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Bone grafts in dentistry
- 1. BONE GRAFTS K I RT I R A N K A F I N A L Y E A R B . D . S .
- 2. CONTENTS • DEFINITION • INDICATIONS •REQUIREMENTS • CLASSIFICATION • BONE GRAFTING TECHNIQUE • EVALUATION • CONCLUSION • REFERENCES
- 3. WHAT IS AGRAFT? • A graft is a viable tissue/organ that after removal from the donor site is implanted/transplanted within the host tissue, which is then repaired, restored and remodeled.
- 4. WHEN SHOULD YOU CONSIDERTHIS OPTION? Ridge augmentation and implants Furcation defects
- 5. Deep intrabony defects(2-3 walled defects) Advancedbone loss Aggressive periodontitis Aesthetics Sinus lift procedures
- 6. WHAT TO EXPECTAFTER THIS PROCEDURE? • Attachment gain • Reduction in pocket depth • Bone fill • Regeneration of other surrounding tissues
- 8. IDEAL REQUIREMENTS • Biologicalacceptibility • Predictability • Facilitate vascularisation • Clinical feasibility • Minimum operative hazards • Minimum post-op. sequelae • Acceptance by the patient • Not too expensive
- 9. CLASSIFICATION According to thetype of graft According to their mode of action
- 10.
- 11. According to theirmode of action OSTEOGENIC/ OSTEOPROLIFERATIVE OSTEOINDUCTIVE OSTEOCONDUCTIVE OSTEOPROMOTIVE
- 12. AUTOGRAFTS • Within sameindividual • GOLD STANDARD • Osteogenic, Osteoinductive & Oteoconductive potencies Tori,Exostosis Ramus, Chin Tuberosity Edentulous spaces, Symphysis Extraction sites Tibia Fibula Ribs Iliac crest
- 14. • Mixture ofbone dust obtained by grounding cortical bone and blood. • Round carbide bur-25,000-30,000 rpm • Donor bone Small particles Patient’s blood coating Coagulum • Sources: -Lingual ridge on the mandible -Exostosis -Edentulous ridges -Bone distal to the terminal tooth -Bone removed from osteoplasty OSSEOUS COAGULUM
- 15. ADVANTAGES • Relatively rapidtechnique • Complements osseous resective procedures that may be required at the surgical site. • Particle size provides additional surface area for the interaction between cellular and vascular elements DISADVANTAGE S • Cannot be used in larger defects because of inability to procure adequate material • Poor surgical visibility • Relatively low predictability • Inability to use aspiration during accumulation of coagulum • Fluidity of the material makes it difficult to handle
- 16. • Removal ofbone from accessible intra oral donor sites by chisels. • Placing them in a sterile plastic amalgam capsule • Triturating it with a pestle. BONE BLEND
- 17. BONE SWAGING • Edentulousarea near the defect required • Bone is pushed into the root surface without fracturing the bone at the base • Technically difficult
- 18. ISOGRAFTS • Monozygotic twins •A.k.a. “Syngenous grafts”
- 19. BONE GRAFT HARVESTING1. Cortico-cancellousblock grafts harvested with a 6-mm trephine and ground to particulated bone chips in a bone mill 2. Bone chips harvested with a sharp bone scraper 3. Bone particles collected from the aspirator with a bone trap filter during the preparation of the osteotomy 4. Bone particles harvested with a piezo-surgery device. It is for harvesting particulate autogenous bone
- 20. PRECAUTIONS WHILE HARVESTING BONE GRAFTS•Carefully evaluate the donor sites for any risks- Radiographically • Use extreme care in making incisions laterally towards the mental nerve and dissect the area with blunt instruments to locate the foramen • Do not elevate or reflect the muscle attachments beyond the inferior border of the mandible. • Suture the wound in layers (muscles and overlying mucosa separately) to prevent post-op wound separation. • While using trephines, drills or saws to cut the bone it must always be done with profuse irrigation to keep the instruments and bone cool. Exceeding 47ºC can cause bone necrosis
- 21. • Do notelevate or reflect the muscle attachments beyond the inferior border of the mandible. • Limit bone cuts to at least 5mm away from the tooth apices, inferior border of mandible and mental foramen. • Do not extend cuts beyond 6mm deep • Do not include both the lingual and the labial cortical plates
- 22. HEALING : • GranulationStage : When hematoma develops , an inflammatory response occurs and the formation of granulation tissue takes place • Callus Stage : Mesenchymal cell differentiates mainly into osteoblasts • Remodelling Stage : Hard callus tissue is replaced by lamella bone • Modelling Stage : Bone adapts to the structural demands due to functional stimuli
- 23. 7 days: Initiationof new bone formation 21 days: Cementogenesis 3 months: New PDL 8 months: Graft fully incorporated into the host with functionally oriented fibers between the bone and the cementum Maturation may take as long as 2 years
