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Alloplastic Bone Grafts

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CONTENTS
Sr. No. TOPIC PAGE

1. INTRODUCTION 1-3
2. REVIEW OF LITERATURE 4-15
3. DISCUSSION 16-36
4. CONCLUSION 37-38
5. BIBLIOGRAPHY 39-44
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INTRODUCTION
 Page 3 of 61

Bone grafting techniques have been used by medical specialists for more than 100 years.

Many factors are involved in the successful incorporation of a grafted material, including

graft type, preparation site, vascularity, mechanical strength and pore size of the material.

These parameters make the use of bone substitutes challenging in terms of reliability and

predictability.1

The four desired properties of the bone graft material are osteogenesis, osteoinduction,

osteoconduction and osteointegration. The only graft material that contains all four

qualities is autologous bone. Options currently include allograft, xenograft and synthetic

grafting materials, with each manufacturer claiming wonderful results.1

Historically autogenous bone grafts were the first bone grafts to be reported. Allogenic

freeze-dried bone was introduced in the early 1970s, while demineralized allogenic

freeze dried bone gained wider application in the late 1980s.The introduction of

xenogeneic and alloplastic bone grafts occurred during the same time.2

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.3 Autogenous bone can be harvested, with or without processing, to yield graft

materials of different forms.4

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Allogeneic bone obtained from a different person and commonly processed by tissue

banks provides an alternative to autogenous bone.3 The grafts are prepared as fresh,

frozen, freeze-dried, mineralized and demineralized and each preparation may be

purchased as cortical chips, cortical granules, cortical wedges or cancellous powder.1

Xenografts are grafts shared between different species. Currently, there are two available

sources of xenografts used as bone replacement grafts are bovine bone and natural coral.

Both sources, through different processing techniques, provide products which are

biocompatible and structurally similar to human bone. Xenografts are osteoconductive,

readily available and risk free of disease transmission.2

The available alloplastic materials can be classified generally as resorbable or

nonresorbable. In general terms, plaster of Paris, calcium carbonate, tricalcium phosphate

and resorbable hydroxyapatite resorb totally or partially in oral and periodontal surgery

sites and the polymers and dense hydroxyapatites do not.5 Synthetic grafting materials or

alloplastic materials have been shown to possess two of the four characterstics of an ideal

graft : osteoconduction and osteointegration.

The ideal synthetic graft material should be biocompatible and elicit minimal fibrotic

changes. The graft should support new bone growth and undergo remodeling. Other

features include similar toughness, modulus of elasticity and compressive strength

compared with host cortical or cancellous bone.1

Allografts are taken from another indivisual of same species with different genotype such

as cadevers, relatives and bone bank.6

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Alloplastic bone graft materials are synthetic, inorganic, biocompatible, and bioactive bone

substitutes that are believed to promote healing of bone defects through Osteoconduction .7

Osteon is suitable for use in sinus graft application

The rationale behind the use of bone grafts or alloplastic materials is the assumption that

the regrowth of alveolar bone would be stimulated because these materials may

either contain bone forming cells (osteogenesis) or serve as a scaffold for bone

formation (osteoconduction) because the matrix of the bone grafts contains bone-

inducing substances (osteoinduction) (Urist 1980, Brunsvold & Mellonig 1993). Such

complete regeneration following grafting procedures would imply that cells derived from

bone possess the ability to form new bone. This means that all therapeutic procedures

involving the placement of bonegrafts or bone substitute implants are based on a

biologic concept which cannot explain how such treatment should result in

regeneration .

The advantages of allografts over autografts are that they eliminate the need of donor site

during surgery and are readily available. However the disadvantages include rejection,

infection, and longer healing periods and they typically result in less bone volumes than

autografts.8

Alloplastic graft materials may have their greatest usefulness as autograft extenders,

being added to available autogenous bone to provide a sufficient total volume of graft

material. They may also be used as carriers for growth factors, antibiotics or other

substances.5
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REVIEW OF
LITERATURE
Page 7 of 61
 Page 8 of 61

1. A.E Fetner, S.B Low, J. Wilson, L.L.Hench9 (1987) conducted a study to

evaluate the particulate form of bioglass in periodontal defects. 3 different sizes

ranges of 45S5 and 45S5.4F bioglass along with comparably sized commercially

available hydroxylapatite (HA) & tricalciumphosphate (TCP) materials were

implanted in surgically created periodontal defects of 6 adult monkeys. Each

animal had 16 experimental sites and 2 unimplanted control sites. Tissue blocks

were obtained at 1, 4,6 & 9 months post-implantation. The 45S5.4F bioglass and

HA materials retained their preimplantation dimensions. In conclusion, bioglass

particulates demonstrated favorable bone and soft tissue compatibility. The

45S5.4F bioglass appears to retain the biological properties of the 45S5 bioglass

with increased resistance to resorption.

2. Raymond A. Yukna, Elizabeth T. Meyer, Suzanne Miller Amos10 (1989)

compared the response of periodontal osseous defects to either grafting with

hydroxylapatite (HA) ceramic or debridement alone over maintenance program

for five years and concluded that following the use of durapatite HA ceramic as a

bone graft material in periodontal osseous defects are at least as good and often

better than those following surgical defect debridement alone.

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3. Prolo DJ, Oklund SA11 (1991) said that Disillusionment with bone cranioplasty

has followed the recurrent experience that orthotopic transplantation of bone to

skull is almost invariably accompanied by a striking propensity for resorption.

Resorption coupled to new bone formation is the usual process of remodeling. A

unique acellular nonosteoclastic resorption, antedating invasion of the graft by

osteoprogenitor cells and unrelated to the remodeling, characterizes the initial

response of bone placed in a skull bed. This previously undescribed resorption in

the skull likely represents passive diffusion of mineral from an altered matrix

(calciolysis) and varies directly with the degree the graft is denatured by

processing. There is the least amount of resorption in the fresh autograft and the

most in autoclaved or chemically treated frozen or freeze-dried grafts.

Remodeling of this diminished template occurs centripetally from skull defect

margins through osteoconductive mechanisms only. Marrow-poor skull with thin

diploe provides few osteoprogenitor cells that slowly, incompletely remodel the

reduced graft over years.

