Periodontology 2000, Vol. 1.
1993, 8&91
Prinred in Denmark. All rights resewed
Bone grafts and periodontal
regeneration
MICHAEL & JAMES T. MELLONIG
A. BRUNSVOLD
One of the biggest challenges remaining in dentistry is
to predictably regenerate the alveolar bone destroyed
by periodontitis. It is exciting to consider how many
more dentitions could be restored to optimum health,
aesthetics and function if this were possible. Great
strides are being made to achieve this goal using the
method of bone grafting and other regeneration pro-
cedures. Recent advances in bone grafting include: 1)
improved procurement and availability of bone graft
material, 2) improved methods for complete detoxi-
fication of diseased root surfaces, 3) better under-
standing ofthe cellkinetics ofwound healing, 4) appli-
cation of the principles of guided tissue regeneration
and 5) the use of growth factors to enhance healing.
Periodontal bone grafting in the past has been con-
troversial and unpredictable. Strong proponents of
bone grafting argue that the majority of healing
studies show better success using grafting materials
than open flap debridement in managing severe oss-
eous defects. Others argue that the amount ofbone re-
generation possible with current techniques is too
limited and unpredictable to be useful.
This review attempts to clarify the role of bone
grafting in the present era of regeneration. The infor-
mation discussed includes a definition of terms, ob-
jectives of bone grafting, types of bone grafts, surgical
procedure and bone banking.
Terminology
Some of the controversy regarding periodontal re-
construction stems from confusion of terminology.
The term regeneration is often used inappropriately
to describe the healing process of repair.
In this review, periodontal regeneration is defined
as the process by which the architecture and function
of the periodontium is completely restored. Repair
of the periodontium is defined as re-establishment
80
Copyright 8 Munksgaard 1993
PERIODONTOLOGY 2000
ISSN 0906-6713
of continuity without full restoration of architecture
and function.
Two other related terms are also commonly con-
fused. New attachment is the reunion of connective
tissue with a root surface that has been deprived of
its periodontal ligament; reunion occurs by the for-
mation of new cementum with inserting collagen
fibers. Reattachment is the reunion of connective
tissue with a root surface on which viable periodontal
tissue is present. The types of grafts are defined sep-
arately in another section of this review.
Objectives of bone grafts
The objectives of periodontal bone grafts are: 1)
probing depth reduction, 2) clinical attachment gain,
3) bone fill of the osseous defect and 4) regeneration
of new bone, cementum and periodontal ligament
(90).Clinical studies and case reports supply valuable
information concerning the first 3 objectives. The last
objective requires histologic analysis to verify (Fig.
1).
Animal studies are of value to indicate the poten-
tial of graft materials to produce favorable results.
The results must be viewed with caution, however,
and should not be directly applied to humans. Ani-
mal studies compare graft and nongraft procedures
in artificially created defects (Table 1). The majority
of these reports indicate a superior result obtained
following the placement of a graft. Nongraft control
sites were never found to be superior to grafted sites.
Human histologic analysis is the gold standard for
determining the true potential of any graft material
to regenerate the periodontium. Histologic evalu-
ation of 159 human periodontal grafts has been re-
ported (Table 2). A critical step in these trials is docu-
mentation on the root surface of where bacterial
contamination occurred prior to treatment. The
methods for this documentation have varied a great

