GITAM DENTAL COLLEGE & HOSPITAL

DEPARTMENT OF
ORAL & MAXILLOFACIAL SURGERY

SEMINAR ON
TISSUE GRAFTING- BIOLOGICAL CONSIDERATIONS OF
AUTOGENOUS & HETEROGENOUS GRAFTS

Presented By:
Dr. Sambhav K Vora
I MDS
CONTENTS:
1. Introduction
2. Types of bone grafts
3. Bone haresting procedures
!. E"bryo#ogica# aspect of bone grafts
$. %ascu#ari&ed. %s. non ascu#ari&ed grafts
'. (echanis"s of bone regeneration
). Bone "orphogenetic protein
*. +ro,th factors
-. .actors affecting bone regeneration
1/. .actors causing re0ection of graft "ateria#
11. +raft suria#
12. S1in grafting
13. (echanis" of hea#ing of s1in grafting
1!. 2eferences

3 tissue graft is a procedure in ,hich tissue fro" a donor is used to rep#ace "issing or
da"aged tissue on a patient.
Tissue grafts can be c#assified as
4ard tissue grafts
Bone 5 bone substitutes..
Soft tissue grafts
S1in grafts
+ingia# grafts
Connectie tissue grafts
BONE +23.T (3TE2I36
3 bone graft is defined as the transp#antation of living bone fro" one #ocation to another.
Transplantation i"p#ies the transfer of #iing ce##s7 ,hereas implantation refers to the
transfer of non#iing ce##s.
1'
There are three pri"ary types of graft "ateria# 8
3utogenous bone grafts
3##ografts
3##op#asts7
9enografts are considered as subgroup.
3## the graft "ateria# ,or1 by either of the "echanis":
3utogenous graft "ateria# ,or1 on a## the three "echanis" i.e osteogenesis 7
osteoconductie 5 osteoinduction
3##ografts ,or1 on "echanis" of osteoconductie 5 osteoinductie
3##op#ast ,or1 on osteoconductie "echanis".
Nor"a##y for #arger defect autogenous graft are used 5 for s"a##er defect either a##op#ast or
a##ograft or a co"bination of both can be used.
3uto#ogous bone grafts:
3uto#ogous bone grafts are the grafts in the for" of the bone ,hich are co##ected fro" the
body of the sa"e person .This graft "ateria# co##ected can be used either as b#oc1 for" or in
the particu#ate for".
There are arious types of auto#ogous bone grafts aai#ab#e ,hich can be harested fro"
either intraora# sites or e;traora# sites.
E;tra ora# sites of haresting bone are:
1. 3nterior i#eu"
2. <osterior i#eu"
3. Tibia
!. Ca#ariu"
$. 2ibs
Intra ora# sites of haresting bone are:
1. (a;i##ary tuberosity
2. =ygo"atico"a;i##ary buttress
3. =ygo"a
!. (andibu#ar sy"physis
$. (andibu#ar ra"us
'. (andibu#ar body
The opti"a# donor site depends on the o#u"e 5 type of regenerated bone needed for
specific cases.
(39I(>( %O6>(E 3%3I63B6E .2O( 3>TO+ENO>S BONE ?ONO2 SITES:
<osterior i#iac crest :1!/"#
3nterior i#iac crest 8 )/"#
Tibia:2/"to !/ "#
Craniu": !/"#
3scending ra"us :$ to 1/ "#
3nterior "andib#e :$ "#
Tuberosity: 2 "#
(isce##aneous @eg7 bone scrapings 7 suction tipsA:aries
3dantages of auto#ogous bone:
1. They contain iab#e ce## that pro#iferate 5 contribute to the ne, bone gro,th
2. They contain b"ps7 capab#e of inducing osteogenesis to produce bone
3. 4ea#ing is faster co"pared to other grafts
@auto#ogous bone hea#s as fast as 3 to ! "onths co"pared to * to 1/ "onths ,ith other graft
"ateria#A
?isadantages :
1. Need for second operatie site
2. 2esu#tant patient "orbidity
3. ?ifficu#ty of obtaining a sufficient a"ount of graft "ateria#
These #i"itations #ed to the dee#op"ent of a##ografts 5 a##op#ast as a#ternatie grafting
"ateria#.
2is1 associated ,ith autogenous bone is "orbidity at the bone harest site.
366O+23.TS:
These are obtained fro" the cadaers or fro" the patients #iing re#aties or non
re#aties7 those obtained fro" cadaers are aai#ab#e through tissue ban1s stored under
co"p#ete steri#i&ation.
3dantages of a##ografts:
1. 2eady aai#abi#ity
2. E#i"ination of donor site
3. 2educed anesthesia 5 surgica# ti"e
!. ?ecreased b#ood #oss
?isadantages:
1. 3ntigenicity of tissue harested 5 concerns of trans"ission of hi or other infections.
2. Transp#anted bone "ay induce a host i""une response
3 .Cadaeric bones "ay be re0ected
.resh a##ografts are the "ost antigenic7 free&ing or free&e:drying the bone significant#y
reduces the antigenicity
Co""on#y used a##ografts are fro&en7 free&e:dried @#ypophi#i&edA7 de"inera#i&ed free&e
dried 5 irradiated.
.?B3 can be used as either "inera#i&ed or de"inera#ised for". ?e"inera#i&ation
re"oes the "inera# phase of the graft "ateria# 5 purported#y e;poses the under#ying
bone co##agen7possib#y so"e gro,th factors 7particu#ar#y b"p ,hich "ay increase its
osteoinductie capabi#ities. 5 a#so causes inadeBuate preseration of the osteoinductie
proteins
(inera#i&ed .?B3 is not osteoinductie but does hae osteoconductie properties
.?B3 is "ore effectie than ?.?B3 in fo##o,ing situation:
1. 2epair 5 restoration of fenestrations
2. (inor ridge aug"entation
3. .resh e;traction sites
!. Sinus #ift cases
$. 2epair of dehiscences 5 fai#ing i"p#ants.
<uros is an a##ogenic "ateria# ,hich is so#ent presered @ as opposed to free&e drying to
e;tract the ,ater co"ponent A7 has been sho,n to ossseointegrate as effectie#y as
cryopresered "ateria# 5 to be eBua##y bioto#erab#e.
It is genera##y be#ieed that b"p 5 other nonco##agenous proteins in the e;posed "atri;
are responsib#e for the osteoinductiity of the ?.?B3
.resh fro&en bone is an a#ternatie to .?B3 5 autogenous bone. It can be obtained as
either corticocance##ous bone or as cance##ous bone.
(a0or disadantage of this is the s"a## ris1 of disease trans"ission.
Irradiated cance##ous bone has a#so been used as a substitute "ateria# for autogenous
"ateria#. This is trabecu#ar bone obtained fro" the spina# co#u"n 5 treated ,ith bet,een
2.$ 5 3.* "egarads of radiation7 irraradiated bone is "ost si"i#ar to the autogenous bone
in ter"s of de"onstrating rapid rep#ace"ent 5 consistent estab#ish"ent of a reasonab#e
ratio of the ne, bone ,ith #ess e;pense 5 "orbidity than that associated ,ith autogenous
"ateria#.
366O<63STS7 9ENO+23.TS 5 TISS>E EN+INEE2E? (3TE2I36:
These inc#ude 8 1. ?eorganified boine bone
2. Synthetic ca#ciu" phosphate cera"ics @eg:hydro;yapetite7tcpA
3. Ca#ciu" carbonate @eg:cora##ineA
(echanis" of action in these "ateria#s is strict#y osteoconduction ,ith ne, bone
for"ation ta1ing p#ace a#ong their surfaces.
4C?2O9C3<ETITE:
Is readi#y bioco"patib#e 5 bonds readi#y to the ad0acent hard 5 soft tissues.
The greater the "ateria# porosity the "ore scaffo#ding it proides for ne, bone gro,th 5
"ore Buic1#y it is resorbed7the "ore crysta##ine the graft the s#o,er its resorption.. hence
a"orphous graft s resorb "ore Buic1#y than the crysta##ine grafts.
BO%INE ?E2I%E? 3NO2+3NIC BONE (3T2I9 (3TE2I36:
Bio:oss is anorganic boine bone ,hich is osteoconductie 5 undergoes physio#ogic
re"ode#ing 5 beco"es incorporated ,ith the surrounding bone. In #arge a#eo#ar ridge
deficiencies7 this anorganic bone can be co"bined ,ith autogenous bone for successfu#
aug"entation.
Osteograf is a "icroporous hydro;yapetite particu#ate "ateria# deried fro" boine
bone. It is aai#ab#e in both s"a## partic#e @2$/:!2/"icro"5 #arge partic#e @!2/:
1///"icro"Asi&es. This "ateria# has been ,ide#y used in co"bination ,ith ?.?B3 for
sinus aug"entation.
<epgen p:1$ is an enhanced for" of boine deried hyro;yapetite that contains an added
synthetic short chain peptide7 p:1$. This co"ponent "i"cs #i1e type I co##agen ,hich is
responsib#e in natura# bone for ce## "igration7 differentiation 5 pro#iferation. It has been
studied that this "ateria# proides enhanced bone for"ation in a shorter ti"e co"pared
,ith the boine deried hydro;yapetiteD dfdba graft "ateria# used for sinus
aug"entation.
SCNT4ETIC BONE (3TE2I36:
It is a synthetic bioactie resorbab#e graft7 osteoconductie non cera"ic graft "ateria#
indicated for contouring 5 i"proing a#eo#ar ridge defor"ities7 fi##ing e;traction
soc1ets7 denta# i"p#ants7 sinus grafts 5 repairing "argina# periapica# 5 periodonta#
a#eo#ar bony defects. This "ateria# is high#y porous crysta##ine c#usters ,hich act as a
physica# "atri; to per"it the infi#tration of bone for"ing ce##s 5 its subseBuent
deposition of host bone. 3s ne, bone is deposited the "ateria# progressie#y resorbs oer
':* "onths period.
T2IC36CI>( <4OS<43TE:
TC< is osteoconductie 5 is indented to proide a physica# "atri; that is suitab#e for the
deposition of ne, bone. It s often used for repairing nonpatho#ogica# sites ,here
resorption of the grafts ,here concurrent bone rep#ace"ent "ight be e;pected. Both
hydro;yapetite 5 TC< are safe 5 ,e## to#erated.
Cerasorb is a beta:trica#ciu" phosphate ,hich is used in bone defect regeneration in the
entire s1e#eta# syste". It is co"p#ete#y resorbed 5 rep#aced by natura# bone in 3:! "onth
period depending on the type of bone.
C36CI>( C32BON3TE (3TE2I36S:
Cora##ine is a cera"ic graft "ateria# synthesi&ed fro" the ca#ciu" carbonate.