4. Lovelace T.B et al12 (1998) conducted a study to compare the use of Bioactive

glass to Demineralized Freeze-Dried bone allograft in the treatment of human

periodontal osseous defect. 15 patients with moderate to advanced adult

periodontitis were selected for the study. Paired osseous defects in each subject

were randomly selected to receive grafts of bioactive glass or DFDBA. Both soft

and hard tissue measurements were taken at baseline and at the 6 month on

reentry surgery. No statistical difference was found when comparing bioactive

 Page 10 of 61

glass to DFDBA. They concluded that bioactive glass is capable of producing

results in the short term (6months) similar to that of DFDBA when used in

moderate to deep intrabony periodontal defects.

5. T. Yoshikawa, H. Ohgushi, M. Akahane et al 13 (1998) investigated the in vivo

osteogenic ability of cultured marrow cells subcultured in porous hydroxyapatite.

This osteogenic ability was compared with that of cancellous bone grafts. Fresh

marrow cells were obtained from young adult rat femora and cultured in a

standard medium for 10 days, then trypsinized and used to make constructs of

porous hydroxyapatite (HA) and cultured marrow cells. The results indicate that

the bone tissue formed by grafting the Dex-treated construct of cultured marrow

cells and hydroxyapatite possesses a high osteoblastic activity comparable to that

of viable cancellous bone. Thus the prefabricated osteogenic subcultured

marrow/HA construct may be applicable in bone reconstructive surgery.

6. Ong M.A et al14 (1998) conducted a study to evaluate the use of bioactive glass

for repairing/regenerating periodontal intrabony defects. 14 patients each with 2

contralateral sites with ≥ 6 mm clinical probing depth and radiographic evidence

of an intrabony defect were selected. One defect was treated with flap

debridement plus bioactive glass and the other with flap debridement alone. Re-

entry surgeries were performed 9-13 months after the initial surgery. Bioactive

glass treated sites had more probing depth reduction and clinical attachment level

gain than debridement only controls.

 Page 11 of 61

7. Marianne M.A. Ong, Robert M.Eber, Maria L.Korsnes15 (1998) evaluated

Bioactive Glass alloplast in treating periodontal intrabony defects and concluded

that bioactive glass was well tolerated by human tissues and resulted in significant

cortical defect fill.

8. Stuart J. Froum, Mea A. Weinberg, Dennis Tarnow 16 (1998) studied was to

compare the repair response of bioactive glass synthetic bone graft particles and

open debridement in the treatment of human periodontal osseous defects. Fifty-

nine delects in 16 healthy adults were selected. Each patient had at least 2 sites

with attachment loss of at least 6 mm with clinical and radiographic evidence of

intrabony or furcation defects. One to 3 months after cause-related therapy (oral

hygiene instructions, scaling and root planing), the following measurements were

recorded prior to surgery: probing depths, clinical attachment level, and gingival

recession. Each defect was surgically exposed and measurements made of the

alveolar crest height and base of osseous defect. The test defects were implanted

with bioactive glass and concluded that bioactive glass showed significant

improvement in clinical parameters compared to open flap debridement.

9. Charles R.Anderegg, David C.Alexander and M.Friedman17 (1999) studied

Bioactive glass particulate in the treatment of molar furcation invasions and

revealed the benefits of Bioactive glass in the treatment of classII furcation

defects regarding the clinical parameters of probing depth reduction and reduction

in bleeding on probing.
 Page 12 of 61

10. Bauer and Muschler18 (1999) concluded that xenograft has the same inherent

problems as allografts and being from a different species, it may cause even more

pronounced immunological problems. Human allograft materials are considered

more effective and more widely available compared to xenografts.

11. Olivier Gauthier, Damien Bvix, Gael Grimandi19 (1999) studied the effect of a

new injectable calcium phosphate biomaterial for immediate bone filling of

extraction sockets in dogs and concluded that calcium phosphate was effective in

enhancing the bone fill of extraction sockets.The material expressed

osteoconductive capacities and the biological properties of the mineral phase were

conserved.

12. G.Pecora, De Leonardis & N.Ibrahim20 (2000) studied the use of calcium

sulphate in the surgical treatment of a through and through periapical lesion and

concluded that calcium sulphate as a bone graft improves the clinical outcome of

surgical treatment of through and through lesion.

13. Hisham F.NASR, Mary Elizabeth et al2 (2000) studied bone and bone

substitutes and suggested that the ideal bone replacement graft should be able to

trigger osteogenesis, cementogenesis and formation of a functional periodontal

ligament.
 Page 13 of 61

14. Peltola21 (2001) suggested that incorporation of hydroxyapatite, Tricalcium

phosphate, Bioactive glass in the host bone is clearly inferior to autogenous bone

graft.They enhance osteoconduction and are not osteoinductive.

15. N. R. Saeed, R. Hensher, N. M. H. McLeod, J. N. Kent22 (2002) said that

aims and indications for temporomandibular joint (TMJ) reconstruction are well-

established but the method of reconstruction is controversial. We describe a

retrospective, two-centre audit of 49 patients treated with costochondral grafting

and 50 patients treated with alloplastic joints. The characteristics of the patients

were similar in both centres and the minimum follow-up period was 2 years. For

each patient a number of variables were recorded including both subjective scores

(pain and interference with eating) and objective data (interincisal distance).

Patients in both groups showed an improvement in symptoms but more patients

required reoperation in the autogenous group.

16. Cameron M. L. Clokie, Hassan Moghadam, Michael T. Jackson et al 23

(2002) evaluated bone regeneration Of Critical Sized Cranial Vault Defects In

New Zealand white rabbits using four commercially available bone substitutes:

OsteoSet (calcium sulphate pellets), DynaGraft Putty (demineralized bone matrix

delivered in a polymer excipient), Norian CRS, and Bone Source (two

commercially available calcium phosphate cements). The presence of osteoclastic

 Page 14 of 61

activity and by the significant decrease in the size of the demineralized bone

particles. By 12 weeks, the demineralized bone putty bioimplant was almost

completely replaced by new bone (95.5%). Both calcium phosphate cement

groups (Norian CRS and Bone Source) had identical patterns of healing. They

clinically were visible and firm and uniformly radiopaque with little evidence of

new bone formation. Histologically the cement remained unresorbed with

little new bone with in the defect at 12 weeks. He concluded that the utilization of

a demineralized bone matrix putty appeared to allow for complete closure of

critical sized calvarial defects in New Zealand white rabbits with viable new bone

at 12 weeks.