Fig. 1. Human block section removed 6 months post-bone
grafting demonstrating regeneration of a functional ap-
paratus: notch (n) placed in subgingival calculus on the
root surface, new cementum (c) artifactually (a) separated
from dentin and old cementum, periodontal ligament
(pdl), residual graft (g) particle of demineralized freeze-
dried bone allograft, new bone formation (nb) and old
bone (ob) (courtesyof G. M. Bowers)
deal (21, 31, 40, 43, 50, 60, 61, 65, 86). At present, the
most scientifically valid proof of regeneration of an
attachment apparatus is a notch placed in the most
apical level of calculus on the root surface (6-8, 15,
23,35). Using this marker, new bone, cementum and
periodontal ligament has been identified following
grafts of osseous coagulum-bone blend (35) and de-
calcified freeze-dried bone allograft (6-8).
In striving for the 4 objectives previously listed for
bone grafting, can we expect the graft materials to
help induce new bone? Bowers et al. (7) studied this
question by comparing the healing of intraosseous
defects with and without placement of decalcified
freeze-dried bone allografts in human periodontal
defects. These defects were submerged by complete
coverage with soft tissue flaps. Periodontal regenera-
tion in 30 grafted and 19 nongrafted defects was
Bone grafts
measured using the most apical level of calculus on
the root surface as a reference marker. Results indi-
cated that regeneration was possible with and with-
out bone grafts in the submerged environment. In
grafted sites, however, more new attachment appar-
atus was found than in nongrafted sites. Also, the
frequency of regeneration was increased in grafted
versus nongrafted sites. Their findings strongly sug-
gest that bone grafts do have an inductive effect on
the periodontium. This issue remains controversial,
however. Egelberg (25) has stated that there is little
indication that bone grafts induce new bone forma-
tion or stimulate connective tissue attachment to
teeth. It appears likely that, in the near future, growth
factors will be used with bone grafts to increase their
induction potential (79). These biologic modifiers
regulate cell proliferation, migration and matrix syn-
thesis and in animal models have been shown to en-
hance regeneration in periodontal defects (51).
The healing of human autogenous periodontal
bone grafts has been described (20,22).The initiation
of new bone formation occurs at 7 days, cemento-
genesis at 21 days and a new periodontal ligament is
seen at 3 months. By 8 months, the graft is incorpor-
ated into host bone with functionally oriented fibers
between bone and cementum. Maturation of grafted
sites may take up to 2 years. Radiographic evidence
of increasing bone density often is not seen until 6
months (54).
Root resorption has been reported as a compli-
cation of bone grafting (22). This problem has only
been observed with fresh iliac cancellous bone and
marrow grafts, suggesting that viable marrow cells
are the cause of the resorption (43, 89). Freezing of
the grafts appear to eliminate this problem. Root re-
sorption has also been correlated with chronic gingi-
val inflammation in the postoperative period caused
by plaque (22). Histologic findings indicate that con-
nective tissue in resorptive bays always contains an
inflammatory cell infiltrate (30). Root resorption fol-
lowing bone grafts is more prevalent in animals than
in humans (3).
A long junctional epithelium between alveolar
bone and root surface has been proposed as an ex-
planation for the infrequent root resorption seen in
humans after bone grafting (46). However, in 74 hu-
man biopsies where bone grafting was performed,
epithelium was rarely observed apical to the level of
active bone formation (6). Junctional epithelium was
never observed apical to the level of new cementum
formation (9).
In summary, animal and human histologic studies
indicate that regeneration of the periodontium is
81
Brunsvold &I MeUonig

Table 1. Controlled histologic studies in animals with bone autografts and allografts in the treatment of periodontal
osseous defects
Number and Defect
Graft type of type
Author Year material animal created Results
Yuktanadana 1959 ICBM 10 D Intraosseous Grafted defects may be eliminated by induction
(105) of bone. Control defects heal by adaptation of
epithelial attachment.
Patterson 1967 ICBM 10 D Furcation A coronal increase of 2-3 mm of bone with
et al. (70) graft. No new bone with control
Hurt (45) 1969 FDBA 4D 2-walled Convincing evidence of acceptability of graft.
No advantage or disadvantage in using graft
Hiatt (41) 1970 CBMA 12 D Intraosseous No significant difference in healing between
graft and control
Rivault 1971 oc 4M Intraosseous Faster and greater osteogenic activity with
et al. (83) small particle bone graft than controls
Narang & 1972 DFDBA 27 D Intraosseous Graft was replaced by new bone and marrow;
Wells (67) less new bone at control sites
Ellegaard 1973 ICBM 6M Furcation ICBM and frozen ECBM yielded a higher
et al. (27) ECBM frequency of regeneration than fresh ECBM and
controls
Ellegaard 1974 ICBM 12 M 3-walled Regeneration is obtained with equal success
et al. (281 ECBM with and without graft.
Coverly 1975 oc 4M 2- and 3-walled In early stages, grafted defects demonstrated a
et al. (17) more advanced level of regeneration than
controls.
Ellegaard 1975 ICBM 19 M Furcation New bone in deepest portion of defect with
et al. (29) graft. No new bone without graft
Youlson 1976 CRMA 4M 2-walled Allograft induced a more rapid osseous repair
et al. (73) than controls.
Nilveus 1978 ICBM 6D Furcation Osseous grafts did not improve results.
et al. (68)
Caton et al. 1980 ECBM 8M Intraosseous Both graft and control healed with an epithelial
(14) lining along the root surface with no new
connective tissue.
Mellonig 1981 FDBA 4M Intraosseous Significantly more regeneration with graft than
(55) control
Klinge et al. 1985 ICBM 10 D Furcation Flap support by the bone graft may facilitate
(47) regeneration.
Sonis et al. 1985 DBP 8 D Intraosseous DBP successfully induced new bone. No
(94) furcation differences were seen between test and control.
Blumenthal 1986 DFDBA 4 D 2-walled Graft healed by regeneration. Control healed
et al. (4) by a long junctional epithelium.
Wad et al. 1988 DFDDA 6D 3-walled Complete regeneration of lost attachment
(101) apparatus with graft. Long junctional
epithelium to base of defect with controls
Passanezzi 1989 ICBM 6D Furcation Abundant new bone, new cementum and
et al. (69) ankylosis with graft. Control defects filled with
connective tissue and new cementum.
Wada et al. 1989 ICBM 3D Furcation Grafts showed more pronounced regeneration
(102) DFDBA and higher periodontal attachment than did
controls.
OC=osseous coagulum autograft; ICBM=intraoral cancellous bone and marrow autograft; ECBM=
extraoral (iliac) cancellous bone and marrow autograft; CBMA=cancellous bone and marrow
allograft; FDBA=freeze-dried bone allograft; DFDBA=decalcified freeze-dried bone allograft; DFDDA=
decalcified freeze-dried dentin allograft; DBP=demineralized bone powder; D=dog; M=monkey.

