BASIC PRINCIPLES IN BONE

GRAFTING AND
RECONSTRUCTION

DR. IZZATI NABILAH ISMAIL

Oral Surgery
Block 3
Year 5
Outline
• Basic wound healing
• Factors in wound healing
• Bone formation & healing
• Socket healing
• Types of bone growth in bone grafting
• Indication for bone grafting
• Bone graft materials
• Principles of bone grafting
• Soft tissue management
 Learning Objectives and Outcomes

• Be able to explain the basic wound healing and the

factors influencing wound healing
• Understand the mechanism of bone formation, bone
healing, socket healing and bone growth in bone
grafting
• Have knowledge of bone graft materials and
substitutes
• Understand the basic principles of bone grafting
• Know the basics of soft tissue management for
wound closure and the reconstructive ladder
 Basic wound healing
Stage Beginning Duration Process
inflammation immediately 4-6 days - Exposed collagen activates
clotting cascades
- Fibrin clot provides
scaffolding and
concentration of cytokines
and growth factors
- Epithelialization, angiogenesis, and provisional matrix
fomation - Activated macrophages
-
- - Mediate
Collagen production is hallmark
Fibroblasts produce granulation fibroblast
tissue; PDGF and epidermal
GF (EGF) are main signalsgrowth factor
of type III collagen (FGF),
and/or
glycosaminoglycans
Remodeling Day 8 Day 8 -
platelet derived growth
Random to organized fibrils
through - Type III collagen replacedfactor
by Type I (PDGF),
years - Increased wound strength
- Collagen organization transforming growth
factor (TGF)
- Cross-linking of collagen

- Essential for progression

to proliferative phase
Stage Beginning Duration Process
proliferation 4-14 days 1-6 weeks - Epithelialization,
angiogenesis, and
provisional matrix fomation
- Collagen production is
hallmark
- Fibroblasts produce
granulation tissue; PDGF
and epidermal GF (EGF) are
main signals of type III
collagen and/or
glycosaminoglycans
remodelling Day 8 Day 8 - Random to organized fibrils
through - Type III collagen replaced
years by Type I
- Increased wound strength
- Collagen organization
- Cross-linking of collagen
 Factors in wound healing
Local factors
Oxygenation • Fibroblasts are oxygen sensitive; when oxygen
tension < 40mm Hg, collagen synthesis cannot take
place
• Hypoxia
• Endothelium responds with vasodilation
• Capillary leak
• Fibrin deposition
• Tumor necrosis factor alpha (TNF-alpha)
induction and apoptosis
• Hyperbaric oxygen
• Normal subcutaneosus O2 tension is 30 – 50
mmHg
• Subcutaneous O2 tension < 30 mmHg =
chronic wound
 Factors in wound healing
Local factors
Tissue edema • Increased tissue pressure
• Compromised tissue perfusion
• Cell death and tissue ulceration
Infection • Decreased tissue oxygen tension and prolonged
inflammatory phase
• Impaired angiogenesis and epithelialization
• Increased collagenase activity
Tissue • Wound healing is accelerated at environmental
temperature temperature of 30oC
Radiation • Stasis and occlusion of small vessels
• Fibrosis and necrosis of capillaries
• Decrease in wound tensile strength
• Direct, permanent and Adverse effect on fibroblasts
 Factors in wound healing
Systemic factor
Systemic • Diabetes
diseases • Larger arteries, rather than the arterioles are
typically affected
• Increased dermal vascular permeability and
pericapillary albumin deposition
• Impaired oxygen and nutrient delivery
Medications • Steroids
• Inhibits both macrophages and neutrophils
• Interferes with fibrogenesis, angiogenesis
• Bisphosphonates
Nutrition • Low protein levels prolong the inflammation phase
• Poor nutrition impairs fibroplasia
 Factors in wound healing
Systemic factor
Smoking • Smoke contains high levels of CO
• Shifts the oxy-Hb curve to left
• Decrease tissue oxygen delivery
• Nicotine acts via the sympathetic system,
resulting in vasoconstriction and limited
distal perfusion
• Smoking 1 pack/day = 3x risk of flap necrosis
• Smoking 2packs/day = 6x risk of flap necrosis
 Factors in wound healing
Systemic factor
Syndromes • Cutis laxa: a condition in which skin becomes inelastic
and hangs loosely in folds
• Due to defective elastin fibers
• Congenital: Autosomal dominant, recessive, or X-
linked recessive
• Acquired: Drugs, neoplasms, or inflammatory skin
conditions
• Ehlers-Danlos syndrome
• Defective collagen metabolism
• Autosomal dominant (majority) and recessive
patterns
Bone formation
 Bone healing
Stage Beginning Process
inflammation immediately - Hematoma formation, and
inflammatory exudates
- Fibrin clot provides scaffolding
and concentration of cytokines
and growth factors
- Hematoma is gradually replaces
by granulation tissue Osteoclasts
start to remove necrotic bone at
fragment ends
 Bone healing
Stage Beginning Process
Soft Callus 2-3 weeks - Replacement of granulation
formation tissue elsewhere in the callus by
fibrous tissue and cartilage
Picture no 1 - Ingrowth of vessels into calcified
callus which starts at periphery
end and moves towards center
Hard callus 3-4 month Through intramembranous and
formation endochondral ossification, callus
converted into rigid calcified tissue
Picture no 2,3,4 (woven bone)
Remodelling Month - year Conversion of woven bone into
Picture no 5
lamellar bone through surface
erosion and osteonal remodeling
 3
Bone
healing