3dantage: It s three di"ensiona# structure is si"i#ar to that of bone.
Interpore 2// is co"posed of pure hydro;yapatite 5 TC<7 ,or1s on osteoconduction.
2esoprtion of this "ateria# ,as ery s#o, both in bone 5 soft tissue co"pared to other
"ateria#s.
Biocora#
Ca#cified a#gae
432? TISS>E 2E<63CE(ENT <O6C(E2:
Biop#ant 4T2 po#y"er is a "icroporous co"posite ,ith a ca#ciu" hydro;ide graft
surface. This po#y"er resorbs s#o,#y 5 is rep#aced by bone after appro;i"ate#y !:$yrs.
It is usefu# in: 1A bone ridge "aintenance by preenting the anticipated #oss of a#eo#ar
bone fo##o,ing e;traction7 presering the height 5 ,idth of the a#eo#ar ridge.
2A 2idge aug"entation
3A ?e#ayed aug"entation7 in ,hich the di"ensions of the a#eo#ar ridge are increased5
bony defects are corrected.
!A 2epair of periodonta# 5 other defects.
BIO3CTI%E +63SS CE23(ICS:
It is co"posed of ca#ciu" sa#ts 5 phosphate in a proportion si"i#ar to that found in bone
5 teeth7 as ,e## as sodiu" sa#ts 5 si#icon ,hich is essentia# for bone to "inera#i&e. It has
t,o properties that contribute to the successfu# resu#ts: 1A re#atie#y Buic1 rate of reaction
,ith host ce##s7 2A 3n abi#ity to bond ,ith the co##agen for"ed in the connectie tissue.
It produces osteogenic ce##s in the i"p#antation site ,hich ,i## co#oni&e the surface of the
partic#es 5 produce co##agen on these surfaces. Osteob#asts then #ay do,n bone "ateria#
on the top of the co##agen 5 this #atter action "ay supp#e"ent that gro,s by
osteoconduction fro" the a#eo#us. This "ateria# bonds not on#y to the bone but a#so soft
connectie tissues.
<eriog#as is a particu#ate for" of biog#ass that bonds to both bone 5 certain soft
connectie tissues. It is co"posed of ca#ciu"7 phosphorus7 si#icon 5 sodiu". Criteria for
successfu# periog#as inc#ude pre treat"ent p#anning7 debride"ent of the defect7
preseration of soft tissue ascu#arity 5 infection contro#. This "ateria# has t,o
faourab#e characteristics: 1A ease of co"pactibi#ity7 2A abi#ity to pro"ote he"ostasis.
4e"ostasis is "ost #i1e#y re#ated to the co"pactibi#ity 5 adhesieness of the "ateria#.
C2ITE2I3 .O2 SE6ECTIN+ 3 +23.T (3TE2I36:
Indiidua#Es syste"ic hea#ing abi#ity @ eg: age7 syste"ic i##ness affecting hea#ing
such as diabetes or autoi""une disorders #i1e sc#eroder"a7 #upus7 preious
surgeries to the area7 preious treat"ent ,ith radiation or che"otherapy7 irradiated
tissue bed.
6oca# osteogenic potentia# of the defect
Osteogenic potentia# of the graft site
SurgeonEs s1i##
Ti"e aai#ab#e for graft "aturation
Bone harvesting procedures:
Intra ora# sites:: (a;i##ary tuberosity:
3nato"ica# #i"its of tuberosity are "a;i##ary sinus7 the pterygoid p#ates7 the "o#ar
teeth75 the greater pa#atine cana#.
3n incision is "ade a#ong the ridge crest in the posterior "a;i##a 5 continued
posterior#y oer the tuberosity5 a ertica# re#easing incision is "ade #atera##y7 this
e;poses the tuberosity7ridge crest 5 #atera# "a;i##a.tuberosity bone is usua##y re"oed
fo##o,ing ref#ection of the antra# "ucosa ,hich a##o,s for "ore aggressie bone
haresting ,ithout concern for "e"brane perforation. Fith the he#p of either chise# 7
ronguer or bone scraper bone is re"oed
=ygo"a:
The "ucoperiostea# f#ap used to gain access to the sinus is ref#ected higher to e;pose the
inferior aspect of the &ygo"a7 0ust aboe the inferior border of the &ygo"atic ri" #atera#
fro" the "a;i##ary sinus7 cores or s"a## bund#es of bone are re"oed using a trephine
bur or carbide bur .The dri## is 1ept para##e# to the #atera# "a;i##a 5 penetration is #i"ited
to 12 to1! "" to aoid infra te"pora# fossa 5orbita# f#oor.
(andibu#ar sy"physis:
sy"y"physis is a good source for procuring s"a##er grafts either in a b#oc1 for" or in
the particu#ate for". This graft "ateria# yie#ds "ore of coticocance##ous graft "ateria#7
co"pared to ra"us
3dantages:
1. 2e#atie#y #o, "orbidity
2. (ini"a# graft resorption.
Indications:
C#ass 3 ridge defects@ both ertica# 5 bucca# bone #ossA
In the anterior "a;i##a @ as b#oc1 for"A
.or sinus e#eations @particu#ate for"A
E;posure of the sy"physis can be obtained through a estibu#ar7 su#cu#ar incision or
attached gingia "ethod.each incision has its o,n adantages 5 disadantages.
Su#cu#ar "ethod:
3dantages:"ini"i&ed b#eeding 5 trau"a 5faci#itated f#ap retraction
?isadantages:difficu#ty in suturing7 recession 5 #oss of bone at the a#eo#ar crest.
%estibu#ar "ethod:
3dantagesGno interferences ,ith the gingia surrounding the anterior teeth7no "enta#is
"usc#e detach"ent7 reduced ris1 of facia# ptosis7abi#ity to use t,o step suturing
techniBue
?isadantages:"ore b#eeding 5 ede"a 5 inisib#e scarring.
The estibu#ar incision is "ade in the "ucosa dista# to the canine teeth appro;i"ate#y
1c" fro" the "ucogingia# 0unction . a "ucoperiostea# f#ap7is ref#ected inferior#y to the
inferior border of the "andib#e 7 osteoto"ies shou#d be carried at #east $"" fro" the
root apices 5 the "enta# fora"ina. The facia# corte; is thic1 5 the under#ying cance##ous
bone is usua##y dense. Bone can be harested for either particu#ate grafting or b#oc1
grafting.
<articu#ate grafting 8 incision is gien5 the area is e;posed 7 ! "" trephine burs
proides both cortica# 5 cance##ous bone . The cores of bone are harested ,ith the
trephine bur. The osteoto"ies can connect or can be "ade ,ith the bone inbet,een the".
The core fro" the donor site can be re"oed ,ith a s"a## he"ostat7 cotton p#iers or
tissue forceps. If "ore "ateria# is reBuired then septa# bone fro" inbet,een the trephined
osteoto"ies can be re"oed ,ith the ronguers7 but can #eae a #arge defect at the donor
site.
B#oc1 bone "ay be harested depending on the si&e of the recipient defect
using carbide bur or sagitta# sa,5 fina##y it is re"oed ,ith the he#p of osteoto"e.
Bone b#oc1s are deposited in the container fi##ed ,ith the steri#e sa#ine so#ution. ?onor
site can be fi##ed ,ith the "icrofibri##ar co##agen to proide he"ostasis.<erforations are
"ade on the recipients site for ne, ascu#arisation at the bone graft. 4arested b#oc1 is
shaped 5 p#aced ,ith the he#p of the scre,s.
Co"p#ications:
?a"aged sub"enta# 5 sub#ingua# arteries
<otentia# da"age to "andibu#ar roots
(enta# nere paraesthesia
Incision dehiscence in donor area
Te"porary a#tered sensation of the #o,er teeth
Chin ptosis
(3N?IB>632 23(>S:
2a"us is one of the ares in the ora# caity that seres as a donor site for haresting
cortica# bone. If #arger a"ount of bone is reBuired then a#ong ,ith it anterior "andib#e is
a#so used.recipient site shou#d be proper#y chec1ed for the a"ount of bone that needs to
be harested fro" the ra"us.
Bone harested fro" the ra"us is usua##y cortica# in nature 5therefore it is usefu# in
areas that reBuire b#oc1 grafts for structura# support rather than particu#ated graft "ateria#
fro" cance##ous "arro, harests. 2a"us yie#ds around !"" thic17 3 c" or "ore in
#ength7 5 up to 1 c" in height of bone.
2a"us grafts are usefu# in
Bone aug"entation before i"p#ant p#ace"ent
Sinus grafting
.acia# aug"entation
Orthognathic surgery
I""ediate reconstruction fo##o,ing tu"our resection.
<rocedure: incision started at the oc#usa# #ee# of the "a;i##ary posterior "o#ars 5
brought anterior#y 7a#,ays touching the bone "edia# to the e;terna# ob#iBue ridge 5
#atera# to the retro"o#ar pad. The #ingua# tissue is a#so dissected fro" the bone for proper
isua#i&ation of the thic1ness of the bone. 2etraction is done by (innesota retractor.
S"a## perforations are "ade to gie the c#inician an idea of the potentia# e;tension of the
cut 5 this perforations are then connected ,hich shou#d cut co"p#ete#y through the
cortica# bone 5 into the cance##ous bone. .ina# separation of the bone is done by chise#.
3s on#y cortica# bone is re"oed inferior a#eo#ar nere is not da"aged .the b#oc1 of the
bone is ready to be cut 5shaped to fit the recipient si&e7 but each piece "ust be #ong
enough to ho#d at #east t,o scre,s. 3 si"p#e resorbab#e co##agen "e"brane ,hich
resorbs in 2 ,ee1s 7 is p#aced oer the grafted bone to retard fibrous do,n gro,th during
initia# hea#ing.
Before p#acing the bone harested fro" the ra"us graft7 the corte; of the recipient site
shou#d be perforated to enhance reascu#ari&ation7 5 the graft shou#d hae inti"ate
contact ,ith the host bone.
Co"p#ications of bone haresting fro" the ra"us:
<otentia# da"age to the inferior a#eo#ar nere
6i"itation of graft si&e 5 shape
Incision dehiscence in donor area
<ostoperatie tris"us
<otentia# da"age to #ingua# nere during f#ap incision
432%ESTIN+ BONE .2O( TIBI3:
Bone obtained fro" tibia contains osteoco"ponent ce##s7 an is#and of "inera#i&ed
cance##ous bone7 fibrin fro" b#ood c#otting 5 p#ate#ets fro" ,ithin the c#ot. Fithin
hours of graft p#ace"ent the c#ots p#ate#et degranu#te re#easing p#ate#et deried gro,th
factors7 transfor"ing gro,th factor 5 other gro,th factorsto initiate the process of
bone regeneration.
3dantages:
3#"ost 2/ to !/ c" cube of non co"pressed bone can be harested fro" the
"arro, spaces.