82
 Bone grafts

Table 2. Controlled studies humans with bone autografts and allografts in the treatment of periodontal
osseous defects
~~ ~

Graft Method of Mean results

Author Year material evaluation Graft Control
Ellegaard & Loe (26) 1971 ICBM Probing and Equal degree of success
radiographs
Patur (71) 1974 ICBM Re-entry No significant difference.
ECBM Graft improved results of treatment
Carraro et al. (10) 1976 ICBM Probing 3.07 mm (2-wall) 2.15 mm (2-wall)
2.35 mm (1-wall) 2.25 mm (1-wall)
Froum et al. (34) 1976 OC-BB Re-entry 2.98 mm 0.66 mm
(71% bone fill) (22% bone fill)
4.36 mm
(61% bone fill)
Hiatt et al. (43) 1978 ICBM Histology Regeneration Lack of
ECBM consistently cementogenesis and
CBMA found bone formation
Moomaw (60) 1978 FDBA Histology New attachment
greater in grafted sites
Listgarten & Rosenberg 1979 ICBM Histology New bone and Little if any new
(50) CBMA cementum cementum or bone
Altiere et al. (2) 1979 FDBA Re-entry 60% defects 60% defects
>50% bone fill >50% bone fill
Pearson et al. (72) 1981 DFDBA X-ray 1.38 mm fill 0.33 mm fill
Movin et al. (62) 1982 ICBM Probing and 3.2 mm gain 2.0 mm gain
X-rays attachment attachment
Dragoo & Kaldahl (18) 1983 DFDBA Histology No difference in healing
Mellonig (56) 1984 DFDBA Re-entry 2.57 mm 1.26 mm
(65%bone fill) (38% bone fill)
Mabry et al. (52) 1985 FDBA Re-entry 1.9 mm (39% fill) 1.0 mm (31% fill)
FDBA+TCN 2.8 mm (61% fill) 1.4 mm (36% fill)
Schrad & Tussing (91) 1985 CBMA Re-entry 1.6 mm 0.8 mm
(54% bone fill) (33% bone fill)
Renvert et al. (81) 1985 ICBM Probing bone 1.2 mm gain 0.8 mm
level Significant only for deepest defects
Hiatt et al. (44) 1986 CBMA Re-entry 4.83 mm fill 0.22 mm fill
Probing bone
Gantes et al. (36) 1988 DFDBA Re-entry No difference between defects treated with
and without bone grafts
Bowers et al. (8) 1989 DFDBA Histology Regeneration in both grafted and nongraft
sites in the submerged environment.
Greater and more frequent regeneration in
grafted sites.
Bowers et al. (9) 1989 DFDBA Histology New bone, No new attachment
cementum, apparatus
PDL
Blumenthal & 1990 DFDBA Re-entry 2.60 mm bone fill 0.38 mm bone fill
Steinberg (5)
OC-BB=osseous coagulum-bone blend autograft; ICBM=intraoral cancellous bone and marrow autograft; ECBM=
extraoral (iliac)cancellous bone and marrow autograft; CBMA=cancellousbone and marrow allograft: FDBA=freeze-
dried bone allograft; FDBA+TCN=freeze-dried bone dograft plus tetracycline; DFDBA=decalcified freeze-dried
bone allograft.

