudarthrose.
The disadvantages of dual grafts are the same as those of single cortical grafts:
(1) they are not as strong as metallic fixation devices.

(2) an extremity must usually serve as a donor site if autogenous grafts are used.
(3) they are not as osteogenic as autogenous iliac grafts, and the surgery necessary to obtain them
has more risk. [17]
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Fig : 60 Cortical cortical cancellous bone graft is harvested from Ilium for scoliosis.
.
Inlay Grafts.
In the inlay technique a slot or rectangular defect is created in the cortex of the
host bone, usually with a power saw. A graft the same size or slightly smaller is then fitted into
the defect. In the treatment of diaphyseal nonunions, the onlay technique is simpler and more
efficient and has almost replaced the inlay graft. The latter is still occasionally used in
arthrodesis, particularly at the ankle.
Albee popularized the inlay bone graft for the treatment of nonunions. Inlay grafts are created by
a sliding technique, graft reversal technique, or as a strut graft. Although originally designed for
the treatment of nonunion of the tibia, these techniques are also used for arthrodesis and
epiphyseal arrest. [17]
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Fig : 61 Fig : 62
Fig : 63
Fig : 61 In this case, A sliding graft is used as a component of ankle arthrodesis. This type of graft is more
likely to be used for a previously failed ankle fusion or for fusion in the absence of the body of the talus;
Fig : 62 A sliding graft is used as a component of knee arthrodesis. This type of graft is more likely to be
used for a previously failed knee fusion and Fig : 63 Strut grafts for anterior spinal fusion.
Medullary Grafts.
Medullary bone grafts were tried early in the development of bone grafting techniques for
nonunion of the diaphyseal fractures. Fixation was insecure, and healing was rarely satisfactory.
This graft interferes with endosteal circulation and consequently can interfere with healing.
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Medullary grafts are not indicated for the diaphysis of major long bones. Grafts in this location
interfere with restoration of endosteal blood supply; because they are in the central axis of the
bone, they resorb rather than incorporate. The only possible use for a medullary graft is in the
metacarpals and the metatarsals, where the small size of the bone enhances incorporation. Even
in this location, however, internal fixation with onlay or intercalary cancellous bone grafting may
be a superior method. [17]
Osteoperiosteal grafts
In osteoperiosteal grafts, the periosteum is harvested with chips of cortical bone. These grafts
have not been proven to be superior to onlay cancellous bone grafting, are more difficult than
cancellous bone to harvest, and may involve greater morbidity; they are rarely used today.
Pedicle grafts
Pedicle grafts may be local or moved from a remote site using microvascular surgical techniques.
In local muscle-pedicle bone grafts, an attempt is made to preserve the viability of the graft by
maintaining muscle and ligament attachments carrying blood supply to the bone or, in the case of
diaphyseal bone, by maintaining the nutrient artery. Two examples are the transfer of the anterior
iliac crest on the muscle attachments of the sartorius and rectus femoris for use in the Davis type
of hip fusion and the transfer of the posterior portion of the greater trochanter on a quadratus
muscle pedicle for nonunions of the femoral neck.
Multiple Cancellous Chip Grafts.

Multiple chips of cancellous bone are widely used for grafting. Segments of cancellous bone are
the best osteogenic material available. They are particularly useful for filling cavities or defects
resulting from cysts, tumors, or other causes, for establishing bone blocks, and for wedging in
osteotomies. Being soft and friable, this bone can be packed into any nook or crevice. The ilium
is a good source of cancellous bone, and if some rigidity and strength are desired, the cortical
elements may be retained.
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In most bone-grafting procedures that use cortical bone or metallic devices for fixation,
supplementary cancellous bone chips or strips are used to hasten healing. Cancellous grafts are
particularly applicable to arthrodesis of the spine, since osteogenesis is the prime concern. [17]
Hemicylindrical Grafts
Hemicylindrical grafts are suitable for obliterating large defects of the tibia and femur. A
massive hemicylindrical cortical graft from the affected bone is placed across the defect and is
supplemented by cancellous iliac bone. A procedure of this magnitude has only limited use, but
it is applicable for resection of bone tumors when amputation is to be avoided.
The fibula provides the most practical graft for bridging long defects in the diaphyseal portion of
bones of the upper extremity, unless the nonunion is near a joint. A fibular graft is stronger than
a full-thickness tibial graft, and when soft tissue is a wound that could not be closed over dual
grafts may be closed over a fibular graft. [17]
Sliding graft
This technique is rarely used today, because internal fixation combined with onlay
cancellous bone graft provides a better result. This technique may be combined with internal
fixation if there is limited space to place a cancellous graft. The disadvantages of the sliding or
reversed bone graft are that, after the cuts are made, the graft fits loosely in the bed, and it creates
stress risers proximally and distally to the nonunion site.
Peg and Dowel grafts