- 24. ALLOGRAFTS • Genetically dissimilarmembers of the same species. • Eg. :-Demineralized Freeze Dried Bone Allografts(DFDBA) – Freeze Dried Bone Allografts(FDBA) DFDBA FDBA Demineralised Not Demineralized More radiolucent More radiopaque Rapid resorption Breakdown by way of foreign body reaction Primary indication-Periodontal disease asso. with natural tooth Primary indication-Bone augmentation asso. with implant treatment Osteoinductive Osteoconductive More BMP Less BMP
- 25. Colllect the grafttissue within 12 hours of the death of the donor Defatten,Cut in pieces, Wash in absolute alcohol,Deep freeze for further use Demineralize the material Ground and sieve- 250-300µm Freeze dried, vacuum sealed in glass vials
- 26. To supress theirantigenic potential RADIATION TREATMEN T • 6 mega Rads of high intensity gamma radiation. FREEZING • Deep freezing - 197ºc liq. N2 freezer for 4 weeks CHEMICAL TREATMEN T • Keeping the graft in Merthiolate solution
- 27. XENOGRAFTS • Donor isof another species. • They are usually referred to as “anorganic bone” • Available source: – Bovine bone -Natural coral -Calf bone -Kiel bone
- 28. ALLOPLASTS • A.k.a. Inertbiologic fillers • Eg. :Tricalcium phosphate(TCP) – Hydroxyapatite(HA) – Bioactive glass
- 29. Biocompatibility composite polymers(BioplantHTR) • Polymethyl methacrylate + Polyhydroxyethyl methacrylate beads • Coated with Calcium Hydroxide • Calcium Hydroxide forms Calcium Carbonate when introduced into the body • Surface for osteoblast cell attachment and bone deposition • 1-3 years later- complete bone formation
- 30. COMPOSITE GRAFTS • Madeof- Na2O–CaO–SiO2–P2O5 • Reffered to as 45S5 bioactive glass. • The material exists in particulate form(90-710µm diameter)- PerioGlas and (300-350µm diameter)- BioGran • Facilitates bone formation
- 31. BONE GRAFTING PROCEDURE INCISION Sulcularincisison made on the lingual and facial aspects
- 32. FLAP DESIGN Prevent flapperforation, Removal of granulation tissue from the lesion that usually attaches to the inner aspect of the flap. Excess thinning of the flap hampers blood supply
- 33. ROOT DEBRIDEMENT Remove hardand soft accretions on the root surface Root biomodification-Saturated solution of Citric Acid (pH=1)
- 34. DEFECT DEBRIDEMENT Debride defectsof soft tissues using hand, ultrasonic, rotating instruments
- 35. PREPARATION OF GRAFTMATERIALS Bone grafts should be wetted with patient’s blood rather than saline or water
- 36. PROMOTION OF BLEEDINGSURFACE In case of a chronic bone lesion the bone is perforated, forms a bleeding environment .
- 37. PRESUTURING Loose sutures placedprior to filling the defect to reduce displacement of bone graft during suturing
- 38. PLACEMENT OF GRAFTINTO OSSEOUS DEFECT The bone graft is transferred with bone graft scoop. Graft is packed firmly but not too tight and should not be overfilled
- 39. FINAL SUTURING Monofilament suturesplaced as interrupted or vertical mattress suture technique
- 40. EVALUATION • CLINICAL METHODS 1.Probing depth measurement 2. Clinical gingival indices 3. Determine the attachment level • RADIOGRAPHIC METHODS -Careful standardized techniques for reproducing the position of the film and tube are required. -Linear-CADIA method offers the highest level of accuracy.
- 41. • SURGICAL RE-ENTRY -Thestate of the bony crest, after healing can be compared with the state of the bone before surgery. Models can also be used. -Disadvantages- Requires frequent and unnecessary 2nd operation. -Does not show the type of attachment that exists. • HISTOLOGIC METHODS -The type of attachment can be determined by this method only. -The tooth needs to be removed along with its periodontium after successful treatment to assess the attachment. -Limited to volunteers who undergo extraction for prosthetic or other reasons and agree to the procedure.
- 42. CONCLUSION • A graftis a viable tissue/organ that after removal from the donor site is implanted/transplanted within the host tissue, which is then repaired, restored and remodeled. • Classification- Based on type, mode of action • Autografts-GOLD STANDARD • Technique- Incision, Flap design Root debridement Defect debridement Preparation of Graft material Promotion of bleeding surface Presuturing Placement of graft Final suturing • Evaluation- Clinically, Radiographically, Surgical re-entry, Histologically.
- 43. REFERENCES • DENTAL BULLETIN(VOL.15 NO.3 MARCH 2010) Intra-oral Autogenous Bone Grafting for Dental Implant Site Preparation by Dr. Gregory TAYLOR • ARTICLE BY NCBI-Bone Grafts in dentistry • CLINICAL PERIODONTOLOGY- Caranzza 10th Edition • TEXTBOOK OF PERIODONTICS- Shalu Bathla
- 44. THANKYOU © k ir t i r a n k a