possible following the use of bone grafts (Fig. 1). At humans averages about 60% of the orignal defect.
least some forms of bone grafts have an inductive The average gain of attachment from several studies
effect. The amount of bone fill is rarely loo%, but in using different materials in varying types of'defects

83
Brunsvold & Mellonig
is 2.68 mm. Although pocket depth reduction is an
objective of bone grafting, these measurements are
seldom reported in the results of bone graft studies.
Types of bone grafts
The 3 types of grafts being used most frequently to-
day in periodontics are autogenous grafts, allografts
and alloplasts. Early evaluations of these procedures
did not include controls. Later, controlled trials were
felt necessary as some therapists speculated that
equal amounts of bone fill can be achieved without
bone grafts.
Autogenous
Autogenous bone grafts are taken from one part of a
patient’s body and transferred to another. Several
types of autogenous periodontal bone grafts include
cortical bone chips, osseous coagulum, bone blend,
extraction socket bone and extraoral cancellous bone
with marrow.
The basis for current periodontal bone grafting
procedures can be traced to Nabers & O’Leary in 1965
(64). They used cortical bone shavings removed by
hand chisels from within the surgical site. Using this
material, they reported coronal increases in bone
height. The intraosseous defects so treated were not
felt to be amenable to other forms of treatment.
Long-term documented success of 6 cases was subse-
quently reported (66).
Osseous coagulum is obtained by using rotary in-
struments on intraoral bone in the surgical site and
then mixing the particles of bone with the patient’s
blood (84). The use of this material is based on the
rationale that the small particle size is predictably
resorbed and replaced by host bone. The mineralized
fragments are also thought to induce bone formation.
Osseous coagulum procedures have disadvantages,
which include aspiration problems, an unknown
quantity of collected bone fragments and limitations
concerning the quantity of bone that can be ob-
tained. The bone blend technique was designed to
overcome some of these problems.
Bone blend is cortical or cancellous intraoral bone
that is obtained with a trephine, chisel or rongeur. It
is placed in an amalgam capsule and triturated into
particle size in the range of 100 to 200 pm (19). Case
reports and controlled clinical trials support the suc-
cess of this material. A mean fill of 73% was reported
in a study of 25 defects (33). In a comparison study,
the bone blend grafts produced 2.98 mm in bone fill
84
compared with 0.66 mm when open flap debride-
ment was used (34).
In addition to obtaining bone from the surgical
site, bone from other sources in the oral cavity has
been used successfully for periodontal osseous grafts.
Donor sites for this bone include healing bony
wounds (381,healing extraction sites (93),edentulous
ridges, tori and the maxillary tuberosity. None of
these sites has been shown superior to the others in
results. In a study of 166 graft sites, a mean fill of 3.44
mm was reported using various sources of intraoral
bone (42). Rosenberg (85) also reported predictable
success with intraoral grafts; he used 50% fill of the
defect as the criterion for success and described a
common need for a secondary procedure to correct
remaining defects. Using pocket measurements, Car-
raro et al. (13)found no advantage for intraoral graft
materials in one-walled defects, but two-walled de-
fects responded more favorably. Renvert et al. (81)
found an advantage for autogenous intraoral grafts
only in deep lesions.
Autogenous grafts of iliac cancellous bone and
marrow offer the greatest potential for induction of
new bone in the periodontium (18, 95). Complete
fill of furcations and interproximal craters has been
reported. Freeze-drying of this material appears to
eliminate the complication of root resorption de-
scribed earlier. The use of this material has not been
widespread, however, probably because of the added
expense, time and surgical procedure required.
These problems, plus the need for increased donor
bone, led to the development of an allogenic source
of bone.
Allografts
Allografts are grafts transferred between genetically
dissimilar members of the same species. Three types
of bone allografts are being used in periodontics. De-
mineralized freeze-dried bone is used most often.
Nondernineralized freeze-dried bone and frozen iliac
cancellous bone is used less frequently.
Demineralized freeze-dried bone induces host
mesenchymal cells to differentiate into osteoblasts
(39). Urist et al. (98-100) showed that demineraliza-
tion and freeze-drying of cortical bone graft material
greatly enhances its osteogenic potential. Hydro-
chloric acid demineralization exposes the bone-
inductive proteins located in the bone matrix. These
proteins, collectively called bone morphogenic pro-
teins, are composed of acidic polypeptides. They are
structurally similar in several species of mammals
(88).The bone-inductive proteins are located in bone
 ~ ~~ ~
matrix and therefore are more abundant in cortical
bone where bone matrix is more abundant.
Since these proteins have the ability to stimulate
host stem cells to differentiate into osteoblasts, de-
calcified freeze-dried bone allografts (DFDBA) are
considered more inductive than nondemineralized
bone. Nondemineralized bone functions through os-
teoconduction by providing a scaffold over which
new bone forms (37).
Healing following the use of demineralized bone
allograft is felt to follow a cascade of events (79).
Attachment of fibroblasts to the extracellular matrix
occurs at day 1. Cell proliferation and differentiation
of chrondroblasts is seen by day 5. By day 7, there are
chondrocytes with synthesis and secretion of matrix.