Dowel grafts were developed for the grafting of nonunions in anatomic areas, such as the
scaphoid and femoral neck, where onlay bone grafting was impractical. In the carpal scaphoid,
the dowel is fashioned from dense cancellous bone. The use of the dowel graft for the
management of nonunion of the femoral neck. Free microvascularized fibula grafts are more
commonly used today. A corticocancellous graft of appropriate length and approximately 25 mm
wide is harvested from the ilium or the tibia. The curvature of the ilium often makes it difficult to
obtain a straight graft of sufficient length.
WĂŐĞ
Fibular bone grafting for defect of tibia cause osteomyelitis

The rules of bone grafting for long defects in the diaphyseal portion of extremity due to
osteomyelitis are:
(1). General status is stable: ESR: < 10 mm/h; CRP: < 10 mg/L ; WBC: <
10.000; Neutrophil: < 60%
(2) Local extremity with bone defect: no swelling, no hot temperature, no pain, and no pus fistula
for at least 3 months.
(3) Remove sclerosis bone until bone bleeding;
(4) Solid fixation of bone graft into bone bed by Kirschner wire or plate and screw and plaste
cast.
(5) The Kirschner wire will be removed when clear clinical and radiographic evidence of solid
union were apparent (mean more than 18 months).
(6) Prolonged orthotic protection was required when ankle transfixation had been performed and
A knee-ankle-foot orthosis was worn until the patient reached skeletal maturity. [17]
Dual-onlay cortical cancellous bone graft is harvested Ilium for congenital pseudarthrosis
of the tibia.
The rules of bone grafting for Congenital Tibial Pseudarthrosis:
(1) The bone and fibrous tissue at the site of the pseudarthrosis are excised completely until
normal bone of the tibial shaft .
(2) The medullary canal of both tibial fragments is reamed with a drill or a Small currette or
both.
(3) The autogenous iliac crest bone graft was applied to anterolateral and posterior part of
the tibia:
(4) Solid fixation bone graft into bone bed by Kirschner wire or plate and screw and plaste
cast.
(5) The needed length of the Kirschner wire is calculated on the basis of the expected length
of the leg after the affected bone and fibrous tissues have been removed and after the
angular deformity has been corrected.
(6) The Kirschner wire will be removed when solid clinical and radiographic union were
apparent (mean more than two years)
WĂŐĞ
(7) Prolonged orthotic protection was required when ankle transfixation had been performed
and a knee-ankle-foot orthosis was worn until the patient reached skeletal maturity. [17]
Potential Autogenous Bone Graft Donor Sites

