Indian Dental Academy's Guide to Bone Grafting Techniques

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Part I
• Introduction
• Keys to bone grafting
 Bone grafting materials
 Socket grafting
Part II
 Maxillary sinus lift & sinus graft surgery
 Intraoral autogenous donor bone grafts
 Extraoral autogenous donor bone grafts

 Absence of infection
 Soft tissue closure
 Space maintenance
 Graft immobilization
 Regional acceleratory phenomenon (RAP)
 Host bone vascularization
 Growth factors
 BMPs
 Healing time
 Defect size & topography
 Transitional prosthesis

 Rapid solution mediated resorption in conditions of
low PH

Causes of graft material infection
 Endogenous bacteria
 Lack of aseptic surgical technique
 Failure of primary soft tissue closure
 Lack of blood supply in early stages of
grafting

Guidelines
 Primary incision should be in keratinized tissue

 Crestal incisionis designed more lingual

 Vertical incisions

 Vertical incisions are made to the height of MGJ &
flap is retracted only 5 mm above the height of MGJ.
This maintains more blood supply to the facial flap
 Incision is not extended to mobile mucosa

 Soft tissue reflection distal to graft
Site is split thickness
 Maintains some of the periosteum around incision
line
 Early vascularization of incision line
 Adhesion of the margins to reduce retraction during
initial healing

 2 techniques depending on
 If less than 5 mm of advancement is necessary
 To expand tissue over larger graft sites (15 x 10 mm)
-- submucosal space technique

For a small graft site
 More apical tissue reflection
 Horizontal scoring of the periosteum parallel to
primary incision

 Developed by Misch in early 1980s
 Full thickness facial flap is elevated off the facial
bone for 5 mm above the height of vestibule
 One incision 1 to 2 mm deep is made through the
periosteum parallel to the crestal incision and 3 to 5
mm above the vestibular height of periosteum

 Blunt dissection is done using soft tissue scissors
(metzenbaum ) to create a tunnel apical to the
vestibule & above the unreflected periosteum

 Thickness of facial flap should be 3 to 5 mm
 Facial flap should be able to pass the lingual flap
margin by more than 5 mm

Disadvantages
 Loss of vestibular depth
 Lack of keratinized tissue on facial region of grafted
site

Methods
Tent screws
Barrier membrane
Ti reinforced membranes
Graft material beneath the membrane

Barrier by bulk
 Concept given by Misch

Methods
 Bone tacks
 Tent screw
 Bone screws  work better with block bone grafts
than particulate

Fixed transitional prosthesis
 Indicated with barrier by bulk tech. using particulate
material
 Prosthesis should have rest seats & clasps to
prevent loading soft tissues

 Local response to a noxious stimulus by which tissue
forms faster than the normal regional regeneration
rate
 Healing is 2 to 10 times faster than normal
physiologic healing
 Begins within a few days after injury , peaks at 1 to 2
months usually lasts 4 months in bone & may take
upto 6 to 24 months to subside

 Source of blood vesels
 Host cortical bone (few
arterioles
 Cancellous bone
(intensely vascular
network
 Blood vessels are
needed to
 Help the autograft
maintain vitality
 To repopulate the area
with osteoblasts www.indiandentalacademy.com

 Host site is decorticated with a rotary drill to increase
amount of host blood vessels at the graft site
 There should be spaces available between graft
particles for blood vessels to enter

Methods to increase tissue growth factors at graft site-

 Use of autologous bone in graft
 PRP
 Use of allografts
 RAP

Gerald D , Carlson ER , Gotcher JE et al
J of Oral Maxillofacial Surg 2006 : 64 (443 – 451)
PDGF mixed with autologous bone can accelerate
mineralization by as much as 40 % during the first
year

Factors affecting healing time
Local
Number of remaining walls of bone
Amount of autogenous bone in the
graft
Size of the defect
Systemic
Diabetes
Hyperparathyroidism
Thyrotoxicosis
Osteomalacia
Osteoporosis
Paget’s disease

 4 to 6 months -- graft volume is less than
5 mm
 6 to 10 months -- graft volume is more
than 5 mm

Defect size effect following aspects of augmentation
 Healing time
 Vascularization
 Transitional prosthesis
 Graft material selection

Augmentation will be faster in an
extraction socket surrounded by 5
walls than for a onlay graft on div
D bone

Transitional resto. effects
 Soft tissue closure
 Maintenance of space
 Immobilization of graft during healing
 Restores esthetics & function
 Contours the soft tissue