The procedure is straight for,ard 5 can be perfor"ed using in office conscious
sedation or genera# anesthesia
Tota# procedure ti"e ag on#y 2/ to !/ "in
B#ood #oss is "ini"a# 5 drainage is not reBuired
<atients report "ini"a# postoperatie pain 5 dysfunction
<rocedure a##o,s i""ediate post operatie ,eight bearing
Co"p#ication s 5 "orbidity rates are #ess co"pared to other "ateria#s . studies
hae sho,n that co"p#ication rates ,ith tibia ranges fro" 1.3H to 3.*H
co"pared to *.'H to -.2H ,ith i#iac crest grafting.
Contrindications:
Need for b#oc1 bone@proides on#y cance##ous bone i.e particu#ate for" of
boneA
<atient s1* years of age or younger
<atients ,ith history of 1nee in0ury or 1nee surgery
<atients ,ith adanced rheu"atoid or degeneratie arthritis
<atients ,ith "etabo#ic bone disease.
Surgica# approach 5 techniBue of haresting:
The s1in is disinfected ,ith betadine app#icators to re"oe surface bacteria. Then a
steri#e surgica# "ar1er ,i## be needed to dra, the anato"ic #and"ar1s on the s1in7 the
#ocation of pate##a 7 head of the tibia5 the gerdy tuberc#e is "ar1ed on the s1in.
6oca# anesthesia ,ith asoconstrictor is first gien subcutaneous#y 5 then deep into
the periosteu". 3nd 1$ b#ade is used to "a1e a 2 to 3 c" incision in #ayers through
the s1in7 subcutaneous tissue7 "usc#e fibre5 periosteu"7 sharp periostea# e#eator is
then used to ref#ect the periosteu" ,hich is fir"#y attached to the bone. The
osteoto"y begins as a series of ho#es for"ing a circ#e ,ith a circu"ference not #arger
than 1 c" 7 these perforations are then connected ,ith the sa"e bur5 the centra#
cortica# bone is then re"oed ,ith the he#p of "o#t curette.
<ostoperatie ,ound "anage"ent:
Inc#udes he"ostatic agents7 suturing 5 anti bacteria# oint"ent. The ,ound does not
need to be drained.before c#osing the donor site hae"ostatic agent is app#ied 5 c#osure
of the soft tissues ,ith resorbab#e suture is perfor"ed in #ayers starting ,ith the
periosteu". The "usc#e is sutured ,ith !:/ chro"ic gut7 fo##o,ed by s1in by $:/
pro#ene suture.
Co"p#ications:
<otentia# entrance into the 0oint space
6i"ited si&e 5 shape of the graft
Entrance into the fibu#a head instead of tibia
<ostoperatie ede"a or ecchy"osis
6arge 5 unsight#y scar.
I6I3C C2EST BONE +23.T:
3nterior approach:
The patient is prepared ,ith poidone iodine soap5 paint 5 draped in an a standard
steri#e fashion. 6oca# infi#tration of 1H #idocaine ,ith epinephrine is gien. 3 no 1$
b#ade is used to "a1e the incision e;tending to the subcutaneous tissue. E#ectro
cautery can be used to gain he"ostatic contro#7 sharp dissection is co"p#eted through
the e;terna# 5 interna# ob#iBue "uscu#ature5 periostea# #ayers to gain access to the
bony crest. 3 sub periostea# ref#ection of the i#iac crest in the "edia# direction is
preferred to aoid dissection of the tensor fascia#ata "usc#es #atera##y creating gait
disturbance. Seera# osteoto"y approaches7 ,ith either conentiona# "a##et 5
osteoto"ies or air or e#ectrica# drien sa, b#ades can be used to gain access to the
cance##ous bone. Tessiers approach @particu#ate cance##ous boneA atte"pts to "aintain
the contour of the crest by perfor"ing ob#iBue osteoto"ies off the #atera# 5 "edia#
aspects 5 retrieing the bone deep to the crest itse#f. If a corticocance##ous b#oc1 is
desired7 fu## thic1ness osteoto"ies are co"p#eted on the "edia# aspect 7detaching the
b#oc1 at the "ost "edia# aspect.
<osterior approach:
3dantages:
(ore bone is aai#ab#e i.e "ore than 2 to 2.$ ti"es the Buantity ta1en fro" the
anterior site.
6ess "orbidity
6ess co"p#ication.
6ess associated b#eeding
6ess gait pain 5 disturbance
?isadantages:
Oera## operatie ti"e is increased
Inabi#ity to operate si"u#taneous#y on both the facia# 5 i#iu" regions
<rocedure:
Incision is "ade at the ,e## defined bony pro"inence #atera##y ,here the
g#uteus "a;i"us inserts. The curi#inear incision courses "edia##y about 3 c"
#atera# to the "id#ine entering at the #ength of about 1/ c".This direct approach
"ini"i&es da"age to the ita# neura# 5 ascu#ar structures.. subperiostea#
ref#ection a##o,s easy access to the desired site. Osteoto"y of around $ c"
re"oes the cortica# p#ate to gain access to the cance##ous "arro,. In both the
approaches once the cance##ous bone is reached7 bone can be harested using
bone gouge or curets.3ny sharp edges are s"oothened7 he"ostasis achieed 5
c#osure is done in #ayers. 3 drain is usua##y reBuired7 e;iting at a site a,ay fro"
the incision 5 suctioned at the #o, inter"ittent strength to aoid continuous
aspiration of the "arro, b#ood..
Co"parision bet,een i#iac crest 5 tibia:
3uto#ogous grafts are considered as the go#d standard for bone substitution7 5
i#iac crest is considered as the choice of "ateria#.
But bone haresting fro" the i#iac crest is associated ,ith !-H of postoperatie
co"p#ications co"pared to tibia ,hich is associated ,ith on#y 2 H of
co"p#ications. i.e #o,er donor site "orbidity7 accessibi#ity7 easier and faster
haresting7 #ess b#ood #oss7 fe,er postoperatie ana#gesic reBuire"ents7 and #ess
gait disturbance
'
But the o#u"e of bone harested is "ore fro" i#iac crest co"pared to the
tibia# grafts.
Cance##ous i#iac bone "easuring around 1 "" is tri""ed 5 used for orbita#
reconstruction ,ithout rigid fi;ation.
1
Bone haresting fro" the ribs:
?epending on the si&e 5 contour7 ! th 7 $
th
5 ' th ribs are best. The si;th rib is
"ost ,ide#y used because it can be accessed through an infra"a""ary crease
incision. Fith the patient in the supine position 7 an infr"a""ary incision is
"ade through the s1in 5 sub cutaneous tissue unti# the fibres fro" the
pectora#is "a0or "usc#e 5 rectus abdo"inis "usc#e are seen attaching to the
si;th rib. 3 periostae# incision is p#aced at the greatest cone;ity on the #atera#
aspect of the rib 5 ,ith the he#p of periostea# e#eators7 the rib is e;posed fro"
its costrocondra# 0unction anterior#y to a posterior #ength as "uch as 1* c".
carefu# e#eation of the periosteu" has to be done or e#se it "ay perforate the
p#eura 5 cause s"a## tears. Once ref#ection is co"p#eted 7 the resection is begun
at the carti#age site 7ta1ing on#y 3"" of carti#age "edia##y. (ore than 3 ""
increases the chance of carti#age separation fro" the bone7 especia##y in
chi#dren. Once the anterior end is separated fro" the sternu" 7 the rib can be
e#eated by p#acing an instru"ent on the undersurface of the rib7 protecting the
parieta# p#eura. C#osure is then done in #ayers. 7 in chi#dren fu## "orpho#ogica##y
nor"a# rib ,i## regenerate ,ithin 1 year 7 ,hereas in adu#ts an inco"p#ete bone
ossic#es rese"b#ing a rib s#o,#y for"s oer 1 to 3 years.
C36%32I36 BONE +23.TIN+:
It has a uniBue characteristic of ear#y reascu#ari&ation ,hich is direct#y re#ated
to the nu"erous ascu#ar syste"s7 as a resu#t the graft suries ,ith #itt#e
di"ensiona# change.the site o haresting bone is para"edian portion of the
parieta# bone as it is the thic1est 5 is a,ay fro" the ita# structures @eg:
superior sagitta# sinusA 5 a#so #ess chance of scar being isib#e in "a#e pattern
ba#dness.. approach to this area is through the he"icorona# or bicorona# incision
7 posterior to the ear5 is carried through the fie sca#p #ayers. The e;posed
craniu" can then be prepared for either sp#it thic1ness or fu## thic1ness graft.
Sp#it thic1ness grfat is "ost co""on in ora# 5 "a;i##ofacia# surgery7a bur is
used to create the shape of the desired graft in the outer corte; to the #ee# of the
cance##ous "arro,. Then ,ith the he#p of cured osteto"e the outer tab#e can
be c#eaed fro" the inner tab#e in the p#ane of the interposed cance##ous
"arro,.
.u## thic1ness grafts are approached fro" a si"i#ar sca#p incisionG #arge fu##
thic1ness bur ho#es are created at the periphery of the desired graft design.The
?ura is then ref#ected fro" the undersurface of the inner tab#e7 a##o,ing a bur or
sa, to connect the bur ho#es ,ithout dura# perforation. The defect created fro"
this graft harested is usua##y repaired by sp#it thic1ness graft harested fro"
the contra #atera# side. This aids in protecting the brain 5 restores sca#p contour.
?rains are usua##y p#aced to reduce the dead space as ,e## as to preent
he"ato"a for"ation. Once the graft is p#aced it is has to be proper#y stabi#i&ed7
if not ,i## resu#t in resorption of the graft.
?ifferent for"s of bone grafts:
There are 2 types of bone graft "ateria#
1. ascu#arised graft
2 .Non:ascu#arised grafts.
The non ascu#ari&ed bone grafts are usua##y of t,o different types 8 cortica# 5 cance##ous.
Corticocance##ous bone grafts hae characteristics of each of these t,o bio#ogica# types.
The easier the penetration of the b#ood esse# into the graft to reascu#arise it7 the #ess
"echanica# strength the graft can ta1e up. The "ore so#id the bone graft is in its for" to
,ithstand "echanica# stress7 the harder it is to reascu#arise it7 to be incorporated 5 to
beco"e a iab#e bone.
Cortica# bone: they are pri"ari#y used in an area ,here there is great "echanica# stress7
proper fi;ation has to be used to a##o, this graft to produce the function needed. This for"
of graft is usefu# in #ong bones but itEs not ery effectie ,hen used in "e"branous bone
sites such as facia# s1e#eton. They are used in discontinuity defects to study "echanica#
strength in response to shear stress 5 to ea#uate stress shie#ding. To achiee an e;act fit in
the cortica# bone app#ication7 a p#entifu# supp#y of auto#ogous bone is needed. This is one of
the "ain reasons ,hy such cortica# graft incorporating structures are used in a##ograft ariety
of bone grafting.