Autogenous bone grafts can be vascularized or non-vascularized. Vascularized bone grafts are
much more complex to harvest and have a great deal of donor site morbidity associated with
their use. Non-vascularized grafts are considerably simpler to harvest and use if they are placed
into a well vascularized recipient bed. [17]
Both intra-oral and extra-oral bony donor sites have been used successfully as sources of
nonvascularized autogenous bone for grafting of maxillofacial defects. The volume of bone graft
required determines the choice of the donor site. [17]
If the defect is small, often local, intra-oral sources can be used. Intra-oral sites are often
preferred since they allow harvesting of bone from the area adjacent to the reconstruction. A
second distant surgical site and the extra-oral scar can be avoided. Intra-oral harvesting can
mostly be performed on an outpatient basis under local anaesthesia. These intra-oral sites can
include mandibular symphysis, mandibular ramus and retromolar area, coronoid process,
maxillary tuberosity, maxillary torus palatinus or mandibular tori, if they are present, and the
zygomatic bone using a specially designed bone collector or suction trap. However the volume
of bone available in intra-oral sites may be insufficient for moderate to large defects. [17]
Fig : 64 Bone Collectors
WĂŐĞ
The above figure showing the specially designed bone collector used to harvest intra-oral cortical
bone grafts of membranous origin, such as from the zygomatic bone. This collector is used as a
suction trap. The surface of the donor site is drilled or trephined with a series of burs producing a
fine dust or slurry of bone. This is suctioned into the bone trap. Great care is taken during an
intra oral harvest to avoid suctioning saliva and dental plaque or other tooth debris into the
harvested bone particles. The suction trap has two control features to avoid this potential
harvesting problem. [17]
When a greater volume of bone is required, extra-oral sources are usually employed. These may
include the anterior or posterior iliac crest, the calvarium, the rib and the proximal tibia.
In fact specially designed devices have been developed to minimize the morbidity at the second
surgical site, made necessary by the harvesting of such grafts. The motorized trephine shown in
consists of a pre-cutter, an internal bone forcep, and a trephine that is capable of ejecting the
harvested cancellous bone core from the anterior iliac crest. This motorized trephine can be used
through a small, 1 cm stab incision over the anterior iliac crest. Up to 7 cores of bone measuring
4.1 mm in diameter by 30 mm in length can be harvested from each anterior iliac crest. The
intervening bone between the harvested bone cores can also be removed, doubling the size of the
harvest. The harvested cores appear to be well trabeculated in the histologic section that is
shown. The grafts can be seen to be quite cellular, containing many osteogenic elements. This is
one of the main advantages of such an autogenous bone graft. The morbidity of this technique is
much lower compared to traditional open anterior iliac crest harvesting techniques. Open
procedures generally require inpatient hospital admission of patients; the closed trephine
approach is routinely performed in day surgery, as an outpatient procedure without hospital
admission. [17]
WĂŐĞ
Fig : 65 Bone driller.
The above figure shows the minimizing the morbidity of extra-oral bone graft harvesting using a
percutaneous power-driven trephine to procure bone graft material from the anterior iliac crest.
WĂŐĞ
Complications
COMPLICATIONS
Complications for grafts from the iliac crest
Some of the potential risks and complications of bone grafts employing the iliac crest as a donor
site include:
Anterior Ilium
Pain
Pain after bone graft harvest from the anterior ilium has multiple origins. It can result from
hematoma, wound infection, neuropraxia of cutaneous nerves, stress fracture, or from the
dissection itself. Pain, from whatever the source, has been noted to last on average 3.75 weeks.
In 90% of patients, symptoms resolve in less than 1 month but 2.8% may have persistent pain
lasting over 3 months.
Cosmesis
Obtaining bone from the anterior ilium most often requires an additional incision from the
recipient site incision. The overall cosmesis has been rated as good in 86.1%, fair in 10.4% and
poor in 3.5%. Additionally, it has been observed that worse ratings are given by women and
those who are obese. Methods to improve cosmesis include using a trap door or subcrestal
window technique to remove the graft allowing for preservation of the natural contour of the
ilium.
Wound healing
Wound healing complications are not uncommon after bone graft harvest and have multiple
origins, including infection, hematoma and wound dehiscence. Even with the use of thrombin-
soaked gel foam and bone wax, residual bleeding often occurs from the cancellous bone. Studies
have shown the presence of hematomas in 4 -10% of patients. Additionally, multiple vessels,
[17]
including the deep circumflex, iliolumbar, and fourth lumbar arteries, may be damaged.
WĂŐĞ
Complications
Nerve damage
Injury to the lateral femoral cutaneous and the ilioinguinal nerves is not an uncommon
complication from anterior graft harvest. Meralgia paresthetica may occur when the lateral
femoral cutaneous nerve is injured. There are three origins of injury to this nerve: neurotmesis of
the nerve as it crosses the crest, neuropraxia from retraction of the iliacus and crush injury during
stripping of the outer table muscles. Symptoms include pain and numbness over the anterolateral
[17]
thigh immediately postoperatively, and these symptoms are commonly worse with walking.
Hernia
Herniation of abdominal contents through a bone graft site has been reported and can be a
potentially serious complication requiring reoperation. Abdominal wall muscles attach to the
iliac crest and prevent abdominal contents from migrating over the crest, and the iliacus muscle
prevents contents from penetrating through a defect in the iliac wing. The hernia forms when
there has been a violation of these muscles with an inadequate repair. It can be diagnosed
clinically with confirmation by CT scan. [17]
Pelvic fracture
The sartorius and tensor fascia lata originate on the ASIS (Anterior superior iliac spine) and have
been reported to cause an avulsion fracture to the ASIS. Hu and Bohlman examined this and
found that a graft taken 30 mm posterior to the ASIS was 2.4 times the strength of a graft taken
at 15mm. Therefore, it is recommended that any vertical cut into the ilium be at least 3 cm
posterior to the ASIS. Osteoporotic, elderly women have been found to be at a higher risk for
this complication. [17]
Gluteal gait
A gluteal gait is an abductor lurch seen as a result of abductor weakness, especially the gluteus
medius. This may be found in up to 3% of patients after graft harvest. Its incidence can be
minimized through a less extensive stripping of the outer table muscles of the ilium and by
[17]
careful re-approximation and secure reattachment of the gluteal fascia to the periosteum.
WĂŐĞ
Complications
Posterior Ilium
Pain
Chronic pain, hyperesthesia and dysesthesia are among the most common complaints after
posterior iliac bone graft harvest. Studies have shown that 29% of patients complain of chronic
pain for longer than 1 year. It also has been shown that patients who have the bone graft taken
for spinal reconstruction surgery have twice the incidence of pain compared with those who have
the graft taken for spinal trauma purposes.
Hematoma or wound Infection