 Transitional acrylic FPD
 Metal reinforced acrylic FPD
 Resin bonded prosthesis
 Fixed temporary - eg temporaray implants
 Removable restoration

Bone graft materials
collagen
Osteogenic
Eg autologous
bone
Osteoinductive
Eg DFDB
osteoconductive

 Sources
Bovine collagen from achilles tendon in the
leg
DFDB
Collagen barrier membranes used for GBR
Resorption rates vary from a few months
to 1 year

Autogenous trabecular bone
• Contains more osteoblasts
• More osteogenic
Autogenous cortical bone
• Contains more bone growth factors
• More osteoinductive

 Should remain vital to be able to produce osteoid
 Recipient site is prepared first
 Should be placed immediately after harvesting or stored
in
 Sterile saline
 lactated ringers solution

 Should not be mixed with other synthetic graft
materials

 Decortication of host bone
 Directly placed on host bone

Phase I
 Osteogenesis
 Bone regeneration by
surviving cells (osteoid)
 4 weeks
Phase II
 Osteoinduction
 BMP release
 2 wks to 6 months , peak at
6 wks
Phase III
 Osteoconduction
 Inorganic matrix
replaced by creeping
substitution
Phase IV
 Cortical plate acts as a
barrier membrane

 The only osteogenic graft material
 Osteoinductive property
 Osteoconduction
 Space maintenance- maintains contour of desired
augmentation

Bone autografts
Allograftsosseous transplanted tissues
from the same species as the recepient
but of different genotype
• Frozen bone
• Freeze dried bone
• Demineralized freeze dried bonewww.indiandentalacademy.com

 Bone can be harvested , frozen & stored to be used
in the same patient at a later date
 Allograft frozen bone is rarely used because of risk
of rejection & disease transmission

 Cortical & trabecular bone is harvested in a sterile
fashion from a disease free donor
 Washed in distilled water & ground to a particle size of
500 micron to 5 mm
 Immersed in 100 % ethanol to remove fat
 Frozen in nitrogen
 Freeze dried & ground to smaller particle size of 250 to
1500 micron

Marx RE , Wong ME
J of Oral & maxillofacial surg 1987 : 45 ( page 988)
 Solvent prserved products have been developed
instead of freeze drying to reduce antigenicity &
assure a minimal risk of contamination

 Ground bone powder is demineralized in 0.6 N HCl
or nitric acid for 6 to 16 hrs.
 After acid bath it is washed & dehydrated

Irradiation
• Doses greater than 2.5 Mrad are
destructive to BMPs
Ethylene oxide sterilization
• 5 hr sterilization at 29 degree celsius
to maintain osteoinductive properties

 Age of cadaver
 Type of bone
 Cortical bone contains higher conc. Of BMPs than trabecular
bone
 Membranous cortical bone exhibits greater conc. Of BMPs
than endochondral cortical bone
 Particle size
Particles smaller than 150 micron are less effective than 250
micron or larger
 Fibres of cortical bone (eg grafton ) are more effective than
particles.

 Putty consistency products
 Fillers do not participate in bone formation

Allografts
• Freeze
dried bone
Alloplasts
• Ceramics
• Polymers
• composites
Xenografts
• Fabricated
from
inorganic
portion of
bone from
animals
other than
humans

• Aluminium oxide
• Ti oxideBioinert
• Ca Phosphate
• Synthetic HA
• Bovine derived bone matrix
• Tricalcium phosphates
• Calcium carbonates
Bioactive

• Non resorbable
• resorbable
• Dense
• porous
• Crysstalline
• amorphous

Atraumatic tooth extraction
Socket grafting

 Periosteum should not be reflected if bone volume is
ideal as it helps bone remodellimg or repair
 Soft tissue drape around the tooth is also affected by
reflection of periosteum

An incision within the sulcus is made preferrably with
a thin scalpel blade , 360 degree around the tooth

Tooth to be extracted should be reduced mesio
distally if the path of removal is obstructed by
adjacent teeth

Time period for socket regeneration is usually 3 to 6
months depending on
 Tooth size
 Root no.
 No. of bony walls around the socket
 Size of alveolus
 Trauma of extraction

In 1993 Miesch & Dietsh suggested different graft
materials & techniques based on the no. of bony
walls remaining after tooth is removed-
 5 bony wall defect
 4-5 wall defect
 2-3 wall defect
 1 wall defect