Vascular invasion, bone formation and mineraliza-
tion are seen at days 10-12. By day 21, marrow is
observed. This series of events has not been de-
scribed in periodontal bone graft sites, however.
The use of DFDBA in human periodontal defects
was first reported by Librin et al. (49). Three sites
responded with 4-10 mm of new bone. In another
study, a mean of 2.4 mm of bone fill was measured
in 27 intraosseous defects using cortical DFDBA (78).
Bone fill ranging from 75% to 95% was described in
another series of case reports (104).
A radiographic analysis of cancellous DFDBA in 16
patients demonstrated a mean fill of 1.38 mm,
whereas 6 control sites showed only 0.33 mm (72).
Ellegaard & Loe (26) described the limitation of using
radiographs as a basis for measurements after bone
grafting. In a controlled re-entry study of 47 peri-
odontal osseous defects, a mean bone fill of 2.6 mm
(65% of defect) was reported with cortical DFDBA
compared with 1.3 mm (38%of defect) without graft
(56) (Fig. 2).
Direct comparison of DFDBA and freeze-dried
bone allograft in 11 paired sites showed no statistical
difference in probing depth reduction, clinical attach-
ment gain or bone fill (87). This is hard to explain in
view of Urist’s findings. Other factors may influence
the choice of using mineralized or demineralized
bone. Both types of bone are processed with multiple
immersions in absolute ethanol. Decalcification in-
volves the added immersion in 0.6 N HCI (58).Both of
these processes are thought to inactivate the human
immunodeficiency virus (HIV) (53,77,82).
Alloplasts are implants of inert materials. They are
described as synthetic bone graft materials. Hydroxy-
apatite is currently the most commonly used alloplast.
In summary, there currently is not an ideal peri-
odontal bone graft material. All have limitations.
Autogenous bone is the material of choice followed
Bone grafts
by allografts and alloplasts. New approaches to the
application of these materials may help overcome
the limitations.
Surgical procedure
The various factors related to the surgical tech-
nique of bone grafting are hard to evaluate scien-
tifically and, therefore, most recommendations are
based on clinical observations (Fig. 3). It is not the
purpose of this review to discuss in detail the tech-
nical aspects of bone grafting. This information is
important, however, and has recently been de-
scribed (59). New methods to enhance bone graft-
ing are continually being proposed and are empha-
sized in this section.
Root debridement is an extremely important step
in bone-grafting procedures. A combination of
ultrasonic and hand instruments is commonly used
to insure that all hard and soft deposits plus altered
cementum are completely removed from the root
surface. Rotary instruments have recently been
shown to enhance the process (92). Fiber-optic
light sources have also been reported to enhance
root debridement (80). In addition, magnifymg
loupes have also been described as valuable ad-
juncts based on clinical observations. These aids
for complete root debridement may improve the
predictability and success of grafts in the future.
Other authors in this volume discuss surface
alterations to enhance periodontal regeneration.
These alterations include demineralization with cit-
ric acid and tetracycline and the use of attachment
proteins and growth factors. There is encouraging
evidence that at least some of these agents may
greatly increase the predictability of bone grafts.
Guided tissue regeneration using membranes
and coronally positioned flaps also holds promise
for increasing the success of bone grafting. Other
chapters review clinical studies combining these
approaches with bone grafts.
In summary, the limited predictability of bone
grafting reported in earlier studies may soon be
overcome by several innovative approaches that
show encouraging results in early reports.
Bone banks
Bone banking has greatly increased the options for
the periodontal therapist in the management of se-
vere osseous defects. Bone graft procedures are no
85
Brunsvold & Mellonig
longer limited by available autogenous bone. An esti-
mated 40,000 periodontal bone grafts obtained from
bone banks are performed annually (58).There have
been reported cases of disease transfer with pro-
cessed freeze-dried bone allografts. The possibility of
disease transfer with bone allografts is very unlikely
if the material is procured and processed according
to tissue-banking protocols (32).If medical and social
screening, antibody testing, direct antigen tests, sero-
logic tests, bacterial culturing, autopsy and follow-
up studies of grafts from the same donor are used,
the chances for disease transfer are approximately 1
86
Fig. 2. A Clinical study with experimental and control
within the same patient. Experimental intraosseous defect
site on the mesial of the mandibular left cuspid. B. Defect
filled with demineralized freeze-dried bone allograft.
C. Graft site demonstrating 3.0 mm of bone fill at the time
of 6-month surgical re-entry. D. Control site on the mesial
of the right mandibular cuspid treated by open flap de-
bridement. E. Surgical re-entry of control site at 6 months
post-surgery demonstrating less than 1.0 mm of bone fill.
in 2 million (10). Further processing decreases the
risk to 1 in 8 million (11).
Some tissue banks use irradiation and ethylene ox-
ide to sterilize bone allografts and thus further de-
crease the possibility of disease transfer. These steps
are controversial, however. Irradiation of bone allo-
graft was reported to destroy bone induction (12,63,
961, but there is no total agreement on this finding
(103).Also, HIV is not reliably inactivated by the cur-
rent radiation dose of 15 pGy (16).
Ethylene oxide unquestionably renders a bone
allograft noninfectious (24). In this process, however,