Hematomas have been found to be less problematic with posterior compared with anterior iliac
graft harvests. This is thought to be secondary to the hemostatic effect of the body placing
pressure on the surgical site. Although this may decrease hematoma formation, it has been
observed that more than 10% of patients present with wound healing problems. Although the
overall majority of complications are mild to moderate wound dehiscence, a 2.7% deep infection
rate has been observed that required treatment with intravenous antibiotics. [17]
Nerve injury
The nerves most commonly at risk are the superior cluneal nerves. Injury to the superior cluneal
nerves may result in pain, hyperesthesia or paresthesia of the buttock region. These nerves pierce
the lumbodorsal fascia and cross the posterior iliac crest 6-8 cm lateral to the PSIS. They travel
in the inferolateral direction. These nerves are intimately associated with the lumbodorsal fascia
making their identification difficult. Previously it was believed that a vertical midline incision
avoided the superior cluneal nerves and resulted in less postoperative pain than a lateral oblique
incision. Ferny Hough et al, failed to show a statistically significant difference in pain between
the use of the lateral oblique incision and the vertical incision, thus concluding that either
approach is appropriate.
WĂŐĞ
Complications
Vascular injury
The superior gluteal artery exits the sciatic notch in the superior most portion and sends branches
to the gluteal muscles. Careless placement of a retractor or removal of graft from the sciatic
notch may result in laceration of the artery or arteriovenous fistula formation. In a cadaver study
by Xu et al the anatomic distances between the superior gluteal vessels and the pelvic landmarks
were measured. The vessels were found to be an average of 62mm from the PSIS (Posterior
superior iliac spine) and 102 mm from the iliac crest. Injury can best be avoided by knowing the
anatomy. The inferior margin of the roughened area just anterior and lateral to the PSIS should
be the caudal limit for bone harvest, and should a retractor be used, it should not be blindly
inserted into the sciatic notch. When vascular injury occurs, the artery may retract into the pelvis
making visibility difficult. [17]
Sacro-iliac (SI) joint instability