 Any resorbable graft material such as alloplast ,
allograft or autograft

 Socket grafting is indicated if
 Labial plate of bone is missing
 One of the lateral plates is thinner than 1.5 mm
 Height is desired
 2 techniques
 BM with a mineralized alloplast or freeze dried bone
 Modified socket seal surgery

 A periotome or thin periosteal elevator is used to
tunnel under the bone periosteum

 barrier membrane is then slid into the pocket created
under the tissue & it extends apical , mesial & distal
beyond the extraction site
 Approx 6-8 mm of BM should extend above the
marginal tissue

 Bone graft material is placed & BM covers the top of
the socket & is tucked in below the palatal tissue

 Developed by Misch et al
 It’s a composite graft consisting of connective tissue
, periosteum & trabecular bone used to seal a fresh
extraction socket
J of Oral Implantology 1999 ; 25 (pages 244 – 250 )

Advantages
 CT graft blends into the surrounding attached
gingiva , offering similar colour & texture of the
epitheliumcontains autogenous bone
 Blood supply is established from the surrounding soft
tissue
 Rapid healing (4 – 5 months )

• Treated similar to 4 wall defect
 Defect size is larger so more bone is
reqd.

 Block graft or cortical autogenous
bone

Misch in 1990, Implant Dent 1993 ;2 (pages 158- 167)
Layers in GBR include the following
 host bone -: decorticated to enhance blood supply ,
growth factors & RAP
 An autograft-: results in more predictable & rapid bone
growth by osteogenesis & osteoinduction
 Mixture of DFDB (30%) , FDB (70%) , & PRP --: Provides
growth factors & space maintenance
 BM & Tent screw -:
 BM prevents fibroblasts from invading the graft site for at
least 6 wks.
 Tent screw decreases mobility
 Primary closure without tension -: prevents contamination
& loss of graft materialwww.indiandentalacademy.com

Sinus grafting was introduced by Tatum in 1970s
 In early 1970s Tatum began to augment post. Maxilla
with autogenous rib bone to produce adequate vertical
bone for implant support
 In 1974 he developed modified caldwell luc procedure
 In 1975 he developed a lateral approach surgical
technique toelevate sinus membrane & place implant
simultaneously
 From 1974 to 1979 primary material for sinus grafting
was autologous bone. In 1980 , Tatum introduced the use
of synthetic bone

 Initial publication on sinus grafting was by Boyne &
James in 1980s
 In 1983 Misch observed that the most predictable
intraoral region to grow boneis the max. sinus floor
once the mucosa has been elevated

 Root tips in the antrum
 Pseudocysts
 Oral antral opening
 Extraction of hopeless teeth
 Unerupted teeth

 Narrowing of osteomeatal complex
 Enlargement of an air cell in the roof of sinus ( haller
cell )
Smoking
 Smokers have a 7 % greater failure rate than non
smokers
 Pt. should refrain from smoking at least 15 days
before surgery & 4-6 weeks after surgery
 Chronic maxillary rhinosinusitiswww.indiandentalacademy.com

 Active sinus infection on the day of surgery
 Significant recurrent history of chronic
sinusitis
 Significant recurrent history of fungal
sinusitis
 Uncontrolled late stage diabetes
 Cystic fibrosis
 maxillary sinus hypoplasia
 Neoplasms www.indiandentalacademy.com

 Antimicrobial medication
Administered at least 1 full day before surgery &
extended for 5 days after surgery
 Local antibiotic medications
To ensure adequate antibiotic levels in a sinus graft ,
it is recommended to add antibiotic to the graft
mixture
Mabry TW , Yukna RA J Periodontology 1985 ; 56 (74
– 81) www.indiandentalacademy.com

 Oral antimicrobial rinse
Gentle oral rinses of chlorhexidine gluconate 0.12 %
should be used twice daily for 2 weeks after surgery
 Glucocorticoids
Initiated 1 day before surgery & continued foe 2 days
after surgery to control oedeme
 Decongestant medications
 Oxymetazoline (0.05%)
 Phenylephrine (1% )

 Analgesics
Codeine containing drugs such as tylenol 3 are the
drug of choice as they have a potent antitussive
effect
 Cryotherapy
 Cold dressings for the first 24 – 48 hrs ,elevation of
head & limited activity for 2-3 days helps reduce
swelling
 After 2-3 days heat may be applied to increase blood
flow & lymph flow

 In 1984 Misch organised a treatment approach for
posterior maxilla based upon the amount of bone
below the antrum

 in 1995 , Misch modified his classificationto include
the lateral dimension of sinus cavity to modify the
healing period protocol
 Smaller width sinnus (0-10 mm) -: less healing time
 Larger width(> 15 mm) -: more time