Cance##ous bone: it is used because of its e;tensie ease of app#ication for achieing fusion
5 for correcting discontinuity defects. It can be used in c#ean conta"inated 5 gross#y
conta"inated bones. The supp#y site "ain#y is the i#iac or i#iac crest graft. They usua##y do
not hae "echanica# strength desired for such reconstruction for app#ication in #arge defects.
Because of this #arge open areas in this graft7 reascu#ari&ation ta1es p#ace ery ,e##7 thereby
bringing ne, ce##u#ar regeneration7 re"ode#ing 5 substitution ,ith ne, bone for"ing as o#d
bone is re"oed.
Corticoncance##ous bone : it usua##y produces the best resu#ts because it enab#es good
ascu#ari&ation to he#p the incorporation of the bone graft ,ith the surrounding structures 5
it a#so gies good "echanica# strength. 3 rigid fi;ation apparatus can be used to produce the
desired contour particu#ar#y in a discontinuity defect app#ication.
Bone grafts can be obtained either b#oc1 or particu#ate for". The b#oc1 for" can be reshaped
before app#ication. >nfortunate#y ,hen #arger b#oc1s are needed the supp#y is #i"ited.
<articu#ar#y because the idea# "ateria# for bone grafting is autogenous bone. The #arger
pieces of bone graft cannot be supp#ied fro" autogenous co"ponents7 particu#ar#y for repair
of #arge continuity defects. This is the "ain reason ,hy it has been necessary in certain
c#inica# app#ications particu#ar#y in orthopedic surgeries to use a##ograft.
<articu#ate bone is co"posed of s"a## chips of bone is usua##y app#ied in an area ,here there
is no need for "echanica# strength. It is used for discontinuity defects ,here the defect is
a#so bridged ,ith "echanica# deice7 interna# or e;terna# 5 the defect is fi##ed ,ith this
particu#ate bone. Fith the adent of i"proed "echanica# unities an interna# rigid fi;ation
structures particu#ar#y ita##iu" 5 titaniu"7 interna# fi;ation is preferred so the patient can
hae near nor"a# function during the hea#ing phase ,hich ,i## ta1e as #ong as 2 years.
E(B2CO6O+IC36 3S<ECTS O. BONE +23.TS:
Bone is either of "e"branous or endochondra# type.
(e"branous bone: It is a bone in ,hich trabecu#ar ossification ,as for"ed denoo in the
e"bryo the pri"itie "esenchy"a# ce##s for" a sheet of "esoder" ,ith a rich ascu#ar
supp#y. Interce##u#ar deposition of co##agen fo##o,s ce##u#ar differentiation. 3s ossification
centres dee#op osteob#asts can be identified ,ithin c#ose#y pac1ed s"a## bund#es of co##agen
fibres7 fina##y ca#ciu" sa#ts are deposited in the interce##u#ar spaces 5 ,ithin the ad0acent
osteoid. Thus the direct bone for"ation occurs ,ithout an inter"ediate process. E;a"p#es of
"e"branous bones inc#udes au#t of the s1u##7 facia# s1e#eton7 "uch of the "andib#e 5 "ost
of the c#aic#e.
Endochondra# ossification: it is a process of bone for"ation in ,hich a pri"itie carti#age is
reBuired before osteoid deposition. E;: "ost of the crania# base7 portion of the "andib#e 5
"a0ority of bones of the a;ia# s1e#eton ,hich are preceded by pri"itie hya#ine carti#age7
,hich differentiates fro" the "esenchy"e ear#y in e"bryonic #ife. This carti#age "atri; is
#ater inaded by b#ood esse#s 5 bone for"ing ce##s ,hich is then resorbed 5 rep#aced by
osteoid.
<eer e"pirica##y noted that fresh hu"an autogenous endochondra# bone @ rib7tibia 7i#iac
crestA,hen orthotopica##y or heterotopica##y transp#anted 7the "a0ority of the grafted bone
,as rep#aced ,ith the fibrous tissue. In contrast ,hen bone of "e"branous origin @o"er A
,as grafted it retained its bony "ass 5 sho,ed no eidence of fibrous rep#ace"ent een
,hen transp#anted to distant heterotopic sites.
It ,as a#so studied that host "aturation at "e"branous bone site ,as significant in both
"atured 5 i""ature ani"a# study co"pared to endochondra# site ,here it ,as not
significant in i""ature ani"a#s.
(e"branous bone consistent#y outperfor"ed endochondra# bone ,ith respect to resorption7
graft orientation7 host stages of "aturation7 "orpho#ogic designs7 5 fi;ation techniBues.
(echanis" of bone regeneration 5 aug"entation:
!
Three different processes are associated ,ith successfu# bone grafting:
Osteogenesis is the process that occurs ,hen suriing osteogenic ce##s fro" ,ithin the graft
produce ne, bone. This "echanis" of graft hea#ing re#ies on iab#e post transp#ant
osteogenic ce##s to beco"e the source of ne, bone for"ation. 3#though "ost ce##s ,ithin the
graft die soon after transp#antation so"e suriing ce##s are be#ieed to ta1e part in
osteogenesis. The superior reascu#ari&ation Bua#ities of cance##ous bone grafts are thought
to resu#t in a greater proportion of post transp#ant osteogenic ce## suria# and7 conseBuent#y7
a greater degree of osteogenesis than in cortica# bonegrafts. The #oca# sources of ce##s
parta1ing in osteogenesis are be#ieed to be the periosteu"7 endosteu"7 "arro,7 and
intracortica# e#e"ents. The ro#e of osteogenesis as a "echanis" of ne, bone for"ation
during nonascu#ari&ed bone graft hea#ing is thought to be of #esser significance than that of
osteoconduction. 3#though osteogenesis has a secondary ro#e in the hea#ing of
nonascu#ari&ed bone graft7 it constitutes the pri"ary "echanis" of ascu#ari&ed bone graft
hea#ing. Ce##s ,ithin these grafts "aintain their b#ood supp#y and re"ain iab#e after
transp#antation
Osteoinduction is the process by ,hich actie factors re#eased fro" the
graft "atri; sti"u#ates ce##s fro" the host to for" ne, bone. Osteoinduction
has been studied e;tensie#yG ho,eer7 there is significant#y #ess research
,ithin the specific conte;t of bone graft hea#ing. Three phases of osteoinductionI
che"o ta;is7 "itosis7 and differentiationIhae been described. In
response to a che"ica# gradient during che"ota;is7 bone induction factors
direct the "igration of ce##s to the area in ,hich they are to be uti#i&ed. .o##o,ing
che"ota;is7 these factors sti"u#ate intense "itogenic and pro#iferatie
actiity in these ce##sG the ce##s differentiate into carti#age and beco"e
reascu#ari&ed by inading b#ood esse#s to for" ne, bone. 2esearch on
osteoinduction during graft hea#ing has de"onstrated that che"ica# and
<hysica# a#terations to the graft7 such as hydroch#oric acid deca#cification
and free&ing7 ,i## decrease its osteoinductie properties . These
.indings suggest that osteoinduction is "ost significant ,hen fresh#y harested
bone grafts are uti#i&ed. Bur,e## suggested that osteoinductie factors
,ithin a bone graft are re#eased by the necrotic bone and "arro, co"ponents
of the graft .The true "echanis"s of osteoinduction during bone
graft hea#ing are sti## un1no,n and "ay proide a ferti#e ground for ne,
research endeaors. Osteoinductie factors hae been sho,n to be po,erfu#
sti"u#ators de noo bone production in bony defect hea#ing of ani"a#
"ode#sG their potentia# app#ications in bone graft hea#ing and incorporation
hae yet to be e;p#oited. 3#though the ro#es of osteoinduction and osteogenesis
are thought to be of #esser significance than osteoconduction in nonascu#ari&ed
bone graft hea#ing7 these three processes are thought to be
inti"ate#y connected.
Osteogenic sti"u#ation or bone induction:
Bone induction syste"s are autogenous.the cance##ous bone "atri; apparent#y has the abi#ity
to sti"u#ate the autogenous "arro, to beco"e "ar1ed#y ostegenic 5 to for" ne, bone.
This graft "atri; 5"arro, substrate is the pri"ary "ode# for bone induction .
4o, the induction ta1es pa#ce:In the particu#ate cance##ous bone graft there are arious
ascu#ar "arro, spaces ,hich contains ce##s of p#uripotent origin as ascu#ar #ining ce##s.
The host bed a#so contains the sa"e types of ce##s7 so there are t,o possib#e approaches to
sti"u#ate the osteob#astic potentia# of p#uripotent ce##s
1. The effect of graft on the itse#f. Fhen the graft is proper#y i""obi#i&ed 5 proper#y
ascu#ari&ed7 its o,n p#uripotent ce##s can be sti"u#ated to for" bone.
2. The effect of the graft on the host bed @i.e on the p#uripotent ce##s of the "arro,
ascu#ar spaces of the recipient siteA.these host p#uripotent ce##s a#so need to be
actiated in the bone inductie process..
In the #ie autograft7there are a#so suriing osteob#asts 5preosteob#asts7,hich hae
a#ready been co""itted to beco"ing bone for"ing ce##s in the graft itse#f.such bone
for"ation fro" e;isting osteob#ast 5co""itted osteob#asts is a short #ied part of the
bone inductie process.so induction can co"e fro" the
1. The graft "ateria# 5 its o,n suriing osteob#asts
2. The induction of the graft s o,n p#uripotent ce##s 5
3. Induction of the pri"itie ce##s of the recipient site s "arro, ascu#ar bed.
The bone graft if proper#y ascu#ari&ed7 Can sti"u#ate its o,n p#uripotent ce##s to for"
bone at the graft site.this graft can a#so initiate the p#uripotent ce##s in the host bed
,hich either differentiate into carti#age or bone. 4o,eer in c#inica# situation of
osseous repair in bone grafting7 "ost of the bone induction resu#ts ,hen the
p#uripotent ce##s fro" the osteob#ast 5bone direct#y7 5 the carti#aginous path,ay
beco"es a "inor one in "a;i##ofacia# osseous reconstruction.
BONE (O2<4O+ENETIC <2OTEIN:
One group of cyto1ines7 bone "orphogenetic proteins @B(<sA7 has been de"onstrated to
hae true osteoinductie properties. B(<s hae been proen to sti"u#ate ne, bone
for"ation in itro and in io. In addition7 they p#ay critica# ro#es in regu#ating ce## gro,th7
differentiation7 and apoptosis a ariety of ce##s during dee#op"ent7 particu#ar#y in
osteob#asts and chondrocytes.
