INTRODUCTION

Periodontal disease is one of the most prevalent afflictions

worldwide. The most serious consequence is the loss of the
periodontal support structure, which includes cementum, the
periodontal ligament, and alveolar bone.
Conventional periodontal treatments, such as root planning,
gingival curettage, and scaling, are highly effective at repairing
disease-related

defects

periodontitis.

These

conventional

therapies

and

are
do

halting

the

progression

of

important

steps;

however,

the

relatively

little

to

prompt

the

regeneration of lost periodontal support structure.

In fact, studies indicate that they typically result in the
development of a long junctional epithelium between the root
surface and gingival connective tissue rather than the regrowth of
tissue that restores the architecture and function.
Thus, more effective techniques that predictably promote the
bodys natural ability to regenerate its lost periodontal tissuesparticularly alveolar bone still need to be developed.
Bone grafting is the most common form of regenerative therapy
today and is usually essential for restoring all types of
periodontal supporting tissue.
To date, histologic evidence in humans indicates that bone
grafting is the only treatment that leads to regeneration of bone,
cementum, and a functionally oriented new periodontal ligament
coronal to the base of a previous osseous defect.

Periodontal regeneration refers to the complete restoration of

functional supporting tissues, including the alveolar bone, the
cementum, and the periodontal ligament.
Regenerative therapy therefore refers to various modalities, such
as bone grafts, root conditioning, and GTR that promote the
bodys natural ability to replace these lost periodontal support
structures.
Periodontal repair refers to the healing of a periodontal wound
with tissue that restores continuity but does not fully restore the
architecture and function of the support structures.
New attachment refers to the reunion of connective tissue with a
root surface that has been deprived of its periodontal ligament.
The new attachment occurs by the formation of new cementum
with inserting collagen fibers.
Reattachment is the reunion of connective tissue with a root
surface n which viable periodontal tissue is present. Nothing new
is formed.
Clinical

objectives

of

bone

grafting

for

periodontal

regeneration
The objectives of bone grafting procedures for patients with
periodontitis are as follows
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 as determined by histologic analysis.

In a review of animal histologic studies, Mellonig found that

75% of these studies indicated favorable regenerative results
when periodontal defects were treated with grafting; none
showed that non-graft control sites were superior to grafted ones.
Ideal characteristics of a bone graft are as follows:
Nontoxic
Nonantigenic
Resistant to infection
No root resorption or ankylosis
Strong and resilient
Easily adaptable
Readily and sufficiently available
Minimal surgical procedure
Stimulates new attachmentCurrently, the only reference point
that is considered valid for histologic studies of periodontal
regeneration is a notch placed in the most apical level of calculus
on the root surface.
Based on this scientifically acceptable criterion, new
attachment apparatus has been observed after certain autogenous
and allogeneic grafts.
The objectives of bone grafting are
1.

regenerate a functional attachment apparatus

2.

decrease pocket depth and

3.

establish a healthy maintainable environment.

The possibilities of bone grafting are as follows:

Actively forms new bone

Induces bone formation

3

Creates passive surface for bone formation

Provides mechanical obstruction

Types of graft materials

Several types of bone grafts have been studied over the
years, and periodontists continue to search for ideal materials.
The types of bone grafts are

Autograft intraoral and extraoral

Allograft freeze-dried, fresh

Xenogenic Kielbone (oxbone)

Alloplastic synthetic

Bone graft materials are generally evaluated based on their

osteogenic, osteoinductive, or osteoconductive potential.
Osteogenesis refers to the formation or development of new
bone by cells contained in the graft.
Osteoinduction is a chemical process by which molecules
contained in the graft (bone morphogentic proteins or BMPS)
convert the neighboring cells into osteoblasts, which in turn from
bone.
Osteoconduction is a physical effect by which the matrix of the
graft forms a scaffold that favors outside cells to penetrate the
graft and from new bone.