17. Staurt Froum et al 24 (2002) compared healing extraction sockets 6 to 8 months

post implantation of a bioactive glass or DFDBA to an unfilled socket control. 30

sockets in 19 patients were randomly divided into 3 treatment groups. 10 sockets

received bioactive glass, 10 sockets DFDBA, and 10 sockets served as unfilled

controls, and histological cores of the treatment sites were obtained. Results

concluded that although the differences in percent vital bone were not statistically

significant among the 3 treatment group, bioactive glass material was observed to

act as an osteoconductive material and had a positive effect on socket healing at 6

to 8 months post extraction. Residual implant material was significantly higher in

DFDBA treated sockets versus bioactive glass treated sockets.

 Page 15 of 61

18. Eros S.Apaydin, Mahmoud Torabinejad et al25 (2003) studied the effect of

calcium sulphate on hard tissue healing after periradicular surgery and concluded

that calcium sulphate was effective on osseous healing after periradicular surgery.

19. James Mah, Joseph Hung, Jinxi Wang et al6 (2004) determined the relative

efficacy of currently available alloplastic bone repair materials in the healing of rat

calvarial defects histologically, histomorphometrically and biochemically. A

representative material was selected from six major classes of bone repair

materials and placed in 4 mm diameter calvarial defects of 6-week-old male

Sprague–Dawley rats (five animals in the control and each of the six experimental

groups). The outcomes were assessed after 2 months for alkaline phosphatase

(ALP) activity and after 4 months of healing for histomorphometry.

20. Sarah Rodriguez, David C. Teller, Francis B. Quinn et al26 (2005) stated the use

of alloplastic materials in nasal structural repair using expanded

polytetrafluoroethylene, silicone, and high density porous polyethylene.

21. K.A.Hing, E.Damien, T.McInness27 (2005) carried a study on biological

evaluation of a morphologically distinct porous hydroxyapatite bone graft

substitute and concluded that hydroxyapatite has osteoconductive properties.

22. Dr.Hom-Lay Wang, Dr.HenryGreenwell et al28 (2005) studied periodontal

regeneration and concluded that alloplasts and xenografts function primarily as

biocompatible space fillers.

 Page 16 of 61

23. Eppley BL, Pietrzak WS, Blanton MW29 (2005) stated that bone healing is a

complex and multifactorial process. This has given rise to many bone graft

technologies that have been used to regenerate bone, creating, perhaps, a

bewildering array of options. The options that surgeons have the most familiarity

with are the ones that have been available the longest (i.e., autograft and

allograft). Although useful for the widest spectrum of clinical applications,

limitations of these grafts has prompted the development of new materials.

Demineralized bone matrix formulations and synthetic ceramic materials are now

being used with greater frequency. These biomaterials have demonstrated their

usefulness in facial plastic and reconstructive surgery with their ability to augment

and replace portions of the craniofacial skeleton. The purpose of this article is to

describe and discuss the alloplastic bone grafting technologies so that the reader

can consider each in the context of the others and gain a better appreciation for

how each fits into the universe of existing and emerging treatments for bone

regeneration.

24. Kandaswamy, Ramachandran et al30 (2006) studied bone regeneration using

hydroxyapatite crystals for periapical lesions and concluded that hydroxyapatite

crystals showed good signs of wound healing indicating that this material is

biocompatible and non-allergenic.

25. Young-Kyun Kim, Pil-Young Yun, Sung-Chul Lim et al31 (2007) evaluated

the use of OSTEON® as a sinus graft material and to measure the effect of

healing at 4 and 6 months after surgery The morphology of OSTEON® was

 Page 17 of 61

observed to be interconnected, with 77% porosity and a pore size of 300–500 lm.

After implantation, the mean percentage of newly formed bone fraction after 4

months and 6 months surgery was 40.6 and 51.9%, respectively. Statistical

analysis indicated no significant difference (p 5 0.135) in the newly formed bone

fraction between the two postoperative periods. The mean LB/WB ratio after 4

months and 6 months surgery was 0.14 and 0.45, respectively,

with significant difference observed between the two postoperative periods (p 5

0.027). Additionally, the mean NB/GM ratio after 4 months and 6 months surgery

was 1.95 and 7.72, respectively, with significant difference observed between the

two postoperative periods (p 5 0.046). He concluded that OSTEON® is suitable

for use in sinus graft application since desirable time-dependent healing was

demonstrated.

32
26. Harry V.Precheur (2007) studied bone graft materials and suggested that

mineralized, solvent dehydrated cancellous bone allografts were replaced by

newly formed bone significantly faster and in greater quantities in the maxillary

sinus when compared with a composite of DFDBA plus deproteinized bovine

bone xenograft.

27. Louis G. Mercuri, Firas Alcheikh Ali, Robert Woolson33 (2008) reviewed the

subjective, objective and quality of life outcomes in a group of

temporomandibular joint (TMJ) ankylosis patients managed by total alloplastic

 Page 18 of 61

replacement surgery with a patient fitted system augmented with periarticular

autogenous fat as evidence for its efficacy in such cases is also presented. He

concluded that total alloplastic replacement with a patient fitted prosthesis seemed

to provide a safe and effective management for reankylosis of TMJ. Autogenous

fat transplantation seems to minimize the recurrence of joint heterotopic

calcification, consequently providing improved and consistent rande of

mandibular motions.

28. Kelston Ulbrict Gomes, Joao Luiz Carlini, Cassia Biron et al34 (2008)

evaluated the efficacy of the application of allogenous bone at the

maxillomandibular reconstruction for future rehabitilation with dental implants.

There result showed success in the majotity of the cases, and dental implants

could be installed. This can be considered as an excellent alternative when

compared with the use autogenous grafts because handling is easier.

29. KT Chandrashekar, Chhavi Saxena7 (2009) determine the efficacy of Biograft-

HT® as a bone graft material in the treatment of vertical defects in generalized

chronic periodontitis patients and their clinical and radiological evaluation. They

concluded that the Biograft -HT improves healing outcomes, leads to a reduction

of probing depth, a resolution of osseous defects and a gain in clinical attachment,

compared with open flap debridement by itself.