There are current#y 1' identified B(<s7 a#though on#y a subset hae been found to be
e;pressed
in fracture hea#ing. B(<s ,ere initia##y characteri&ed by >ristG their identification ,as based
on the capacity of de"inera#i&ed bone po,der to induce de noo bone for"ation in an
intra"uscu#ar pouch7 de"onstrating the abi#ity to direct#y induce "esenchy"a# connectie
tissue to beco"e bone:for"ing osteoprogenitor ce##.
?uring fracture repair 5 graft hea#ing7 B(<:27 B(<:3 @a#so 1no,n as osteogeninA7 B(<:!7
and B(<:) @O<:1A hae been found to be e;pressed to arying degrees. B(<s are initia##y
re#eased in #o, #ee#s fro" the e;trace##u#ar "atri; @EC(A of fractured bone.
Osteoprogenitor ce##s in the ca"biu" #ayer of the periosteu" "ay respond to this initia#
B(< presence by differentiating into osteob#ast. I""uno#oca#i&ation de"onstrates an
increase in detectab#e B(<:2J! in the ca"biu" region of the periosteu". B(< receptor I3
and IB e;pression is dra"atica##y increased in osteogenic ce##s of the periosteu" near the
ends of the fracture in the ear#y postfracture period or post grafting period. 3ppro;i"ate#y 18
2 ,ee1s postfracture or graft p#ace"ent7 B(<:2J! e;pression is "a;i"a# in chondroid
precursors7 ,hi#e hypertrophic chondrocytes and osteob#asts sho, "oderate #ee#s of
e;pression. It is hypothesi&ed that the ro#e of B(<s in fracture repair is to sti"u#ate
differentiation in osteoprogenitor and "esenchy"a# ce##s that ,i## resu#t in osteob#asts and
chondrocyte. 3s these pri"itie ce##s "ature7 B(< e;pression decreases rapid#y. B(<
e;pression te"porari#y recurs in chondrocytes and osteob#asts during "atri; for"ation7 and
eentua##y decreases during ca##us re"ode#ing.
TC<ES O. B(<s T4EI2 <2O<E2TIES7 6OC3TION 5 2O6ES:
B(<:1: functions as proco##agen C: proteinase responsib#e for re"oing carbo;y#
propeptides fro" proco##agen I7 2 73 . It actiates b"p but not osteoinductie
B(<:2: osteoinductie 7 e"bryogenesis7 differentiation of osteob#asts 7 adipocytes7
chondrocytes 5 a#so "ay inf#uence osteoc#ast actiity 7 "ay inhibit bone hea#ing
It is #ocated in the bone7 sp#een7 #ier7 brain7 1idney7 heart7 p#acenta.
B(<:3:@osteogeninA: osteoinductie 7 pro"otes chondrogenic phenotype
It is #ocated in the #ung7 1idney7 brain7 intestine.
B(<:!: osteoinductie7 e"bryogenesis7 fracture repair7 gastru#ation 5 "esoder"
for"ation @"ouseA.
It is #ocated in the apica# ectoder"a# ridge7 "eninges7 #ung7 1idney7 #ier.
B(<:$::osteoinductie7 e"bryogenesis. It is #ocated in #ung7 1idney7 and #ier.
B(<:':: not osteoinductie7 e"bryogenesis7 neurona# "aturation7 regu#ates chondrocyte
differentiation. It is #ocated in the #ung7 brain7 1idney7 uterus7 "usc#e7 s1in.
B(<:)::@osteogenic protein:1A osteoinductie7 e"bryogenesis7 repair of #ong bones7 a#eo#ar
bone7 differentiation of osteob#asts7chondrob#asts 5 adipocytes. It is #ocated in the adrena#
g#ands7 b#adder7 brain7 eye7 heart7 1idney7 #ung7 p#acenta7 sp#een 5 s1e#eta# "usc#es.
B(<:*@osteogenic protein:2A osteoinductie7 e"brogenesis7 sper"atogenesis@"ouseA.
B(<:*B@osteogenic protein:3Ainitiation 5 "aintainance of sper"atogenesis@"ouseA.
B(<:-::osteoinductie7 sti"u#ates hepatocyte pro#iferation7 hepatocyte gro,th 5 function.
B(<:12 5 B(<:13::inhibition of ter"ina# differentiation of "yob#asts.
Osteoconduction: it is a physica# effect by ,hich the "atri; of the graft for"s a scaffo#d that
faors outside ce##s to penetrate the graft 5 for" the bone. Bone conduction i"p#ies that a
surgica# syste" has the abi#ity to inf#uence ce##s that are a#ready progra""ed to beco"e
osteob#ast to differentiate "ore efficient#y and "ore e;peditious#y in bringing about bone
for"ation. Therefore effectie bone conduction ta1es p#ace on#y in a#ready predeter"ined or
preprogra""ed ce##s and not in p#euripotent ce##s. This is best seen in the apparent effect of
the graft in #eading bone repair fro" the surface of recipient site to produce an oergro,th of
the bone. The bone repair in these cases is e;tre"e#y #i"ited and cou#d not usua##y be used.
3## bone graft "ateria# possesses at #east one of the three "odes of action.
%3SC>632I=E? %E2S>S NON %3SC>632I=E? +23.TS
3t the ce##u#ar #ee# one of the t,o outco"es is possib#e either the osteocytes in the graft can
#ie or die. But the "ost i"portant factor ,hich is of concern is b#ood supp#y.
In the non ascu#ari&ed bone graft the bone frag"ents are #aid across the defect. On#y
nutritiona# support aai#ab#e is ia diffusion fro" the surrounding tissue bed. If the tissue bed
is a#so co"pro"ised the graft is in further danger. The first eent to occur is death of the
osteocytes farthest fro" the nutritiona# supp#y and it is said that ,ith the death these ce##s
secrete a substance that pro"otes neoascu#ari&ation. Osteoc#ast brea1do,n the necrotic
bone and the essse#s begin to "igrate into this region. These ne, esse#s bring
osteoprogenitor ce##s ,hich initiate ne, bone for"ation a#ong the path of a ne, esse#. This
#eads to an adancing front for ne, bone for"ation ia the brea1do,n of donor bone
@creeping substitutionA. It occurs "ore rapid in cance##ous bone than cortica# bone.
Creeping substitution refers to the "oe"ent of ne, tissue through channe#s "ade by b#ood
esse#s inading a transp#anted bone. This ter" ,as first used by 3;hausen in 1-/). To
describe the dyna"ic hea#ing and reconstructie process of bone transp#antation. 3;hausen
deter"ined that bone transp#ants undergo necrosis7 and that necrotic bone is rep#aced by ne,
bone ia creeping substitution
T,o things to be considered:
1. 3s they are dependent upon nutritiona# support7 they cannot be transp#anted into s"a##
defects.
2. They depend on the condition of tissue bed at the recipient site. If the bed has a poor
b#ood supp#y the osteocytes die too Buic1#y and the graft does not surie #ong enough
to generate a good osteob#astic response.
%3SC>632I=E? BONE +23.T
This graft carries its o,n b#ood supp#y so bone hea#ing occurs ,ithout bony resorption and
creeping substitution. This #eads to greater strength in the graft "uch sooner after the repair7
,hich decreases the ris1 of fracture and enab#es Buic1 repair of the defect. The graft is not
dependent on the state of the surrounding tissue of the defect. So it can be transp#anted into
"ore hosti#e eniron"ents. The increase b#ood supp#y a#so decreases the incidence of graft
re0ection. These free ascu#ari&ed bone grafts can be transp#anted into #arger defects. .ree
ascu#ari&ed grafts cou#d a#so be transp#anted as a co"posite graft ,ith s1in or "usc#e
attach"ent and this ,ou#d be usefu# for reconstruction ino#ing both bony and soft tissue
defects.
Nonvascularized Bone Graft Physiology
4ea#ing and incorporation ino#e the processes of inf#a""ation7
2eascu#ari&ation7 osteoconduction7 osteoinduction7 osteogenesis7 and re"ode#ing.
3n i"portant aspect in @nonascu#ari&edA bone graft hea#ing is that a
Substantia# portion of the bio#ogica# actiity originates fro" the host. (ost
%iab#e osteocytes ,ithin the graft itse#f die Buic1#y after transp#antation7 rendering
the graft co"paratie#y inert ersus the host. ?espite this substantia#
bio#ogica# interactions occur bet,een the graft and the host7 and the graft
has a funda"enta# ro#e in deter"ining its o,n fate. This bio#ogica# interp#ay
bet,een graft and host estab#ishes the fina# resu#t. 3943>SEN noted that bone grafts
initia##y undergo partia# necrosis7 fo##o,ed by an inf#a""atory stage7 in ,hich the e;isting
bone is rep#aced ,ith ne, bone by osteob#asts that are brought in through the inading
b#ood esse#s. 3;hausen coined the ter" KKcreeping substitutionEE to describe
the s#o, process of esse# inasion and bony rep#ace"ent. (ore recent#y7
These eents hae been referred to as osteoconduction7 and both ter"s are
used interchangeab#y.
4e"ato"a for"ation around the bone graft is the first eent that
occurs after graft transp#antation7 usua##y caused by b#eeding fro" the
surgica# disruption of host soft tissues and the recipient bony bed. ?uring
this ear#y stage7 on#y a s"a## "inority of the ce##s ,ithin the bone graft
are sti## iab#e7 #ocated at the graftEs periphera# surface. These surface ce##s
surie7 o,ing to ear#y reascu#ari&ation or by p#as"atic i"bibition
3n inf#a""atory reaction around the graft ensues and #asts for $8) days. The inf#a""atory
tissue beco"es reorgani&ed into a dense fibroascu#ar stro"a around the graft7 and the onset
of ascu#ar inasion occurs at 1/81! days bringing ce##s ,ith osteogenic potentia# into
the graft . These ce##s @osteob#asts and osteoc#astsA begin to rep#ace the graft7 ,hi#e the
interstices of the o#d bone act as a scaffo#d for the deposition of ne, bone. 3s the deposition
ta1es p#ace through osteob#ast actiity7 resorption of necrotic bone occurs through
osteoc#astic actiity7 and the bone graft is s#o,#y penetrated by ascu#ar tissue. These
processes continue to occur unti# reascu#ari&ation and deposition are co"p#ete.
13
I"portant factors for graft suria#:
1. (echanica# stress@on#ay or in#ay graftA
2. (icroarchitecture of the graft "ateria#.@cance##ous or cortica# boneA
3. 2eascu#ari&ation
3fter transp#antation7 #oss of this stress #ed to resorption and poor o#u"e "aintenance
,hen co"pared to grafts fro" non:stress:bearing donor sites7 such as the ca#ariu"7that
is the reason ,hy i#iac bone resorbs faster than the ca#aria# bone because it reBuires "ore
of stress 5 ,ithout ,hich it resorbs.