Fig. 3. k Bone graft technique. Baseline soft tissue meas-
urements are made of probing depth and clinical attach-
ment level at the completion of the hygiene phase of treat-
ment. B. Facial and lingual mucoperiosteal flaps are
reflected. The osseous defect is debrided of a l l soft tissue,
the root surface planed, hemeostasis achieved, and hard
the ethylene oxide may also interfere with bone in-
duction (106). Residual ethylene oxide in the graft
has been shown to be toxic to fibroblastsand to cause
morphologic changes in fibroblasts that may not be
reversible (48). Others have found ethylene oxide to
be acceptable and safe (75).
The steps in processing bone allografts for dental
use usually include the following (58):
0 Cortical bone is obtained in a sterile manner within
12 h of death of the donor. It is preferred over can-
cellous bone since it is less antigenic and contains
more bone-inductive proteins.
0 The bone is cut into 0.5- to 5-mm particles and
immersed in 100% ethanol for 1 h. Within 1 min
of this treatment, viruses are inactivated (82). The
ethanol completely penetrates cortical bone (74).
0 The bone is frozen, further decreasing the risk of
disease transfer (11).
Bone grafts
tissue measurements made from the cementoenamel
junction to the alveolar crest. C. Hard tissue measure-
ments are also made from the cementoenamel junction to
the deepest point of the bony defect. D. Defect is Wed
with cortical demineralized freeze-dried bone allograft.
The flaps are replaced and sutured.
0 The bone is ground to a particle size of 250 to BOO
pm. This particle size range was shown to promote
osteogenesis, whereas particles smaller than 125
pm induce a macrophage response (57).
The bone is again immersed in ethanol.
0 The bone may or may not be demineralized.
0 The allograft is freeze-dried to permit long-term
storage and reduce antigenicity (76, 97).
In summary, bone allografts appear to be extremely
safe. Patient concerns about disease transfer, how-
ever, will probably increase. Therefore, an under-
standing by dentists of the processing and risks is
important so that patients’ questions can be ad-
equately answered. Also, the selection of a bone
bank that conforms to the standards of the Amer-
ican Association of Tissue Banks (1) appears to be
crucial.
87
Brunsvold & Mellonig

Conclusion
Periodontal bone grafts have the potential to com-
pletely regenerate the periodontium destroyed by
periodontal disease. Complete regeneration, how-
ever, is unpredictable at present. When the results
of several human studies are averaged together, the
amount of bone fill of the original defect is about
60%. Also from these studies, using different ma-
terials and varying types of defects, the average gain
of attachment is 2.68 mm. Recent developments re-
lated to bone grafting may greatly enhance their pre-
dictability in the future. These include improved
methods for root detoxification, a better understand-
ing of wound healing, application of the principles
of guided tissue regeneration, and use of growth fac-
tors to enhance healing. The danger of disease trans-
fer from freeze-dried bone allografts in periodontics
is extremely low. An estimated 40,000 periodontal
bone grafts obtained from bone banks are performed
annually. From these, there are no reported cases of
disease transfer.

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