 Page 19 of 61

Fig. 5 - Biphasic Calcium Phosphate Bioceramics for Implants

Fig. 6 - Bone Graft

 Page 20 of 61

30. Bae JH, Kim YK, Kim SG et al35 (2010) evaluated the use of Osteon as a sinus

bone graft material and to measure the loss of sinus bone graft volume and

marginal bone loss around the implants. They concluded Osteon is suitable for use

in sinus graft application.

31. Sahoo N, Roy ID, Desai AP. et al36 (2010) evaluated the outcome in healing of

reconstructed cranial defects with an autogenous bone graft v/s alloplastic

materials and concluded that autogenous calvarial bone grafts have better

mechanical, biologic, and immunologic properties. This procedure allows the

surgeon to reconstruct moderately large cranial defect with ease of access within

single or adjacent incision to the operating site with minimal postoperative

morbidity and discomfort.

 Page 21 of 61

DISCUSSION
 Page 22 of 61

HISTORY OF BONE REPLACEMENT GRAFTS

Historically autogenous bone grafts were the first bone grafts to be reported. Allogenic

freeze-dried bone was introduced in the early 1970s, while demineralized allogenic

freeze dried bone gained wider application in the late 1980s.The introduction of

xenogenic and alloplastic bone grafts occurred during the same time.

Regenerative therapy with bone replacement grafts did not gain acceptance until the

1980s. Currently the ability of bone replacement grafts to bond to bone is being

examined.

The use of hydroxyapatite products had improved the clinical parameters of bone

regeneration.38

Beta Tricalcium phosphate has been used in the treatment of periodontal osseous lesion

since 1978.39 The use of Bioactive glasses was reported.13 The experimental studies in

monkeys have suggested that bioglass grafting of periodontal intrabone defects may

favour new cementum formation was reported.40

Several calcium phosphate biomaterials have been tested since the mid-1970. They have

excellent tissue compatibility and do not elicit any inflammation or foreign body
45,46
response. Two types of calcium phosphate ceramics (Fig.5) have been used,

Hydroxyapatite and tricalcium -phosphate. 47,48,49

 Page 23 of 61

Bioactive glass is a non-resorbable material whose medical use evolved 25 years ago due

to its reported advantage of forming a strong bond with living tissues, both bone and soft

connective tissue and to its having a modulus of elasticity similar to that of bone. This

bonding is theorized to prevent fibrous encapsulation from occurring at the material

interface.12

The replacement of bone is a complex and demanding undertaking. Bone formation

occurs, when osteoblasts secrete collagen molecules and ground substance. The collagen

moecules polymerize to form collagen fibers. Collagen salts precipitate in the ground

substance along the collagen fibers to form osteoid. Osteoblasts become trapped in the

osteoid and then are called osteocytes.41

Bone formation in grafting is characterized by three types of bone growth: Osteogenesis,

Osteoinduction and Osteoconduction. Osteogenesis is the formation of new bone by

osteoblasts derived from the graft material itself. Osteoinduction is the ability of a

material to induce the formation of osteoblasts from the surrounding tissue at the graft

material itself. Osteoinduction is the ability of a material to induce the formation of

osteoblasts from the surrounding tissue at the graft host site, which results in bone

growth. Osteoconduction is the ability of a material to support the growth of bone over a

surface.2
 Page 24 of 61

Although not directly responsible for bone formation, an additional characteristic,

osteointegration which is the ability to chemically bind to the surrounding bones, is

desirable to aid in the incorporation of the graft at the host site . Study comparising

between a

conventional technique and two bone regeneration techniques in periradicular surgery

and concluded that when regulation techniques were used with or without synthetic

filling material, the lesions of larger size had healed completely in 12 months.38 When the

conventional technique was used, there were persistent small radiducent areas in those

larger lesions.

There was evaluation of the healing of periapical lesions of more than 10 mm and

showed clinical and radiographic evidence of complete bone regeneration when the

membrane technique was used as a barrier.20 Thus the simultaneous use of regeneration

techniques and filling materials allows a more predictable healing response by the action

of a double mechanism: Firstly there occurs re-population of the defect with regenerative

cells derived from the periodontal ligament and the endosteum and secondly the filling

material acts as reservoir and matrix for the deposition of new bone.39

The vascularized periosteum has the most significant osteogenic capacity at 2 weeks,

with a constant level of activity maintained thereafter, it forms new bone soon after the

operation, and the amount of bone increases as time passes.40

 Page 25 of 61

The Xeno grafts (Fig. 9) ( anorganic /bovine bone) shows graft similarity to natural bone

and helps in bone regeneration. The hydroxyapatite crystals have many advantages as a

biomaterial over other bone grafts.28

- No donor site is required

- No risk of transmission of disease.

The bone grafts (Fig. 6) containing hydroxyapatite gets more rapidly incorporated into

the host bone, because its surface already incorporates the biological apatite. This is one

of the rationale for empoloying bovine bone as a substitute material.10

Autologous Platelet Rich Plasma has shown to enhance osseous wound healing of

autogenous bone grafts in both quality and quantity have compared PRP combined with a

biodegradable ceramic, porous hydroxyapatite with a mixture of HA (Fig.7) and saline in

the treatment of human intrabony defects.33

Calcium sulphate alone or mixed with demineralized free dried bone allograft (Fig. 1)

appears to be a promising substance to be used as a filling material under membrane for

regeneration.

The concept of having a material that could be totally resorbable, safe, maintain space,

act as a reservoir of calcium ions for bone mineralization and be inexpensive and able to

act as a barrier is of great benefit.25

 Page 26 of 61

Bioactive glass alloplast in treating periodontal defects and suggested bioactive glass was

well tolerated by human tissue, Bioactive glass with a particle size range of 90 to 710

micrometer, report better mean defect fill in grafted sites.14 In most cases, the goal of

placing a bone graft is to regenerate lost tissue as well as simply to repair or fill the

defect. Thus, graft materials ideally should transfer an optimal

quantity of viable osteocompetent cells including osteoblasts and cancellous marrow stem

cells to the host site.