On#ay bone grafts are sub0ected to "ore forces een fro" the soft tissue 7,hich causes it
to resorb faster7 ,hen co"pared to in#ay ,hich has no force fro" soft tissue 7so #ess
resorption.
I#iac bone a#so had "ore of cance##ous bone7 ,hich causes "ore of its resorption
co"paped to ca#aria# bone
.actors affecting reascu#ari&ation at the recipient site:
2ecipient bed eniron"ent
+raft position @in#ay or on#ayA
+raft "icroarchitecture@ cance##ous or cortica#A
<resence of rigid fi;ation
<resence of periosteu".
Cancellous bone graft revascularization & healing
Occurs due to the #arge spaces bet,een the trabecu#ae that per"it unobstructed inasion of
%ascu#ar tissue. 3utogeneic cance##ous bone graft hea#ing is diidedinto ear#y and #ate
phases .The early phase, occurring ,ithin the first ! ,ee1s7 is characteri&ed by
inf#a""ation7reascu#ari&ation7 and osteoinduction.Osteocyte precursors and osteocytesthat
surie transp#antation begin producing ne, bone. Bone "arro, necrosis occurs7 fo##o,ed
by inasion of host granu#ation tissue. 2eascu#ari&ation7 ,hich "ay begin as ear#y as 2days
after transp#antation7 rapid#y progresses. Bone "orphogenetic proteins and other gro,th
factors induce "igration of osteob#ast precursor ce##s to the graft. These ste" ce##s
differentiate into osteob#asts and ne, bone for"s by the end of the ear#y phase. 3t ! ,ee1s7
actie bone resorption and ne, bone for"ation occurs throughout the graftLs interior.
The late phase is a continuu"7 proceeding through osteoconduction and eentua# graft
incorporation. 3ctie graft resorption ,ith ne, capi##ary ingro,th continues.
(ature osteob#asts #ine the edges of the dead trabecu#ae as osteoid is deposited around the
necrotic core. 2e"ode#ing proceeds and the graft is eentua##y rep#aced ,ith #ie host bone.
S1e#eta# strength is restored as the trabecu#ae gradua##y return to nor"a#. The end of the
#ate phase is characteri&ed by rep#ace"ent of the cance##ous autograft ,ith the host s1e#eton.
This occurs appro;i"ate#y ' "onths after transp#antation and is usua##y co"p#ete by 1 year .
<eriphera# bone ca##us re"ode#s and conso#idates into ne, corte;
1'
Cortical bone graft revascularization & bone deposition:
%ascu#ar inasion of cortica# bone graft is thought to be #i"ited7
due pri"ari#y to its dense #a"e##ar structure that constrains esse#s to
inading the graft a#ong the pree;isting haersian and %o#1"annEs cana#s. Fhi#e cance##ous
bone grafts precede ,ith initia#
Osteob#astic actiity7 reascu#ari&ation of cortica# bone grafts proceeds ,ith
Initia# Osteoc#astic actiity. Osteoc#astic en#arge"ent of the haersian and
%o#1"annEs cana#s "ust occur before esse#s are ab#e to penetrate the graft. The course of
reascu#ari&ation begins at the graft periphery. In cance##ous
grafts7 esse# inasion "ay begin ,ithin a fe, hours post transp#antation7
and the process is co"p#eted in a fe, days. In cortica# grafts7 the ear#iest
esse#s enter the graft at ' days7 and the process of reascu#ari&ation "ay
ta1e "onths7 often resu#ting in inco"p#ete graft reascu#ari&ation
@12/712!A. inco"p#ete#y reascu#ari&ed regions of necrotic graft "ay persist
indefinite#y7 sea#ed off fro" the iab#e regions of the graft. The fina#
appearance of a cortica# bone graft is often a patch,or1 of necrotic bone7
interspersed by areas of ne, bone.
Healing of allograft & alloplastic material:
?epending on the genetic differences bet,een host and donor7 three types
of responses are obsered: 3cceptance @type 1A7 <artia#
3cceptance @type 2A7 or 2e0ection @type 3A
In a Type 1 response7 there is no apparent genetic disparity and the host accepts the
a##ogeneic bone. Inf#a""ation decreases7 incorporation proceeds
in a "anner si"i#ar to autograft7 and the a##ogeneic bone fu##y incorporates. 2adiographic
union7 re"ode#ing7 and incorporation are identica# to autografts. 4isto#ogic data regarding
cu"u#atie bone for"ation7 porosity7 and rate of resorption "atches
that for autografts
3 Type 2 response indicates a greater genetic difference bet,een host and donor7 a##o,ing
partia# incorporation ,ithout proo1ing co"p#ete resorption . ?espite this #ac1 of
histoco"patibi#ity7 these a##ografts and a##oi"p#ants genera##y proceed to a satisfactory
c#inica# resu#t a#though at a s#o,er rate .>nder these conditions7 ingro,ing esse#s beco"e
occ#uded due to a heightened inf#a""atory reaction . %ascu#ar penetration and ne, bone
for"ation are #ess e;tensie7 #eading to arying a"ounts of
necrosis . 3 type 2 response "ay be characteri&ed by a iab#e graft peri"eter @seera#
"i##i"etersA,ith a necrotic centra# portion7 #i"ited creeping substitution7 de#ayedMnonunion
of the host a##ograftMi"p#ant interface7 bone ca##us bridging of the a##ograftMi"p#ant seg"ent7
#i"ited bony re"ode#ing7 increased freBuency of fatigue fracture7 #oss of a##ograftM
i"p#ant si&e7 decrease in "echanica# strength7 and tenuous soft tissue attach"ent to
a##ograftMi"p#ant .
3 type 3 response occurs ,hen significant genetic differences e;ist bet,een host and donor .
These a##ografts are rapid#y and co"p#ete#y resorbed. This igorous re0ection occurs by
continuous7 unre"itting periphera# resorption. There is no histo#ogic or
radiographic eidence of incorporation.
1'
Immunogenicity
Sources of a##ogeneic bone i""unogenicity hae been studied in detai# . The "ost critica#
aspect is ,hether the host recogni&es the donor bone as foreign or se#f . 3##ogeneic bone7
#i1e other a##ogeneic tissues7 induces an i""une response7 and fo##o,s
the sa"e i""uno#ogic ru#es as other grafting tissues . Its bio#ogic fate is deter"ined by the
aggressieness of the hostLs response .3##ografts and a##oi"p#ants are attac1ed pri"ari#y by
the ce##u#ar #i"b of the i""une syste"7 rather than the hu"era# . The initia# response
ino#es a ce##u#ar inf#u; of "acrophages and neutrophi#s fo##o,ed
by T and B #y"phocytes . T: and B:ce##s hae antigen:specific receptors that recogni&e
a##oantigens. T:ce##s are further separated into C?!D he#per ce##s andC?*D cytoto;ic:
suppressor ce##s.L ,hich are ino#ed in antigen recognition . 3 specific i""une response is
triggered ,hen the T:ce##s recogni&e a##oantigens as Nnonse#f.N This recognition actiates T:
ce##s to secrete cyto1ines that7 in turn7 sti"u#ate osteoc#astic actiity.
This resu#ts in e;cessie resorption and fai#ure of incorporation
1'
igid fi!ation in bone grafts:
2igid fi;ation i"proes on#ay graft suria# ,hen co"pared to graft ,ithout fi;ation
or ,ith ,iring. The reasons be#ieed responsib#e for i"proed suria# ,ith rigid
fi;ation inc#uded increased pri"ary bone hea#ing and "ore rapid reascu#ari&ation
by irtue of graft i""obi#ity. rigid fi;ation of on#ay bone grafts is thought to preent
resorption7 #oss of o#u"e7 and #oss of pro0ection
periosteum:
<resering the periosteu" on a bone graft during transp#antation has been
Sho,n to i"proe graft suria# in the craniofacia# region .the i"portance for ear#y
reascu#ari&ation of the graft "ateria# ,as thought to be increased due to presence of
periosteu".
Three #ayers of the periosteu" ,ere describedIan outer ascu#ar
net,or17 ,ith co""unications to the interna# portions of the bone7 a
"idd#e #ayer of osteogenic resere ce##s7 and the inner ca"bia# #ayer. They
proposed that bone graft reascu#ari&ation ,as enhanced by "eans of the
outer periostea# #ayer and its direct connections to the interior of the graft
Bone graft recipient site:
.actors affecting graft suria# at the recipient site:
1. 3ascu#ar bed
2. Irradiated area
3. Infection
!. Tissue scarring.
3 bonegraft p#aced in a defect nor"a##y occupied by bone is 1no,n as orthotopica##y
transp#antedG a graft p#aced in a site nor"a##y not occupied by bone
is heterotopica##y transp#anted.
Fhita1er introduced the concept of the bio#ogica# boundary
,hich is an e;tension of Fo#ffEs #a, and (ossE functiona# "atri;
theory. (ossE theory states that as the craniofacia# s1e#eton gro,s7
its soft:tissue eniron"ent "ay hae a significant ro#e in shaping its
"orpho#ogy. 4e be#ieed that the body has predeter"ined physica# boundaries that hae a
"a0or ro#e in bone graft suria#. 4e hypothesi&ed that on#ay grafts7 by irtue of their
position7 genera##y disturbed these boundaries and ,ou#d e#icit a response fro" the
bodyEs natura# tendency to "aintain the boundary by resorbing the graft.
Fhita1er noted that in#ay bone grafts did not disturb bio#ogica# boundaries7
,hi#e basa# bone adance"ents estab#ished ne, ones. But the "echanis" for this theory ,as
not proed.
ole of gro"th factors in bone healing:
#
+ro,th factors that can he#p in bone hea#ing are
<#ate#et deried gro,th factor
Transfor"ing gro,th factor
Insu#in derier gro,th factor
.ibrob#ast deried gro,th factor
<#ate#et deried gro,th factor:
It is re#eased fro" p#ate#et a#pha granu#e7 "acrophages or "onocytes7endothe#ia# ce##s
5 as ,e## as fro" osteob#ast ce##s.
The specific actiities of <?+. inc#udes "itogenesis@increase in the ce## popu#ation of
hea#ing ce##sA7 angiogenesis@endothe#ia# "itosis into functiona# capi##ariesA7 5
"acrophage actiation@debride"ent of the ,ound site 5second phase source of
gro,th factors for continued repair 5 bone regenerationA.