5
Socket healing
1. Heals by secondary intention
2. Inflammation
3. Epithelialization
• Epithelium migration towards bed of granulation
tissue and makes contact with epithelium migrating
from the other sides
Socket healing
4. Fibroplasia
• Ingrowth of capillaries and fibroblasts
• Angiogenesis and fibroplasia begins at the bottom
of the socket and spreads upward long socket walls
• Trabeculae of woven bone formation starts at walls
and apical portion
• Lamellar bone starts to form from lining of socket
towards center of socket
5. Remodeling
• Primary bone trabeculae remodel to form thicker
secondary spongiosa
Socket healing
Three types of bone growth in bone
grafting

1. Osteogenesis
Material that facilitates generation of bone from bone
forming cells (e.g. vital osteoblasts)

2. Osteoinduction
Material that enables the process that supports
mitogenesis of undifferentiated mesenchymal cells,
leading to the formation of osteoprogenitor cells to
form osteoblasts (e.g. Bone morphogenic proteins,
growth factors) (Urist MR, 1960’s)
3. Osteoconduction
Property of a matrix that acts as a scaffold to support
attachment of bone-forming cells for subsequent
bone formation (e.g. allografts, xenografts, alloplasts)

Additionally
• Osseointegration
• Ability of dental implants to chemically bind to
surrounding bone
 General Indications of Bone Grafting
1. Ridge augmentation for implants
2. Periodontal defect
3. Alveolar cleft defects
4. Preprosthetic preparation
5. Large bony defects created by
cysts and tumors
6. Extensive trauma
7. In orthognathic surgery
8. Following jaw resection
9. Reconstruction of TMJ
All graft materials are
• Dependent on Local and systemic environment
• Without a good host and host bed any material will fail!

Bone grafting material

Bone graft Bone substitutes

 Autologous graft  Alloplastic
 Allograft (same species)
 Xenograft (different species)
 1. AUTOLOGOUS GRAFT

From one site to another within the same individual

 Gold standard
Osteoconductive → Hydroxyapatite, collagen
Osteoinductive → BMP, TGF-β
Osteogenic → Osteoprogenitor cells
Autologous bone harvest sites

 Calvarial bone
 Mandible → symphyseal area,
ascending ramus
 Hip → anterior or posterior
 Radius
 Humerus
 Femur
 Tibia → plateau or pilon
May be cortical, cancellous or a combination of both
Cancellous
 Revascularizes sooner due to spongy architecture
 Has greater cellular diversity and activity
Cortical
 Initially strong, weakening overtime, before regaining
strength
ADVANTAGES OF AUTOLOGOUS BONE GRAFTS

 Perfect biocompatibility with body’s own growth

factors & structural proteins
 Absence of antigenicity

LIMITATIONS OF AUTOLOGOUS BONE GRAFTS

• Limited quantity
• Limited structure and shape
• Donor site morbidity
TECHNIQUES OF AUTOLOGOUS BONE HARVEST

Intramedullary bone marrow aspiration

To fill bone defects
Nonunion or fracture repair
For bone examination
Open harvest to obtain cortical and cancellous bone
Augment bone width and height for implants
To fill in extraction socket
Cleft defects
TECHNIQUES OF AUTOLOGOUS BONE HARVEST
 2. ALLOGRAFT

Tissue graft from donor of same species as the

recipient but not genetically identical
Cadaveric origin
Processed by freezing OR demineralisation + freezing
Comes as DFDBA (demineralized/decalcified freeze-dried
allograft) / FDBA freeze-dried bone allograft)
Removing mineral component, allows ↑ expression of
osteoconductive proteins
Resorbable
In form of particles, sheets, blocks, preformed bones
Demineralized bone matrix
 DBX  Osteofil
 DynaGraft  Regenafil
 Grafton  …others
 Optefil