Bone is a dynamic organ that can regenerate. Regeneration may be defined as restoration

of form and function. Developmental insufficiency, pathology, surgical resection and

traumatic avulsion can lead to osseous deficits. Exploitation of the regenerative capacity

of bone has spawned a diverse spectrum of modalities to correct these deficits. The

development of a bone graft material to replace bone remains a formidable challenge in

modern dentistry. How to reconstruct bone defects in maxillofacial region successfully

has not been satisfactorily resolved. The search for an ideal bone substitute has been

actively pursued for over 20 years. Alloplastic materials have been used with success to

replace the lost bone.16

While using a bone graft, the expectation is that the defect will heal and some form of

new bone formation will occur. Three biologic processes are involved in new bone

formation within a bone graft - osteogenesis, osteoconduction and osteoinduction.4

 Page 27 of 61

Osteogenesis is the ability of the graft to produce new bone and this process is dependant

on presence of live bone cells in the graft. Osteogenic graft materials contain viable cells

with the ability to form bone (osteoprogenitor cells) or the potential to differentiate into

bone forming cells (inducible osteogenic precursor cells). Osteogenesis is a property

found only in fresh autogenous bone and in bone marrow cells.

Osteoconduction is a physical property of the graft to serve as a scaffold for viable bone

healing. It allows for the ingrowth of neovasculature and infiltration of osteogenic

precursor cells into the graft site. Osteoconductive properties are found in cancellous

autografts and allografts, demineralised bone matrix, hydroxyapatite, collagen and

calcium phosphate.

Osteoinduction is the ability of graft material to induce stem cells to differentiate into

mature bone cells. This process is typically associated with the presence of bone growth

factors within the graft material or as a supplement to bone graft. Bone morphogenic

protein and demineralised bone matrix are the principle osteoinductive materials.3

Autogenous bone1 is considered as the gold standard of grafting materials. This type of

bone graft has a potential to retain vital cells, is replaced by host and does not induce an

immunologic reaction. When defect is small, an autologous bone graft is best but in

larger defects, an autogenous bone graft is not always feasible because of an additional

surgical procedure to procure the material with increased morbidity and there may be

insufficient quantities of autogenous bone for grafting large or multiple defects.

 Page 28 of 61

As an alternative, allogenic bone, xenogenic bone or alloplastic bone substitutes have

been used. Advantages of these materials are good induction potential, ready availability,

inexpensive, elimination of a second surgical procedure and reduced hospitalisation time.

Increasing demand and interest in market share stimulated tissue banks and

manufacturers to claim superiority of one product over another. Due to the variable

physical and chemical nature among bone replacement grafts,the goal of reproduction or

reconstitution of lost periodontal structure has been met with varying success or failure.

Alloplastic grafts (Fig.2) are indicated for the patients who have the time for a rigorous

treatment regimen and postsurgical maintenance program. The use of such grafts is also

dictated by patient acceptance, financial factors, availability of graft material, past

experience with bone-grafting procedures, case selection, etc.

Types of Graft Materials

The three primary types of bone graft material are autogenous bone, allografts and

alloplasts of which commercially available xenografts are generally considered a

subgroup. The mechanism by which these graft materials work normally depends on the

origin and composition of the material. Autogenous bone, an organic material harvested

from the patient, forms new bone by osteogenesis, osteoinduction. and osteoconduction.

Harvested from cadavers, allografts, which may be cortical or trabecular. have

osteoconduclive and possibly osteoinductive properties, but they are not osteogenic. Allo-
 Page 29 of 61

plasts, which may be composed of natural or synthetic material, are typically only os-

teoconductive.

In determining what type of graft material to use, the clinician must consider the

characteristics of the bony defect to be restored. In general, the larger the defect, the

greater the amount of autogenous bone required. For small defects and for those with

three to five bony walls still intact, alloplasts may be used alone or with allografts. For

relatively large defects or those with only one to three bony walls intact, autogenous bone

must be added to any other type of graft material being considered. Soft tissue ingrowth

can be a complication

during augmentation procedures with any grafting materials, So guided bone regeneration

(GBR) using resorbable or nonresorbable membranes is often employed.

CLASSIFICATION OF BONE GRAFTS

 Human bone

 Autogenous grafts

 Extraoral

 Intraoral

 Allogenic grafts

Fresh frozen bone

Freeze dried bone allografts

 Page 30 of 61

Demineralized freeze dried bone allografts

Bone substitutes

 Xenogenic grafts

Bovine derived hydroxyapatite

Coralline calcium carbonate

 Alloplastic grafts

Polymers

Bioceramics

Tricalcium phosphate

Hydroxyapatite

 Bioactive glasses

Autogenous Bone

Autogenous bone, long considered the gold standard of grafting materials, is currently the

only osteogenic graft material available to clinical practitioners. Grafted autogenous bone

heals into growing bone through all three modes of bone formation; these stages are not

separate and distinct, but rather overlap each other. Common areas from which

autogenous bone can be harvested include extraoral sites such as the iliac crest or tibial

plateau and intraoral sites such as the mandibular symphysis, maxillary

 Page 31 of 61

Fig. 11 - Tricalcium Phosphate

Fig. 12 - Tricalcium Phosphate

Page 32 of 61
 Page 33 of 61

Fig. 3 - Bio Active Glass material

Fig. 4 - Bio Active glass

 Page 34 of 61

Fig. 7 - Hydroxyapatite Bone graft in an OPG

Fig. 8 - Sinus Bone graft

 Page 35 of 61

tuberosity, ramus, or exostoses. Less resorption has been associated with the use of

mandibular bone grafting.With iliac crest grafts resorption may be reduced during healing

by the use of expanded polytetrafIuoroethylene (e-PTFE) membranes or slowly

resorbable collagen membranes. Bone grafts obtained intraorally generally result in less.

morbidity; however, intraoral donor sites provide a significantly smaller volume of bone

than do extra oral sites such as the iliac crest or tibial plateau.2

The optimal donor site depends on the volume and type of regenerated bone needed for

the specific case.

Autogenous bone is highly osteogenic and best fulfills the dental grafting requirements

of providing a scaffold for bone regeneration. The disadvantages associated with the use

of autogenous bone are the need for a second operative site, resultant patient morbidity,

and in some cases the difficulty of obtaining a sufficient amount of graft material

(especially from intraoral sites). These limitations led to the development of allografts

and alloplasts as alternative grafting materials.4

Requirements for Alloplastic Materials

 They should be complex systems (drug delivery systems). These are composed

from a basic substance, the carrier substance, and the active substances

transported by the latter.