 SA1 conventional implant placement
 SA2 sinus lift & simultaneous implant placement
 SA3 sinus graft with immediate or delayed
endosteal implant placement
 SA4 sinus graft healing & extended delay of implant
insertion

 Indicated when sufficient bone height is present
for the placement of endosteal implants
 Evaluation of sinus is less critical
 Implants left to heal for 4-8 months
 Progressive loading suggested in d3 & d4 bone

 Root form implants are used
 At least a 12 mm in height implant for a 4
mm threaded implant

 Osteoplasty or augmentation is suggested to
increase width of bone
 Augmentation may be done by
 Bone spreading
 Autogenous onlay
 Appositional grafts

Onlay autogenous bone grafts are
indicated

 indicated when10-12 mm of vertical bone is present
 Tatum originally developed the technique in 1970 &
Misch published it in 1987
 Antral floor is elevated through implant osteotomy by
0-2mm
 Compresses the bone below the antrum , causes a
greenstick fracture in the antral floor & slowly
elevates the unprepared bone & sinus membrane
over the broad based osteotome
 Prosthetic treatment similar to SA1 after 4-6 months

 Indicated when at least 5 mm of vertical bone &
sufficient width are present between the anral floor &
crest of residual ridge

 Anesthesia
 Maxillary branch of trigeminal nerve is blocked
 Long acting anesthetic such as bupivacaine(0.5%) or
etidocaine(1.5%) is preferred
 Incision line & reflection
 Crest incision is made on the palatal aspect of maxilla
from tuberosity to one tooth anterior to the anterior wall of
sinus
 Vertical relief incision is made on the distal to enhance
access to max. tuberosity
 Anterior incision is made at least 10 mm ant to the ant
wall of sinus

Access window
 Tatum access window is 2-5 mm above the antral
floor , 2-5 mm from the anterior wall 15 mm long &
10 mm in height

Carbide bur in paint brush stroke is used to outline the
access window

 Flat ended metal punch & mallet is used to lightly
tap & green stick fracture the access window from
the lateral wall of maxilla

 Sharp blade of the curette is placed against the inner
wall of bone & is used to scrape off the sinus
membrane from the bone

 Layered approach to grafting

 Implant placement

 Soft tissue closure
Soft tissues & periosteum must be approximated for
closure without tension

 Indicated when less than 5 mm bone exists between
sinus floor & crest of residual ridge

 Lateral wall approach is performed for sinus graft as
in SA 3 procedure
 Medial wall of sinus membrane is elevated at least
16 mm fron the crest so that adequate height is
available for implant placement
 If bone from max tuberosity is not enough ,
additional bone may be harvested from above the
roots of maxillary premolars or mandibular
ascending ramus www.indiandentalacademy.com

 Intra operative
 Membrane perforation
 Antral septa
 Bleeding
 Short term
 Incision line opening
 Paresthesia
 Acute maxillary rhinosinusitis
 Long term
 Oroantral fistula
 Maxillary surgical cysts

 Mandible
 Symphysis
 Body
 Ramus
 Maxillary tuberosity
 Extraosseous tori
 Ridge osteoplasty
 Extraction sites
 Implant osteotomy

 Convenient surgical access
 No cutaneous scar
 Patients report minimal donor site discomfort
 Inherent biological benefits attributable to the
embryologic origin of donor bone
 Experimental evidence shows that grafts from
membranous bone show less resorption than
endochondral bone. Maxilla & body of mandible are
membranous bones
J Oral Maxillofacial surgery 1996 : 54 (15-
20)

 Early revascularization of membranous bone grafts
helps in improved maintenance of graft volume
 Bone from the maxillofacial skeleton contains
increased concentration of growth factors & BMPs
Plastic reconstructive surgery 1994 : 93 ( 732 –
738)
Improved survival of craniofacial bone grafts is
caused by their 3-D structure
J oral maxillofacial surg 1996 :54 (15 –
20 )
Mand. Cortical bone grafts show little volume loss &
show good incorporation at short healing times

 In 1992 Misch et al used mandibular symphysis &
ramus bone grafts for endosteal dental implants
J of oral maxillofacial implants 1992 : 7 ( 360 –
366 )

Symphysis
Ramus

 Easier graft harvest
 Less post – op discomfort
 Less neurosensory complications
 Less incision line opening
 Less anesthesia reqd.
 More profound LA with fewer drugs
 Less concern of changes in facial
morphology