INDICATIONS
1. Large structural defects
2. Filler / support
3. As expander in autologous graft
to fill in inadequate spaces
4. Cortical defects
Advantages

 Match in constitutional elements and architecture

 Theoretically unlimited supplies

Disadvantages

Not structural
Not workable
Osteogenesis inexistent
Osteoconductivity minimal
Osteoinductive capacity varies
Knowledgable issues regarding allografts

Risk of HIV transmission is 1 in 1.6 million

Hep B and Hep C transmission has been reported
Histocompatibility improved with freezing and
processing
Relies on favorable host bed
Weakens with revascularization → problems with
incoporation
Successful in ridge augmentation & sinus lift
(Kassolis 2007, Minichetti 2004, Leonetti 2003, Van Der Berch 2000, Boyce 1999, Tomford 1995)
 3. XENOGRAFT

Bovine in origin
Theoretical risk
Transmission of bovine spongiform
encephalopathy
Experiments & data indicate no risk (Wenz 2001, Sogal 1999)

Example → Bio-oss (Geistlich Pharmaceutical, Switzerland)

Improved clinical & radiographic parameters when

used with barrier membranes (Vouros 2004)
Excellent integration, biocompatible & high success
rate in various bone augmentation procedures
(Proussaefs 2002, Artzi 2003, Valentini 2000, Yildirim 2000, 2001)

Combination with Pepgen – 15 (synthetic peptide

representing cell binding site of collagen) produces
enhanced bone formation
(Thompson 2006)
 4. ALLOPLAST

Synthetic bone substitutes

Provide physical framework for bone ingrowth
Resorbable or non-resorbable
Come as particles or pore sizes
Sometimes combined with
Carriers to improve handling
Bioactive proteins to provide osteoinduction
Alloplast materials include

1. Coral & algae-derived hydroxyapatite

2. Calcium sulfate
3. Calcium phosphates
4. Bioactive glass
5. Collagen
6. Polymers
Advantages of bone substitutes
 Unlimited availability
 Rapid conversion to bone
 Precise shaping to fill up complex defects
 Immediate compression stability
 Absence of antigenicity & disease transmission
 Reproducible biological & mechanical characteristics
 Comparison
Autograft Allograft Xenograft Alloplast
Main Autologous Unlimited
advantage No donor site
Main Limited Non-autogenous
disadvantage Donor site
Bone gain 3D (vertical 3d
3-6mm) Theoretically more: alone / combined
(vertical 3-15mm)
Bone Comparable
resorption Gradual resorption subject to physiologival stress
application
Cost Minimal Expensive
Complication Donor site Infection
morbidity Host rejection
++ Chiapasco 2006, Cordaro 2002, Rocuzo 2004, Prousaeffs 2002)
PRINCIPLES OF BONE GRAFTING

1. Ideal properties of bone grafts

 Biocompatible
 Bioresorbable
 Osteoconductive
 Osteoinductive
 Osteogenic
 2. Bone graft healing
• 2 main types of bone graft healing based on types
of autograft bone
Cancellous grafts Cortical grafts
1. Creeping substitution 1. Undergo a reverse
2. They are revascularized creeping substitution
more rapidly and process;
completely; 2. Resorption occurs first,
3. Apposition of bone then 3. New bone apposition
followed by a resorptive replacing the resorbed
phase graft
4. Cancellous grafts will be 4. Grafts remain as mixtures
replaced completely with of viable bone and
new bone necrotic bone in center
3. Blood supply
 Cortical preparation at recipient bed by making
perforations until bone bleed to expose vital
osteoblasts and osteoprogenitor cells
 Tension free water tight closure of flap

4. Stabilization
 Rigid fixation
 Good contact between bone graft and recipient bed
SOFT TISSUE MANAGEMENT

• To ensure survival of bone grafts, requires soft tissue

closure
• Primary wound closure which heals via primary
intention
• Requires healthy vascularized flaps and tension free
water-tight closure

• In cases with soft tissue defects, wound heals via

secondary intention or requires tissue donor
• Primary intention can be achieved by local flaps
• Types of flaps:
• Local flaps
• Advancement flap: buccal advancement flap
• Rotation flap: palatal rotational flap
• Transposition flap: Z-plasties
• Distant flaps
• Pedicled flaps
 Donor tissues adjacent
 to recipient site (local tissue transfer)
 Tissues transferred to a new location with
vascular supply still attached
 E.g: temporalis flap, tongue flap

• Free flaps
 Donor tissues harvested together with intact
vessels which is detached and then transferred to
recipient site and anastamosed to recipient vessles
 E.g.: radial forearm flap, fibula flap
Tissue grafts
• Survival of tissue graft is totally dependent on
seepage of nutrients from carefully prepared graft
bed
Question:
Difference between grafts and flaps?