Cases of instability and dislocation of the SI joint have been reported after posterior iliac bone
harvest. There are many ligaments that make up the SI joint complex. Most notably are the dense
interosseous ligaments that are more numerous superiorly and offer the primary support. In
addition, there are the short and long posterior ligaments and the thin anterior ligaments, which
assist in the support. Compromise of these ligaments can result in instability and over time may
result in pubic rami fractures and possible dislocation of the SI joint. [17]
Ureteral injury
Ureteral injury is a very rare complication but important because of its severity. The ureters run
deep through the sciatic notch and use of electrocautery or careless placement of a retractor can
cause injury. Presenting symptoms may include fever, ileus, hematuria and hydronephrosi. [17]
Complications of allograft
Nonunion
Nonunion, by convention, implies nonhealing of the graft±host junction at 1 year and has been
reported from 11 to 30%. Factors that have been implicated are age (older age), type of graft
(highest in arthrodesis), location (worse for diaphyseal junction), stage of disease (higher for
WĂŐĞ
Complications
stage 2 or 3), requirement of adjuvant therapy (higher for chemotherapy or radiotherapy),

infection, fracture, type and stability of fixation, and revision surgery (worse as number of
procedures increase). Infection and fracture rates are higher in patients with nonunions and
subsequent outcomes are poorer. Apart from these mechanical reasons, immunological response
may also play a part in nonunion. To treat nonunions, various procedures have been
recommended, including autogenous bone graft, double plating for stable fixation, and
vascularized fibular grafts. [17]
Fractures
Allograft fracture has been seen in 12±54% of cases, depending on the variables involved and the
definition of fracture. Fractures generally occur after 6 months, around the time of
revascularization; most fractures (75%) occur during the first 3 years of implantation.
Chemotherapy, radiation, cortical penetrating internal fixation, nonunion at host±graft junction,
infection, type of graft (higher for osteoarticular and arthrodesis transplant), location (more for
femur), gap more than 2 mm, and larger grafts (more than 14.5 cm) have been linked with
fracture in various studies. [17]
Infection
Infection is the most devastating complication after allograft transplant, often the leading cause
of graft failure. It is associated with other complications and a worse outcome. The incidence has
been reported to be 9±30%. About 75% were diagnosed within the first 4 months after
implantation in the study by Lord et al. and 70% within the first month in a study by Dick and
Strauch. Polymicrobial infection may be present in 50% of the cases and Staphylococcus
epidermidis may be the most common single organism.
Factors associated with local wound problems are an extensive surgery (tumor stage, more bone,
soft tissue or skin loss, duration of surgery, postoperative hematoma or drainage), adjuvant
WKHUDS\ WKH SDWLHQW¶V LPPXQH VWDWXV DQG PXltiple surgeries. Late infection is unrelated to
adjuvant therapy and may happen anytime. [17]
WĂŐĞ
Complications
Graft disease transmission

Donor screening is the first step in preventing the use of contaminated grafts. Both the FDA
(Food and Drug administration) and AATB (American Association of tissue bank) have detailed
guidelines regarding the medical history as well as clinical test results of the donor. Screening is
currently done for HIV, hepatitis B virus, hepatitis C virus, human transmissible spongiform
encephalopathy, syphilis, human T-lymphotropic virus, and cytomegalo virus. Bone allograft
contamination is rare, and in a previous study had been estimated to be less than 0.3%. The
number of actual infections from allografts is very low: two reports of HIV in 1988, 1992; three
reports of hepatitis, hepatitis B in 1954, hepatitis C in 1992, 1993 and one fatal clostridium
transmission in 1995. When examining graft tissue, however, one study reported five (18.5%) of
27 femoral heads from live donors and three (37.5%) of eight allografts from cadavers to be
infected. [17]
WĂŐĞ
ŽŶĐůƵƐŝŽŶƐ
Conclusions
Autogenous bone graft continues to be the gold standard for the filling of bone
defects in oral and maxillofacial surgery, spinal surgery, trauma, and treatment of
malunions, nonunions and tumors. Each site of autologous bone graft has its
advantages and disadvantages, including the anatomic location, which may make
one site preferable over another, depending on the graft recipient site. With the
increasing use of bone substitutes, it is important to understand all the risks of
autogenous bone harvest before possibly exposing a patient to one of the rare but
potentially serious complications.
In conclusion it may be stated that autogenous particulate cancellous bone is the