Autogenous Grafts
Autogenous grafts, which are harvested from the patients
own body, are considered the gold standard among graft
materials because they are superior at retaining cell viability.
These grafts contain live osteoblasts and osteoprogenitor
stem cells and heal by osteogenesis. In addition, autogeneous
grafts

avoid

the

potential

problems

of

histocompatibility

differences and the risk of disease transfer.

AUTOGENOUS BONE GRAFTS:
A. INTRAORAL SITES

B. EXTRAORAL SITES
(ILIAC CREST)

1. OSSEOUS COAGULUM
2. BONE BLEND
3. INTRAORAL CANCELLOUS
BONE MARROW TRANSPLANTS
4. BONE SWAGING.

BONE FROM INTRAORAL SITES:

In 1923, Hegedus attempted to use bone grafts for the
reconstruction of bone defects produced by periodontal disease.
The method was revived by Nabers and OLeary in 1965, and
numerous efforts have been made since that time to define its
indications and technique.

Autogeneous bone can often be harvested from intraoral sites

including,
Edentulous ridges
Tori
Maxillary tuberosity
Healing bony wound or extraction sites
Bone trephined from within the jaw without damaging the roots
And bone removed during osteoplasty and osteotomy.
Osseous Coagulum
Robinson described a technique using a mixture of bone dust and
blood that he termed osseous coagulum. The technique uses small
particles ground from cortical bone and it provides additional
surface area for the interaction of cellular and vascular elements.
Bone is removed with a carbide but #6 or #8 at speeds between
5000 and 30000 rpm, placed in a sterile dappen dish or amalgam
cloth, and used to fill the defect. The obvious advantage of this
technique is the ease of obtaining bone from already exposed
surgical sites, and its disadvantages are its relatively low
predictability and inability to procure adequate material for large
defects.
Bone Blend:
Some disadvantages of osseous coagulum derive from the
inability to use aspiration during accumulation of the coagulum;
another problem is the unknown quantity of the bone fragments
in the collected material. To overcome these problems, the socalled bone blend technique has been proposed.
6

The bone blend technique uses an autoclaved plastic capsule and

pestle. Bone is removed from a predetermined site, triturated in
the capsule to a workable plastic like mass, and packed into bony
defects.
Froum and co-workers have found osseous coagulum bone
blend procedures to be at least as effective as iliac auto grafts
and open curettage.
Intraoral Cancellous Bone Marrow Transplants
Cancellous bone can be obtained from the maxillary
tuberosity, edentulous areas, and healing sockets. The maxillary
tuberosity frequently contains a good amount of cancellous bone
particularly if the third molars are not present also foci of red
marrow are occasionally observed. After a ridge incision is made
distally from the last molar bone is removed with a curved and
cutting rongeur. Care should be taken not to extend the incision
too far distally to avoid sectioning the tendons of the palatine
muscle also the location of the maxillary sinus has to be analyzed
on the radiograph to avoid cutting into it.
Edentulous ridges can be approached with a flap and
cancellous bone and marrow are removed with curetters. Healing
sockets are allowed to heal for 8 to 12 weeks, and the apical
portion is used as donor material. The particles are reduced to
small pieces.
Bone swaging: this technique requires the existence of an
edentulous area adjacent to the defect from which the bone is
7

pushed into contact with the root surface without fracturing the
bone at its base. Bone swaging is technically difficult, and its
usefulness is limited.

BONE FROM EXTRAORAL SITES

Iliac Autografts: The use of fresh or preserved iliac cancellous
marrow bone has been extensively investigated. Data from human
and animal studies support its use, and the technique has proved
successful in bony defects with various numbers of walls, in
furcations, and even supracrestally to some extent
However, owing to problems associated with its use, such as
postoperative infection, exfoliation, sequestration; varying rates
of healing; root resorption; and rapid recurrence of the defect, in
addition to increased patient expense and difficulty in procuring
the donor material, the technique is no longer in use.
Allografts
Allografts

are

bone

taken

from

one

human

for

transplantation to another. These grafts, procured from deceased

persons, are typically freeze-dried and treated to prevent disease
transmission and are available from commercial tissue banks.
There are various types of allografts available, including 1.
Freeze-dried bone allograft (FDBA)
2. Demineralized freeze-dried bone allograft (DFDBA).
Both allografts and xenografts are foreign to the organism and
therefore have the potential to provoke an immune response.
8