 Page 36 of 61

Fig. 1 - Allograft

Fig. 2 - Alloplastic Bone Graft

 Page 37 of 61

 Carriers are materials without active factors. They can be produced from organic

tissues as well as from synthetic structures.

 Carriers should hold a limited amount of the active substances for a limited period

of time and make them available for local requirements (Hollinger and Leong

1996).

 At the same time, carriers should function as bone-substitution material (Zellin

and Linde 1997) with a definable absorption and transformation rate.

 They should enable characterization of their biochemical, physical and

pharmacological properties and must be biocompatible.

 The long-term tolerability also affects degradation products that are produced at

the time of decomposition.

 Page 38 of 61

 The decisive factor with regard to the osteoconductive effect of the carrier is the

synchronization between the carrier's decomposition rate and the bone's growth

rate (Hutmacher et al. 1998)

Synthetic bone material

OsteoGen (Impladent, Holliswood, NY) is a synthetic bioactive (Fig.3) resorbable graft

(SBRG).7

It is an osteoconductive, non ceramic graft material indicated for contouring and im-

proving alveolar ridge deformities; filling extraction sockets; using around dental

implants and in sinus grafts (Fig.8) and repairing marginal, periapical, and periodontal

alveolar bony defects. A true synthetic, OsteoGen contains no organic components and

can be used without fear of disease transmission.

This material is highly porous crystalline clusters act as a physical matrix to permit the

infiltration of bone-forming cells and the subsequent deposition of host bone. As new

bone is deposited, the material progressively resorbs over a 6- to 8-month period.

Depending on the size of the defect and the patient's age and metabolism, ap-

proximately 80% of the material will be resorbed within 4 to 6 months.7

 Page 39 of 61

OsteoGen was approved for marketing by the Food and Drug Agministration in 1984

and is available in sterile crystalline cluster form (300 to 400 micrometer) in 0.5-, 1.5-,

and 3.0-g vials and 0.3-g prefilled syringes.

Tricalcium phosphate

Tricalcium phosphate is a porous form of calcium phosphate, the most commonly used

form of which is p-tricalcium phosphate. It serves as a biological filler which is partially

resorbable and allows bone replacement. Conversion of the graft is pivotal to periodontal

regeneration; first, serving as a scaffold for bone formation, and then permitting

replacement with bone. Tricalcium phosphate (Fig.11) as a bone substitute has gained

clinical acceptance, but the results are not always predictable. In direct comparison with

allogeneic cancellous grafts, the allogeneic grafts appear to outperform tricalcium

phosphate (Fig. 12) . The tricalcium phosphate particles generally become encapsulated

by fibrous connective tissue and do not stimulatebone growth.

However some bone deposition has been reported with tricalcium phosphate grafts.

Hydroxyapatite, Calo (PO4I6 (OH12) , is the primary mineral component of bone.

Synthetic hydroxyapatites have been marketed in a variety of forms, primarily as a

porous nonresorbable, a dense or solid nonresorbable, and a resorbable (non-ceramic,

porous) form.
 Page 40 of 61

Fig. 9 - Xenograft
 Page 41 of 61

Fig. 10 - Edentulous Mandible

 Page 42 of 61

It is a stable, non-toxic and inert material. The porous form of material increases its

osteoconduction. Hydroxyapatite is unfortunately brittle and prone to fracture while

being

shaped or pressed into place. Studies have shown that bovine collagen is effective in bone

repair. No foreign body or inflammatory cells are found. In collagen treated defects, bone

formation is more rapid than in untreated cases. In 1977, Mittelmier developed the idea

of a new biodegradable bone replacement material based on the main components of

bone; collagen and hydroxyapatite. Radiologically, the healing process of a bony defect

is said to be complete by the end of twelve months, thus it takes long time for the real

assessment of bone healing.19

Hydroxyapatite resorbability is determined by the temperature at which it is processed.

Resorbability is desirable if the graft is eventually to be replaced by the host bone. When

prepared at high temperature (sintered), hydroxyapatite is nonresorbable, nonporous,

dense,and has a larger crystal size . Dense hydroxyapatite grafts are osteophillic,

osteoconductive and act primarily as inert biocompatible fillers. They have produced

clinical defect fill greater than flap debridement alone in the treatment of intrabony

defects. Porous hydroxyapatite (Interpore 200, Irvine, CA) is obtained by the

hydrothermal conversion of the calcium carbonate exoskeleton of the natural coral genus

Porites into the calcium phosphate hydroxyapatite.It has a pore size of 190 to 200 pm,

which allows bone ingrowth into the pores and ultimately within the lesion itself .

Combinations of the two primary forms of calcium phosphate have been studied to take
 Page 43 of 61

advantage of the rapid resorption of p-tricalcium phosphate and the inert scaffold of

dense hydroxyapatite.37

TCP is similar to hydroxyapatite, but it is not a natural component of bone material. In

the body, TCP is converted in part to crystalline hydroxyapatite. The rate of TCP

resorption varies and appears to depend greatly on the material's chemical structure,

porosity, and particle size. Like all bone substitute materials, TCP is osteoconductive and

is intended to provide a physical matrix that is suitable for the deposition of new bone. It

is often used for repairing nonpathologic sites, where resorption of the graft with

concurrent bone replacement might be expected. TCP can also be used with osteogenic or

osteoinductive materials to improve the handling characteristics of the graft during place-

ment. Both hydroxyapatite and TCP are safe and well tolerated.45

Cerasorb (Curasan, Kleinostheim, Germany) is a beta-tricalcium phosphate (beta-TCP)

material that has been certified for use in bone defect regeneration in the entire skeletal

system. In June 2000 it was certified in Europe as a synthetic material carrier for the

patient's own PRP. The material is resorbed completely and is generally replaced by

natural bone in a 3- to 24-month period, depending on the type of bone. During the pro-

cess, collagen and blood vessels are incorporated with the Cerasorb granules

(micropores) and the intergranular cavities (macropores). Collagen fibers guide

capillaries and newly formed bone before resorption begins. Although highly porous,
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Cerasorb is stable and highly resistant to abrasion. Generally, a round-particle size of 10

to 63 micrometers prevents phagocytosis by macrophages.24

Calcium carbonate materials

Coralline is a ceramic graft material synthesized from the calcium carbonate skeleton of

coral. One of its advantages is that it has a three-dimensional structure similar to that of

bone. A recent study conducted among a population of young, growing patients

demonstrated the suitability of coral granules for ridge preservation in the posterior

maxilla and mandible (Fig.10) in the presence of ankylosed primary teeth and

congenitally absent permanent teeth but found it unsuitable for treatment in the

traumatized anterior maxilla.30

Interpore 200 is an example of a porous coralline hydroxyapatite, This material is

essentially composed of pure hydroxyapatite and some TCP, and its mechanism of action

is osteoconduction.27 Interpore 200 (in blocks and granules) has been used as an implant

graft that provides a matrix for bone ingrowth. as an onlay graft for the alveolar ridge.