material of choice for bridging a bony defect in the maxillofacial area when
mechanical strength is not needed. They heal in the same way as cancellous bone
blocks do.
WĂŐĞ
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WĂŐĞ
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AUTOGENOUS BONE GRAFT IN ORAL AND MAXILLOFACIAL SURGERY

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I am grateful to respected Dr. Mohan Gundappa, principal, Teerthanker Mahaveer

I dedicate my Library Dissertation to my supportive Parents and my younger brother

S.NO. TOPIC PAGE NO.

5. Bone Physiology & Healing 28 - 37

6. Classifications of Bone Graft 38 - 45

9. Indications For Various Techniques  - 82

Figure No. Title Page No.

1 Microscopic Structure of Bone 14

6 Vessels in the Periosteum 21

55 Posterior iliac graft is shown 68

56 Thin bicortical cancellous grafts is harvested for 69

57 (a) Operative view showing the split rib grafts 

58 Single-onlay cortical bone graft is shown for 

Bone grafts may be used for the following purposes:

Basic knowledge of bone grafting

Types of Bone Grafts

Conditions for success in bone grafting

Ferhan Yaman et al (2007) ± Conducted a study to investigate the methods of removing

Teresa Mao, Kamakshi V (2010) ± Conducted a study of bone resorption is a natural

Cassiano Costa Silva Pereira et al (2011) ± Conducted a study for Maxillomandibular

Giacomo De Riu et al (2012) ± Conducted a study to evaluate the results of mandibular

Sherin.A.Khalam et al (2014) ± Conducted a study to evaluate the secondary alveolar bone

Muthukumar Santhanakrishnan et al (2014) ± Conducted a study to evaluate the need for an

K Harshakumar et al (2014) ± Conducted a study to evaluate the placement of endosteal

Davide Donati, et al (2016) ± Conducted a study and concluded as follows:

Fig : 1 Microscopic Structure of Bone

Bulges, depressions, and holes that serve as:

Mechanical Loads on the Human Body.

Compression: pressing or squeezing force directed axially through a body.

3. Mechanical Stress and Strain

Yield point (elastic limit): permanent deformation

Failure point: loss of mechanical continuity.

Composition and Structure of Bone

Compressive strength - ability to resist pressing or squeezing force.

Building Blocks of Bone

Water ~ 25-30% important contributor to bone strength.

Cortical Bone (compact mineralized tissue with low porosity)

Trabecular Bone (less compact with high porosity. [5]

Fig : 3 Cancellous Bone

Fig : 4 Compact Bone

Compact bone consists almost entirely of extracellular substance, the matrix.

Vascular supply of bone

Lamellar bone, the lamellarer Schalenknochen of German histologists, is usually replacement,

Fig : 6 Vessels in the Periosteum

Bone Matrix and Bone cells

Fig : 7 Bone Cells

Bones are formed by two mechanisms:

Stages of intramembranous ossification

1. Ossification occur in the fibrous connective tissue membrane.

2. Bone matrix (osteoid) is secreted within the fibrous membrane.

3. Woven bone and periosteum formation.

4. Bone collar of compact bone form and red marrow appears.

Stages of Endochondral Ossification

Briefly, the mechanostat consists of 4 major components:

Fig : 13 Utah paradigm of skeletal physiology

Pathophysiology of Bone Remodeling

Autogenous cancellous marrow grafts undergo a well-documented and predictable healing

These growth factors include:

!

9. Indications For Various Techniques - 82

57 (a) Operative view showing the split rib grafts

58 Single-onlay cortical bone graft is shown for