Attempts have been made to suppress the antigenic potential of

allografts and xenografts by radiation, freezing, and chemical
treatment.
Bone allografts are commercially available from tissue banks.
They are obtained from cortical bone within 12 hours of the
death of the defatted, cut in pieces, washed in absolute alcohol,
and deep frozen. The material may then be demineralized, and
subsequently ground and sieved to a particle size of 250 to 750
mm and freeze dried. Finally, it is vacuum sealed in glass vials.
Numerous steps are also taken to eliminate viral Infectivity.
These include exclusion of donors from known high-risk groups
and various tests on the cadaver tissues to exclude individuals
with any type of infection or malignant disease.
The material is then treated with chemical agents or strong acids
to effectively inactivate the virus, if still present. The risk of
human

immunodeficiency

virus

(HIV)

infection

has

been

calculated as 1in 1 to 8 million and is therefore characterized as

highly remote.
UNDECALCIFIED

FREEZE-DRIED

BONE

ALLOGRAFT

(FDBA):
Several clinical studies by Mellonig, Bowers, and co-workers
reported bone fill exceed 50% in 67% of the defects grafted with
FDBA and in 78% of the defects grafted with FDBA plus
autogenous bone.
9

FDBA, however, is considered an osteoconductive material,

whereas

decalcified

FDBA

(DFDBA)

is

considered

an

osteoinductive graft. Laboratory studies have found that DFDBA

has a higher osteogenic potential than FDBA and is therefore
preferred.
DECALCIFIED FREEZE-DRIED BONE ALLOGRAFTS
Experiments by urist and co-workers have established the
osteogenic potential of DFDBA.

Demineralization in cold,

diluted hydrochloric acid exposes the components of bone

matrix, closely associated with collagen fibrils that have been
termed bone morphogenetic protein.
In 1975, Libin et al reported three patients with 4 to 10 mm
of bone regeneration in periodontal osseous defects studies were
made with cancellous DFDBA and cortical DFDBA. The latter
resulted in more desirable results (2.4 mm versus 1.38 mm bone
fill).
Bowers and associates, in a histologic study in humans, showed
new attachment and periodontal regeneration in defects grafted
with DFDBA.
Mellonig and associates tested DFDBA against autogenous
materials the calvaria of guinea pigs and showed it to have
similar osteogenic potential.
These

studies

provided

strong

evidence

that

DFDBA

in

periodontal defects results in significant probing depth reduction,

10

attachment level gain, and osseous generation; the combination

of DFDBA and guided tissue regeneration has also proven very
successful.
A bone-inductive protein isolated from the extracellular matrix
of human bones, termed osteogenin has been tested in human
periodontal defects and seems to hence osseous regeneration.
XENOGRAFTS:
A xenograft is a graft between different spiecies.
2 sources of xenograft are,
Bovine bone &Natural coral
1. Bovine-derived hydroxyapatite
2. Coralline calcium carbonate
3. Calf bone (Boplant)
4. Kiel bone

Bovine Bone:
Commercially available bovine bone is processed to
yield natural bone mineral minus the organic component.
currently

available

bovine

derived

HA

is

deproteinated , retaining its natural microporous structure that

support cell mediated resorption. This becomes important if the
product is to be replaced with new bone.
2 products currently available as
Osteograf &
11

 BioOss
Both

have

been

reported

to

have

good

tissue

acceptence with natural osteotrophic properties.