and as an interpositional implant in the mandible. Some researchers have found the shape

of this material to be easily modified during surgery to obtain an exact fit. However other

investigators have found it to be brittle and difficult to handle.

 Page 45 of 61

The resorption rate of porous ceramic graft material such as Interpore 200 has been

studied. Although the material was expected to degrade faster when placed in soft

tissue, it was found that resorption was extremely slow, both in bone and soft tissue.

Bone can grow around the material and into its porosities; however, the material

takes a significant amount of time to resorb and to be replaced with bone.43

Biocoral (Inoteb. LeGuernol, Saint Gonnery, France) is another resorbable porous graft

material. It is a natural coral in the form of aragonite (more than 98% calcium carbonate)

that is not altered by processing. It has been reported that the clinical response to this

material, particularly related to periodontal osseous defect fill, is similar to or slightly

better than the response to other hydroxyapatite graft materials. The size and shape of the

particles facilitate ease of handling and manipulation during surgery. This calcium

carbonate also is not readily displaced from the treatment site.

Calcified algae

C-Graft (The Clinician's Preference, Golden, CO) has been used successfully for more

than 10 years for grafting and remodeling bone. Similar to bone in its crystalline, porous

surface structure and chemical composition. C-Graft is a calcium phosphate ceramic with

the hexagonal crystalline structure of hydroxyapatite and a large specific surface area

with high bioactivity. C-Graft has an interconnecting microporosity that guides hard and

soft tissue formation and can be very effective for filling tooth extraction sites and bone
 Page 46 of 61

defects. It is an inorganic, biocompatible calcium phosphate material derived from

calcium-encrusted sea algae, which are processed in order to develop an apatite material

that is analogous to bone apatite.It is provided sterile in prefilled vials and has a granular

size range of 300 to 2,000 micrometer. One study demonstrated that the texture of C-

Graft acted as an osseoconductive scaffold for osteoblastic cells and that it also facilitated

matrix deposition. The particles underwent osseointegrated as well as physiologic bone

remodeling.19

Hard tissue replacement polymer

HTR"M Synthetic Bone (Bioplant, Norwalk, CT) is a biocompatible microporous

composite of polymethylmethacrylate, polyhydroxylethylmethacrylate and calcium

hydroxide. Favorable clinical results have been achieved with HTRTM (the acronym

stands for hard tissue replacement) in the treatment of intrabony and furcation defects.

However, improved clinical results with this bone replacement graft have not always

been achieved. Histologically, new bone growth has been found deposited on HTRTM

particles. Its hydrophilicity enhances clotting, and its negative particle surface charge

allows adherence to bone. It appears to serve as a scaffold for bone formation when in

close contact with alveolar bone. Clinical defect fill and resolution can be achieved

supporting its use as a biocompatible alloplastic bone substitute.24

 Page 47 of 61

The polymer resorbs slowly and is replaced by bone after approximately 4 to 5 years.

Bioplant HTR has been reported to be an effective material for use in the following

situations:

1. Bone (ridge) maintenance, by preventing the anticipated loss of alveolar bone

following extraction, preserving the height and width of the alveolar ridge

2. Ridge augmentation, in which immediate use following extraction increases the

height and width of the alveolar ridge

3. Delayed augmentation (after extensive atrophy has already occurred), in which the

dimensions of the alveolar ridge are increased and bony defects are corrected

4. Repair of periodontal and other bony defects

Bioactive glass ceramics

Bioactive glass is a non–resorbable material whose medical use evolved 25 years ago.

The first bioactive glass, was invented by Dr. L. Hench in 1969.4 Bioactive glass has

been used in treating periodontal intrabony defects. This in addition to being

5
osteoconductive, bonds directly to bone tissue.

There are two forms of bioactive glass currentlyavailable. PerioGlas@( Block Drug Co.,

Jersey City, NJ) and BiogranTM (Orthovita, Malvern, PA). Bioactive glasses are

composed of CaO, Na, O, SiO, P205 and bond to bone through the development of a

surface layer of carbonated hydroxyapatite. When exposed to tissue fluids, bioactive

glasses are covered by a double layer composed of silica gel and a calcium-phosphorous

rich (apatite) layer. The calcium phosphate-rich layer promotes adsorption and
 Page 48 of 61

concentration of proteins utilized by osteoblasts to form a mineralized extracellular

matrix. It has been theorized that these bioactive properties guide and promote

osteogenesis, allowing rapid formation of bone. PerioGlas has a particle size ranging

from 90 to 710 pm, which facilitates manageability and packing into osseous defects.

Compared to tricalcium phosphate, hydroxyapatite and unimplanted controls, Formation

of hollow calcium phosphate growth chambers occurs with this particle size because

phagocytosing cells can penetrate the outer silica gel layer by means of small cracks in

the calcium-phosphorous layer and partially resorb the gel. This resorption leads to the

formation of protective pouches where osteoprogenitor cells can adhere, differentiate and

proliferate.