Less width & length of bone

 Slight curved triangular shape in the midlineis often
well suited for re-establishing the arch form in
maxillary anterior ridges
 Average interforaminal distance is greater than 4 cm
, so more bone volume is available

 Width & height requirements for augmentation
 Mandibular symphysis : when more than 4 cm of
bone is desired ( C-w bone volume )
 Mandibular ramus :when graft width is less than 4
mm ( div. B to B-w bone volume )
 Mandibular symphysis along with its cortical inferior
border : when an augmentation for height is required

 Location of the host or recepient site
Recepient site
• Anterior mandible
• Posterior mandible
• maxilla
Donor site
• Symphysis
• Ramus
• ramus

 host site prepration
 Bone harvest
 Graft fixation
 Post operative instructions

 Presence or absence of molars
 Width & height of external oblique ridge in the body
of the mandible
 Distance from the external oblique ridge & ramus to
the inferior alveolar nerve
 Width of posterior ramus is evaluated using
reformatted CT image

 As a result of these
variables a rectangular
piece of cortical bone
about 3 – 6 mm in
thickness may be
harvested from the
ramus. Length may
range from 1 – 3.5 cm &
height usually is not
greater than 1 cm

 After harvesting graft may be stored in sterile saline
or immediately fixed to the recepient site
 Trabecular surface of the graft should be in contact
with decorticated surface of the host bone
 Donor block & recepient site contouring
 2 or more fixation screw sites should be prepared for
each bone block

 Holes in the donor
block should be
slightly larger than the
outer diameter of
fixation screws but
smaller in diameter
than the head of the
screw

 A high speed lindemann bur or carbides are then
used to recontour the block bone & smmothen any
sharp edges or corner after it is fixed
 Barrier membrane
 Not routinely used with cortical block bone grafts
 Indicated if more particulate or trabecular bone is
used
 Indicated if block graft is inadequate to fill the entire
space

 Flap should be approximated &
sutures placed such that there is no
incision line tension or tissue ischemia

 Stop smoking at least 3 days before surgery &
until incision line has healed
 Removeble soft tissue prosthesis should not be
worn
 Confirm to regular post operative follow up

 Intraoral block grafts
 4 months for maxillary recepient
 5 – 6 months for mandibular recepient sites
 Particulate onlay grafts
6 -9 months

 Iliac crest
 Tibia
 Cranium
 Rib
 fibula

Advantages
 Large volumeouter portion of the graft may be
primarily cortical with major portion of trabecular
bone underneath
 Volume of the bone harvested permits contouring of
2/3 of the mandible or maxilla or filling a large bony
defect
 Relative ease of access & harvesting

Disadvantages
 Rapid bone resorption of 30 – 90 % has been
reported when conventional dentures are placed on
top of the reconstruction
Curtis et al JPD 1987 ; 57 (73-
78)
• post operative pain & gait disturbances

Complications
 Pain
 Herniation of the abdominal contents
 Fracture neuralgia
 Hematoma seroma
 Infection cosmetic deformity

 Proximal tibial metaphysis provides an excellent
source of trabecular bone
 Primarily used with with BM & GBR procedure
because major part of the harvest is trabecular in
nature

Disadvantages
 Contraindicated in adolescents & children coz
disruption of epiphyseal growth centre my occur
 Fat content of the marrow is sometimes greater than
that found in the ilium

Complications
 Hematoma
 Post operative pain
 Infection
 Dhiscence ( incidence ranging from 1-4% )

Sites
 Iliac crest
 Scapula
indications
 Blood supplybto the graft site is severely
compromised
 Recipient bed is scarred
 Carcinoma patients who have undergone radiation
therapy
 Div. E bone anatomy : discontinuity defects of thewww.indiandentalacademy.com

Advantages
 Maintains normal physiologic function
 Simultaneous placement of implants with
microvascular bone flap reconstruction has shown
an approximately 80% success rateusing Ti implants
with a short follow up

 Disadvantages
 Attaing primary graft stability is often
difficult coz graft is often very
spongeous with a thin cortical layer

 Refers to the formation of new bone between
vascular bone surfaces created by an osteotomy &
separated by gradual distraction
Indications
 Mucoskeletal conditions such as post traumatic
defects
 Repair of continuity defects
 Mandibular lengthening
 Maxillary advancement

 Contemporary implant dentistry by Carl E Misch ; 3
ed
 Dental update 1997 ; 24 (332-337)

Indian Dental Academy's Guide to Bone Grafting Techniques

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