Previously it is available as
Periograf&
Alveolograf
CORROLLINE CALCIUM CARBONATE:
Biocoral is a calcium casrbonate obtained from a
natural coral, genus porites, and is composed primarily of
aragonite. It is biocompatible and resorbable with a porous size
of 100-200um , similar to the porosity of spongy bone .
In contrast to porous HA,derived from the same coral
by heat conversion and non resorbable, calcium corbonate is
resorbable. It does not require a surface transformation in to a
corbonate phase as do other bone substitutes to initiate bone
formation

hence,

it

should

more

rapidly

initiate

bone

formation .
Xenografts:
Calf bone (Boplant), treated by detergent extraction,
sterilized, and freeze dried, has been used for the treatment of
osseous defects.
Kiel bone is calf or ox bone denatured with 20%
hydrogen peroxide dried with acetone, and sterilize with
ethylene oxide.

12

Anorganic bone is ox bone from which the organic material

has been extracted by means of ethylenediamine; it is then
sterilized by autoclaving.
Recently, however, Yukna and co-workers

used a natural,

anorganic, microporous, bovine-derived hydroxyapatite bone

matrix, in combination with a cell binding polypeptide that is a
synthetic clone of the 15 amino acid sequence of type I collagen.
The addition of the cell binding polypeptide was shown to
enhance the bone regenerative results of the matrix alone in
periodontal defects.
ALLOPLASTS OR NONBONE GRAFT MATERIALS.
In addition to bone graft materials, many nonbone graft materials
have been tried for restoration of the periodontium.
Among them are
Sclera,
Dura,
Cartilage,
Cementum,
Dentin,
Plaster of Paris,
plastic materials,
Bioceramics HA & TCP
Bioactive glasses
13

Polymers
Coral-derived materials.
ALLOPLASTS OR NONBONE GRAFT MATERIALS.
In addition to bone graft materials, many nonbone graft materials
have been tried for restoration of the periodontium.
Among them are
Sclera,
Dura,
Cartilage,
Cementum,
Dentin,
Plaster of Paris,
plastic materials,
Bioceramics HA & TCP
Bioactive glasses
Polymers Coral-derived materials.
Sclera:
sclera was originally used in periodontal procedures
because it is a dense fibrous connective tissue with poor
vascularity and minimal cellularity. This affords a low incidence
of antigenicity and other untoward reactions. In addition, sclera
may provide a barrier to apical migration of the junctional
epithelium and serve to protect the blood clot during the initial
healing period.
14

Although some studies show that sclera is well

accepted by the host and is sometimes invaded by host cells and
capillaries and replaced by dense connective tissue, it does not
appear to induce osteogenesis or cementogenesis. The available
scientific research does not warrant the routine use of sclera in
periodontal therapy.
Cartilage has been used for repair studies in monkeys and
treatment of periodontal defects in humans. It can serve as a
scaffolding when so used, new attachment was obtained in 60 of
70 case studies. However, cartilage has received only limited
evaluation.

PLASTER OF PARIS.
Plaster of Paris (calcium sulfate) is biocompatible and
porous, thereby allowing fluid exchange, which prevents flap
necrosis. Plaster of Paris resorbs completely in 1 to 2 weeks, One
study in surgically created three-wall defects in dogs showed
significant regeneration of bone and cementum. It was found be
useful in one uncontrolled clinical study, but other ivestigators
have reported that it does not induce bone ormation. One report
suggested its use in combination with DFDBA and a Gore-Tex
membrane. Its use unless in human cases, however, has not been
proven.

15

PLASTIC MATERIALS
HTR

(Bioplant)

polymer

is

nonresorbable,

microporous,

biocompatible composite of polymethylmethacrylate (PMMA) &

polyhydroxylethylmethacrylate(PHEMA) and calcium hydroxide.
The polymer resorbs slowly and is replaced by bone after
approximately 4-5 years.
A clinical 6-month study showed significant defect fill and
improved attachment level, Histologically, this material is
encapsulated by connective tissue fibers, with no evidence of
new attachment (Stahl et al 1991).
Histologically, new bone growth has been found deposited on
HTR particles.
formation

It appears to serve as a scaffold for new bone

when

in

close

contact

to

alveolar

bone.