Bioglass (Fig. 4) (US Biomaterials, Jersey City, NJ) is composed of calcium salts and

phosphate in a proportion similar to that found in bone and teeth, as well as sodium salts

and silicon, which are essential for bone to mineralize. An amorphous material, bioactive

glass ceramic is not available in a crystalline form (to strengthen the material) because its

developers suggested that degradation of the material by tissue fluids and subsequent loss

of the crystals could cause a loss of integrity. Because it is not porous, tissue and blood

vessel ingrowth is prevented. The biologic impact of this property is not known, and few

studies support the use of this material in periodontal and maxillofacial applications.38
 Page 49 of 61

Bioactive glass ceramics have two properties that contribute to the successful results

observed with its use: (1) a relatively quick rate of reaction with host cells, and (2) an

ability to bond with the collagen found in connective tissue.16 It has been reported that

the high degree of bioactivity may stimulate the repair process and induce osteogenesis.

Because the bioactivity index is high, reaction layers develop within minutes of

implantation. As a result, osteogenic cells in the implantation site may colonize the

surface of the particles and produce collagen on these surfaces. Osteoblasts then lay

down bone material on top of the collagen. The latter action may supplement the bone

that grows by osteoconduction from the alveolus.

Bioglass is reported to bond not only to bone, but also to soft connective

tissues.Collagen produced by osteogenic and nonosteogenic cells (eg, fibroblasts)

becomes embedded in the interfacial layer as it grows and may provide a compliant

adherent interface with the graft material.21 The cells also appear to lay down collagen

above the level of the

particulate. This collagen attaches to the superficial particles, immobilizing them in the

soft tissue. A mechanically compliant layer approximately 0.3 mm in thickness is created,

which may aid in the repair of the connective tissue ligament. However, much of the

biologic significance of the properties of bioactive glass remains to be discovered, and

there is no documentation that the material aids in periodontal regeneration. For-

example, one study recommends against the use of bioactive glass alloplast and GBR to

augment a localized ridge to place implants.12

 Page 50 of 61

PerioGlas (NovaBone, Alachua, FL) is a synthetic particulate form of Bioglass that

bonds to both bone and certain soft connective tissue. PerioGlas is composed of

calcium, phosphorus, silicon, and sodium.41

The rate and density of new bone deposition may increase with the use of PerioGlas

particles compared with hydroxyapatite crystals. This bioactive synthetic grafting

particulate is indicated for the treatment of infra bony defects. Criteria for successful,

PerioGlas use include pretreatment planning, debridement of the defect, preservation

of soft tissue vascularity, and infection control.13

In animal studies, PerioGlas has demonstrated two favorable characteristics: ease of

compactability and ability to promote hemostasis. When well packed into osseous

defects, this material was strongly adherent and appeared to harden into a solid mass

after placement in the defect. After a few minutes, it remained in the osseous defect,

even when a suction tip or handpiece was used in the vicinity. Hemorrhaging from the

defects

stopped within a few seconds after graft placement. This hemostasis is most likely

related to the compactability and adhesiveness of the material.The material appeared

to partially repair intraosseous defects through osteoproduction resulted in osseous

and cementum repairs superior to those obtained with hydroxyapatite and TCP

initiated a rapid chemical bond that appeared to impede the downgrowth of epithelium
 Page 51 of 61

(although this finding has not been confirmed in human studies) was easily mixed,

transferred, and packed and was well contained in the defect site may have hemostatic

attributes within intraosseous defects.41

Particle size was not related to the healing response. They concluded that by bonding to

both bone and connective tissues, PerioGlas achieved improved grafting results.14

Biogran (3i Implant Innovations, Palm Beach Gardens, FL) is a resorbable bone graft

material made of bioactive glass granules that are chemically identical to , perioGlas. The

difference between PerioGlas and Biogran is the size range of particles 300 to 355

micrometer for Biogran and 90 to 710 micrometer for PerioGlas.14

Biogran is hydrophilic and slightly hemostatic; it stays in place in the defect when

bleeding occurs. When wetted with sterile saline or the patient's blood, a cohesive mass

forms that can be shaped to fill the defect. Bone transformation and growth occur within

each granule. This osteogenesis, guided by bioactive glass particles, occurs at multiple

sites, rapidly filling the osseous defect with new bone that continuously remodels in the

normal physiologic manner. Such controlled bioactivity reportedly permits material and

bone transformation to occur simultaneously.15

 Page 52 of 61

Synthetic substitutes create a new avenue for clinicians to explore as adjuncts in surgical

procedures. These materials may not be necessarily be used solely for reconstructive

procedures , but when used in the right situations in combination with autologous,

allograft or other synthetics, the result have the potential for more desirable results. The

future of bone graft substitutes will come to expand with increasing technologic

advances, which allow us to better understand better healing, the role that factors such as

BMP, transforming growth factors, platelet derived growth factors, and others play in this

process when desired.

Hydroxyapatite cement formed an effective osseoconductive scaffold for bone

replacement. The addition of demineralized bone powder to the cement to serve as a

carrier of osseoinductive factors did not result in additional bone being formed.

The application of calcium phosphate cement under intra operative image guidance is

effective in the treatment of orbital wall fracture or defects reconstructions. The

application of cement paste in the orbital region, Due to physical properties, is limited to

small defects or to situations with supporting underlying fragments only. When compared

to autogenous bone split grafts the cement offers the possibility of repeat corrections

during the shaping and moulding of the orbital walls. This leads to a slight but

measurable increase in precision of restoration of the orbital volume, especially in the

deeper part of the orbit.

Alloplastic substances do not undergo resorption. However the major factor that causes

resorption of bone grafts ( assuming that they were placed in adequate contact with

underlying bone and a firm osteosynthesis ) is tightness of the overlying soft tissues.
 Page 53 of 61

Under these circumstances, an alloplastic substance will either erode into the underlying

bone, as has been frequently observed in the mandibular symphsis and malar region or

break through the tight soft tissue envelope and become extruded as has been in the nasal

implants.

The potential disadvantages of alloplastic reconstruction relate mainly to wear or failure

of the material. Where particles can generate a gianmt cell foreign body reaction with the

potential loosening of the implant, resulting in occlusion change or displacement or

fractures.

The site of reconstruction, size of the defect to repair, objectives of the surgery,

examination of the patient, desires of the patient and knowledge of the graft materials are

all factors that must be entertained before the surgery begins. There are many options in

graft materials from which to choose, all with advantages and disadvantages. Knowledge

of this information distinguishes a good surgeon from a great surgeon.

 Page 54 of 61

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2. Hisham F.Nasr, Marye Lizabetha Ichelmann-reidy & Raymonda Yukna: Bone

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