Transfor"ing gro,th factor:
It is present in abundance in the bone "atri;7 ,ith bone representing the "a0or site for
the storage of the T+. 8beta in the body.the pri"ary effect of T+. 8beta is on the
bone for"ation7 particu#ar#y in the ear#y phase of the osteob#ast dee#op"ent.it
sti"u#ates "atri; protein synthesis by hu"an osteob#asts.the "ost i"portant function
of T+. beta 1 5 T+. beta 2see"s to be che"ota;is 5"itogenesis of osteob#ast
precursors7 5 they a#so hae the abi#ity to sti"u#ate osteob#ast deposition of the
co##agen "atri; of ,ound hea#ing 5 of the bone. In addition they a#so inhibit
osteoc#ast for"ation 5 a#so bone resorption7 thus faoring bone for"ation than
resorption.
It direct#y inhibits both pro#iferation 5 differentiation of the osteoc#ast precursor ce##s
5 inhibits the function of the "ature osteoc#asts ,ith reduction in reactie e o;ygen
radica#s.
Insu#in #i1e gro,th factor:
It consists of t,o proteins:I+. 1@so"ato"edin cA 5 I+.2 @s1e#eta# gro,th factorA
,hich are secreted by osteob#asts7both the factors induce preosteob#ast pro#iferation 5
differentiation7 osteob#ast co##agen synthesis75 inhibit co##agen brea1do,n.I+. bound
to the protein in the "atri; "ay be re#eased in the actie for" fo##o,ing osteoc#astic
resoeption.#ocaa#y produced I+.1secreted by fibrob#ast5 ce##s in the bone 5 carti#age
is contro##ed by ariety of factors. Corticosteroids reduces I+.1 synthesis.
.ibrob#ast gro,th factor:
The "atri; proteins7 acidic .+. 5 basic .+.are produced by osteob#ast7bind heparin
5 are angiogenic factors. But there effects on bone inio are not 1no,n.in itro they
cause pro#iferation of osteob#ast progenitor ce##s but inhibit differentiation7 5 do not
appear to effect the osteoc#ast..+.s sti"ute ne, bone for"ation.
$%IN G&'($
3 s1in graft is the re"oa# and transp#antation of hea#thy s1in fro" one area of the body
@source area or donor siteA to another area @recipient areaA ,here the s1in has been da"aged.
The source sites "ost co""on#y used for s1in grafts are the inner thigh7 #eg7 buttoc1s7 upper
ar"7 and forear".
There are three "ain types of s1in graft techniBues:
1. Sp#it:thic1ness graftIthis is the re"oa# of the top #ayer of s1in @epider"isA and part
of the "idd#e #ayer @der"isA. This type of graft a##o,s the source site to hea# "ore
Buic1#y. 4o,eer7 the graft is a#so "ore fragi#e7 and "ay be abnor"a##y pig"ented.
This is the "ost co""on s1in graft used.
2. .u##:thic1ness graftIthis is the re"oa# and transfer of an entire area of s1in.
3#though this type of graft reBuires stitches to hea# the source site7 the fina# outco"e is
usua##y better. .u##:thic1ness grafts are usua##y reco""ended for areas ,here
cos"etic appearance is i"portant7 such as the face. 4o,eer7 fu##:thic1ness grafts can
on#y be p#aced on areas of the body that hae significant ascu#ari&ation @b#ood
esse#sA7 so its use is so"e,hat #i"ited.
3. Co"posite graftsIthis is the co"bination of s1in and fatG s1in and carti#ageG or
der"is and fat7 ,hich are used in areas that reBuire three:di"ensiona#ity7 such as the
nose.
The use of oneLs o,n s1in as the source area is ca##ed an autograft. 4o,eer7 if there is not
enough s1in on the body to proide graft coerage for another area on the sa"e body7 then
s1in "ay be harested fro" outside sources. These a#ternate sources are on#y "eant for
te"porary use unti# your o,n s1in gro,s bac1. Three co""on options:
1. 3##ograftIS1in ta1en fro" another hu"an source7 such as a cadaer.
2. 9enograftIS1in ta1en fro" an ani"a# source.
3. Synthetic tissue
Indications of the s1in graft:
1. Treat"ent of burn
2. Chronic u#cers @such as enous pressure7 trau"atic 5radiation induced u#cersA
3. S1in defects caused by re"oa# of s1in cancer.
!. ?a"aged areas are too #arge to be c#osed by stitching.
'ull)thic*ness s*in grafts
.u##:thic1ness s1in grafts are idea# for isib#e areas of the face that are inaccessib#e to #oca#
f#aps or ,hen #oca# f#aps are not indicated. .u##:thic1ness grafts retain "ore of the
characteristics of nor"a# s1in7 inc#uding co#or7 te;ture7 and thic1ness7 ,hen co"pared ,ith
sp#it:thic1ness grafts. It contains the entire der"is7 so pri"ary contraction is greater than the
contraction seen ,ith the sp#it thic1ness graft. Secondary contraction ho,eer7 ,hich occurs
as graft hea#s is "ini"a#. This is i"portant on the face as ,e## as on the hands and oer
"obi#e 0oint surfaces. .u##:thic1ness grafts in chi#dren are "ore #i1e#y to gro, ,ith the
indiidua#. 4o,eer7 fu##:thic1ness s1in grafts are #i"ited to re#atie#y s"a##7
unconta"inated7 ,e##:ascu#ari&ed ,ounds and thus do not hae as ,ide a range of
app#ication as sp#it:thic1ness grafts. ?onor sites "ust be c#osed pri"ari#y or7 "ore rare#y7
resurfaced ,ith a sp#it:thic1ness graft fro" another site.
$plit)thic*ness s*in grafts
Sp#it:thic1ness s1in grafts can to#erate #ess idea# conditions for suria# and hae a "uch
broader range of app#ication. They are used to resurface #arge ,ounds7 #ine caities7
resurface "ucosa# deficits7 c#ose donor sites of f#aps7 and resurface "usc#e f#aps. They a#so
are used to achiee te"porary c#osure of ,ounds created by the re"oa# of #esions that
reBuire patho#ogic e;a"ination prior to definitie reconstruction. Sp#it:thic1ness s1in graft
donor sites hea# spontaneous#y ,ith ce##s supp#ied by the re"aining epider"a# appendages7
and these donor sites "ay be reharested once hea#ing is co"p#ete.
Sp#it:thic1ness grafts a#so hae significant disadantages that "ust be considered. Sp#it:
thic1ness grafts are "ore fragi#e7 especia##y ,hen p#aced oer areas ,ith #itt#e under#ying
soft tissue bu#1 for support7 and usua##y cannot ,ithstand subseBuent radiation therapy. They
contract "ore during hea#ing7 do not gro, ,ith the indiidua#7 and tend to be s"oother and
shinier than nor"a# s1in because of the absence of s1in appendages in the graft. They tend to
be abnor"a##y pig"ented7 either pa#e or ,hite7 or a#ternatie#y7 hyperpig"ented7 particu#ar#y
in dar1er:s1inned indiidua#s. Their #ac1 of thic1ness7 abnor"a##y s"ooth te;ture7 #ac1 of
hair gro,th7 and abnor"a# pig"entation "a1e these grafts "ore functiona# than cos"etic.
Fhen used to resurface #arge burns of the face7 sp#it:thic1ness grafts "ay produce an
undesirab#e "as1#i1e appearance. .ina##y7 the ,ound created at the donor site fro" ,hich
the graft is harested is often "ore painfu# than the recipient site to ,hich the graft is app#ied
?onor sites:
Sp#it thic1ness graft: anterior 5 #atera# aspect of thigh7 buttoc1s
.u## thic1ness graft: 2etroauricu#ar 5 pre auricu#ar region
(ucosa# graft: chee1 5 pa#ate.
O<E23TI%E TEC4NIO>E:
Found preparation:
Opti"a# s1in graft success is inf#uenced by seera# factors that shou#d be addressed ,ith
thorough recipient site preparation prior to grafting7 3 ,e## ascu#ari&ed recipient bed is of
ut"ost i"portance in suria# of the s1in graft. Fith so"e e;ceptions7 s1in grafts rare#y ta1e
,hen p#aced on bone7 carti#age7 or tendon ,ithout the presence of periosteu"7
perichondriu"7 or paratenon.
The procedure for haresting and grafting s1in aries so"e,hat according to the si&e7 the
e;tent of grafting needed to coer the ,ounded site7 and the type of cos"etic reconstruction
reBuired7e;tensie facia# ,ounds that ino#e the nose7 #ips7 or eyes "ay reBuire s1in
grafting and a series of p#astic surgery interentions to reconstruct nor"a# function and
appearance.
The si&e of the ,ound @recipient siteA is "easured7 and a te"p#ate or pattern of the area to be
coered is "ade. Then a donor site is se#ected
?onor site se#ection:
?onor site se#ection is based on "u#tip#e factors7 inc#uding s1in co#or7 te;ture7 der"a#
thic1ness7 ascu#arity7 and anticipated donor site "orbidity.

.u##:thic1ness grafts proide a suitab#e co#or "atch for defects of the face. The pattern for
the graft shou#d be en#arged by 3:$H to co"pensate for the i""ediate pri"ary contraction
that occurs because of the e#astin fibers contained in the graft der"is7 and the donor site then
"ay be infi#trated ,ith #oca# anesthetic ,ith or ,ithout epinephrine. The fu##:thic1ness s1in
graft is e;cised ,ith a sca#pe# at the subder"a# #ee# of the superficia# fat. The residua#
adipose tissue is subseBuent#y re"oed ,ith sharp cured scissors prior to p#ace"ent in the
recipient bed7 as the fat is poor#y ascu#ari&ed and preents direct contact bet,een the graft
der"is and the ,ound bed. ?onor site defects resu#ting fro" fu##:thic1ness grafts "ust be
c#osed pri"ari#y or7 rare#y7 ,ith a ,ith a sp#it:thic1ness graft7 since no epithe#ia# structures
for regeneration re"ain.
Sp#it:thic1ness s1in grafts are co""on#y harested fro" the thigh7 buttoc1s7 abdo"ina# ,a##7
or sca#p. The "ethod of haresting the sp#it:thic1ness s1in graft depends pri"ari#y on the
si&e and thic1ness needed for coerage of the defect. S"a##er grafts can be ta1en using a
Npinch graftN techniBue using a sca#pe# b#adeG s#ight#y #arger freehand grafts can be obtained
,ith a Fec1 b#ade. <o,ered der"ato"es are "ost co""on#y used to harest sp#it:thic1ness
s1in grafts7 as they hae a rapid#y osci##ating b#ade that can be set at an ad0ustab#e depth and
,idth for the graft.
6idocaine ,ith epinephrine "ay be in0ected subcutaneous#y at the donor site prior to
haresting7 ,hich aids in reducing b#ood #oss and proiding greater tissue turgor to faci#itate
graft harest. The s1in and der"ato"e can be #ubricated ,ith "inera# oi# or steri#e sa#ine to
enab#e easy g#iding of the der"ato"e oer the s1in. Epinephrine:soa1ed gau&e "ay be
app#ied to the donor site i""ediate#y fo##o,ing harest to achiee he"ostasis.
(eticu#ous he"ostasis of the recipient bed is a#so 1ey in preenting he"ato"a for"ation
bet,een the graft and ,ound bed. 4e"ostasis is typica##y achieed through use of
epinephrine and sa#ine:soa1ed gau&e7 particu#ar#y in fresh#y e;cised burns7 in co"bination
,ith precise e#ectrocoagu#ation. Infection a#so co"pro"ises graft suria#G therefore7 carefu#
preparation of the recipient bed is necessary. 3 recipient bed that contains a bacteria
concentration greater than 1/
$
organis"s per gra" of tissue ,i## not support a s1in graft.
Graft survival &healing:
The u#ti"ate success of a s1in graft7 or its Pta1e7Q depends on nutrient upta1e and ascu#ar
ingro,th fro" the recipient bed7 ,hich occurs in 3 phases. The first phase ta1es p#ace during
the first 2!:!* hours. The graft is initia##y bound to the recipient site through for"ation of a
fibrin #ayer and undergoes diffusion of nutrients by capi##ary action fro" the recipient bed by
a process ca##ed plasmatic imbibition. The second phase ino#es the process of
inosculation7 in ,hich the donor and recipient end capi##aries are a#igned and estab#ish a
ascu#ar net,or1.

2eascu#ari&ation of the graft is acco"p#ished through those capi##aries as ,e## as by
ingro,th of ne, esse#s through neoascu#ari&ation in the third and fina# phase7 ,hich is
genera##y co"p#ete ,ithin !:) days. 2einneration of s1in grafts begins appro;i"ate#y 2:!
,ee1s after grafting and occurs by ingro,th of nere fibers fro" the recipient bed and
surrounding tissue. Sensory return is greater in fu##:thic1ness grafts because they contain a
higher content of neuri#e""a# sheaths. Si"i#ar#y7 hair fo##ic#es "ay be transferred ,ith a
fu##:thic1ness graft7 ,hich a##o,s the graft to de"onstrate the hair gro,th of the donor site.
Sp#it:thic1ness grafts are u#ti"ate#y hair#ess.

The a"ount of der"is present in the graft deter"ines the degree of contraction i""ediate#y
after harest fro" the donor site and fo##o,ing p#ace"ent and reascu#ari&ation in the
recipient bed. .resh#y harested grafts undergo i""ediate recoi# as a resu#t of e#astin in the
der"is in a pheno"enon ter"ed pri"ary contraction. Therefore7 a fu##:thic1ness s1in graft
contracts "ore initia##y fo##o,ing harest as it contains the der"is in its entirety. Secondary
contraction is #i1e#y due to "yofibrob#ast actiity and is defined as the contraction of a
hea#ed graft. The degree of secondary contraction is inerse#y re#ated to the thic1ness of the
s1in graft.
3ccording#y7 sp#it:thic1ness s1in grafts contract "ore than fu##:thic1ness grafts fo##o,ing
p#ace"ent in the recipient bed. .or that reason7 fu##:thic1ness grafts are preferab#y used in
areas that ,ou#d be significant#y i"pacted functiona##y or aesthetica##y by scarring or scar
contracture7 such as the head and nec17 hands7 genita#s7 or breast.
.actors inf#uencing graft suria#:
1. Secure fi;ation7 ,hich per"its inoscu#ation of the de#icate neoascu#ature
2. ?ressing on the graft7 to preent dessication 5protect the graft fro" the shearing forces
that "ight disrupt neoascu#arisation.
3. 4ea#thy recipient bed.
!. Certain conditions #i1e chronic enous u#cers7 irradiated ,ound bedsG conta"inated ,ound
site ,i## i"pair proper neoascu#arisation.
Graft application:
One of the "ore co""on and e;peditious "ethods of affi;ing a graft to the recipient site is
,ith surgica# stap#es7 particu#ar#y to #arge recipient areas. In chi#dren or in sensitie areas of
adu#ts7 se,ing the graft into p#ace using absorbab#e sutures "ay be "ore prudent.
In se#ection of the fina# dressing7 the preention of shearing forces7 sero"a7 or he"ato"a
for"ation bet,een the graft and recipient site is essentia#. (eshing or NpiecrustingN the graft
"ini"i&es the ris1 of graft #oss secondary to he"ato"a or sero"a for"ation. The preention
of shearing forces that "ay disrupt graft ta1e is acco"p#ished by proper#y securing the graft
to the site7 ,hich typica##y ino#es use of a bo#ster dressing or a negatie pressure dressing.
3 bo#ster dressing typica##y is co"posed of "oistened cotton ba##s ,rapped in a petro#eu"
gau&e such as 9erofor" 7 ,hich is secured by p#acing sutures radia##y around the ,ound and
tying the" to each other oer the bo#ster dressing to proide constant7 #ight pressure to the
graft. .or s1in grafts to the upper or #o,er e;tre"ity7 an >nna boot dressing "ay be app#ied7
as it perfor"s the necessary action of "aintaining graft integrity but a#so a##o,s for
ear#y"obi#i&ation.

3#ternatie#y7 negatie pressure dressings preent shearing forces and reduce f#uid co##ection
bet,een the graft and recipient bed7 thereby faci#itating p#as"atic i"bibition and
reascu#ari&ation7 #eading to a significant i"proe"ent in oera## sp#it:thic1ness s1in graft
suria#.3 nonadherent "ateria# such as 3daptic "ust be p#aced as an interface bet,een the
s1in graft and the sponge to preent disruption of the graft ,hen re"oing the dressing. The
initia# dressing shou#d be #eft in p#ace for appro;i"ate#y $ days @3:) daysA un#ess pain7 odor7
discharge7 or other sign of a co"p#ication dee#ops. 3 he"ato"a or sero"a encountered at
the dressing change shou#d be addressed by "a1ing a s"a## incision direct#y oer the
co##ection and e;pressing the under#ying contents in order to "ini"i&e disruption of graft
adherence.
2eferences:
1. Alireza Ghassemi, MD, DMD, PhD,Mehrangiz Ghassemi, DMD, Dieter Rieiger, MD, DMD, PhD,
Ralf!Dieter "ilgers, D#$, PhD,anMar$us Gerressen, MD, DMD, PhD,Co"parison of ?onor:Site
Engraft"ent 3fter 4aresting %ascu#ari&ed and Nonascu#ari&ed I#iac Bone +rafts+ % &ral Ma'illofa$ #urg
()*1+,-!1+-., /00-
2. Ben0a"in C Food7 (?7 $*in+ Grafts. e(edicine Specia#ties R <#astic Surgery
3. Bishara S. 3tiyeh7 (?7 .3CS
7
Christian 3. 3#:3""7 (?7 3#i 3. Nasser7 (?7 I"proed 4ea#ing
of Sp#it Thic1ness S1in +raft ?onor Sites7 The Sourna# of 3pp#ied 2esearch o# 1 :2//1
!. Bone +rafting: Bone +raft Incorporation7 (edscape C(E+ Neurosurg
.ocus. 2//3G1!@2A T 2//3 3"erican 3ssociation of Neuro#ogica# Surgeons
$. Bone 4ea#ing and Spina# .usion: 2o#e of +ro,th .actors in Bone (etabo#is" (edscape C(E7
Neurosurg .ocus. 2//2G13@'A T 2//2 3"erican 3ssociation of Neuro#ogica# Surgeons
'. Constantinos E. Ni1o#opou#os7 3ndreas .. (arogenis7 +#y1eria <etrochei7 3 three:di"ensiona#
"edica# i"aging "ode# for Buantitatie assess"ent of pro;i"a# tibia s. anterior i#iac crest cance##ous
bone. The Unee 1$ @2//*A 233823)
). Christopher +. .in1e"eier7 (? Current Concepts 2eie,7 Bone:+rafting and Bone :graft
Substitute7 T4E SO>2N36 O. BONE 5 SOINT S>2+E2C %O6>(E *!:3 V N>(BE2 3 V (32C4
2//2
*. ?aid 4. Ui"7 (?7W7 2ichard 2hi"7 (?7 6ing 6i7 (<47 Su#ia (artha7 B37Bryan S,ai"7 B37
2obert S. Banco7 (?7 6ouis +. Senis7 (?7 Scott +. Tro"anhauser7 (?7<rospectie study of i#iac
crest bone graft harest site pain and "orbidity.The Spine Sourna# : @2//-A
-. ?ona#d S +rande7 (?7 S1in +rafting7 e(edicine Specia#ties R ?er"ato#ogy
1/. .acia# trau"a7 Seth 2. Tha##er7 F.SCOTT (c?ona#d
11. U 2iden7 Uey topics in ora# 5 "a;i##ofacia# surgery7 second edition.
12. (3TS 4366(3N 5 3N?2E3S T4O2.Bone substitutes and gro,th factors as an a#ternatie X
Co"p#e"ent to autogenous bone for grafting in i"p#ant dentistry7 <eriodonto#ogy 2///7 %o#. !)7
2//*7 1)281-2
13. 2obert E. (ar;7 ??S7 Bone and Bone +raft 4ea#ing7 Ora# (a;i##ofacia# Surg C#in N 3" 1- @2//)A
!$$8!''
1!. Seoung:4o 6ee7 ??S7 <h?7 Byung:4o Choi7 ??S7 <h?7 Sing;u 6i7 ??S7Seung:(i Seong7 ??S7
<h?74an:Sung Ui"7 <h?7 and Chang:Cong U7 Co"parison of corticocance##ous b#oc1 and
particu#ate bone grafts in "a;i##ary sinus f#oor aug"entation for bone hea#ing around denta#
i"p#ants@Ora# Surg Ora# (ed Ora# <atho# Ora# 2adio# Endod 2//)G1/!:32!:*A
15. S1in grafting+ Encyc#opedia of Surgery: 3 +uide for <atients and Caregiers
1'. Tho"as S. Cypher7 ?<(7 Sordan <. +ross"an7 ?<(.Bio#ogica# <rincip#es of Bone +raft 4ea#ing
@The Sourna# of .oot and 3n1#e Surgery 3$@$A:!13:!1)71--'A
1). F. 6. 3deye"o7 T. 2euther7 F. B#och7 C. Uor1"a&7 S. 4. .ischer7 S. E. =oY ##er7 3. C.Uueb#er:
4ea#ing of on#ay "andibu#ar bone grafts coered ,ith co##agen "e"brane or boine bone
substitutes: 3 "icroscopica# and i""unohistoche"ica# study in the sheep. Int. S. Ora# (a;i##ofac.
Surg. 2//*G 3): '$18'$-.
1*. FI66IS C. C3(<BE667 T4E 3>TO+ENO>S BONE +23.T7 % 1one %oint #urg Am.
1-3-G21:'-!:)//

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