Its

hydrophilicity enhances clotting, and its negative particle surface

charge allows it to adhere to bone.
HTR is a clinically beneficial, biocompatible, osteophilic,
and osteoconductive alloplastic bone substitute.
CALCIUM PHOSPHATE BIOMATERIALS.
Several calcium phosphate biomaterials have been
tested since he mid-1970s and are currently available for clinical
se.

Calcium

phosphate

biomaterials

have

excellent

tissue

compatibility and do not elicit any inflammation or foreign body

response.

These

materials

are

osteoconductive,

not

osteoinductive meaning that they will induce one formation when

16

placed next to viable bone but not when surrounded by non

bone-forming tissue such as skin.
Two types of calcium phosphate ceramics have been used:
1. Hydroxyapatite(HA has a calcium-to-phosphate ratio of 1.67,
similar to that found in bone material. HA is generally
nonbioresorbable.
2. Tricalcium phosphate (TCP), with a calcium-to- phosphate
ratio of 1.5, is mineralogically B-whitlockite. TCP is at least
partially bioresorbable.
Dense, nonporous, nonresorbable.
Porous, nonresrbable(xenograft)
Resorbable, low temperaturederived
(Bioactive glass, & polymers)
1. When prepared at high temperature (sintered),HA is non
resorbable, non porous &dense & has a larger crystal size.
Dense HA grafts are osteoconductive ,&act primarily as
inert biocompatible fillers.
1. Porous HA is obtained by the hydr45othermal convertion
of the calcium carbonate exoskeleton of the natural coral
genus porites, in to HA .It has a pore size of 190-200um ,
which allows fibrovascular ingrowth

& subsequent bone

formation in to the pores & ultimately with in the leision

itself .
17

2. Another form of synthetic HA is a resorbable , low

temperature

processed

perticulate

material

The

resorbable form is is nonsintered with particles measuring

300-400um I t has been proposed that non sintered HA
resorbs acting as a mineral reservoir inducing new bone
formation via osteoconductive mechanism.
Case reports and uncontrolled human studies have shown
that

calcium

phosphate

bioceramic

materials

are

perfectly

tolerated and can result in clinical repair of periodontal lesions.

Several controlled studies were conducted on the use of 1 and
Calcitite clinical results were good, but histologically these
materials appeared to be encapsulated by collagen.
BIOACTIVE GLASS.
Bioactive

glass

consists

of

phosphates,

and

silicondioxide; & dental applications it is used in the form of

irregular particles measuring 90 to 170 m (PerioGlas, Block Drug
Co., Jersey City, NJ) or 300 to 355 m (BioGran, Ortho Vita,
Malvern, PA). When this material comes into contact with tissue
fluids,

the

surface

of

the

particles

becomes

coated

with

hydroxycarbonateapatite, Incorporates organic ground proteins

such as chondroitin sulfate and glycosaminoglycans, and attracts
osteoblasts that rapidly form bone.
This material may have potential, and clinical studies are
needed to establish its real usefulness.

18

Periglass has a particle size ranging from 90-170um , which

facilitates manageability& packing in to osseous defects.
When compared to TCP,HA &unimplanted controls ,
Fetner et al showed perioglas produced significantly greater
osseous &cementum repair . It also appeared to retard epithelial
down growth , which authors contend may be responsible for its
enhanced cementum &bone repair.
Biogran has a narrower range of particle size of the
purportedly critical 300-355um size range, which has been
reported to be advantageous for guiding osteogenesis. Formation
of hallow 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 & partially resorb the gel. This resorbtion
leads to formation of protective pouches where osteoprogenitor
cell can adhere differentiate & proliferate.

CORAL-DERIVED MATERIALS.
Two different coralline materials have been used in
clinical periodontics natural coral & coral derived- porous . Both
are biocompatible but whereas natural coral hydroxyapatiteis
resorbed slowly (several months), porous hydroxyapatite Is not
resorbed or takes years to do so.
Clinical studies on these materials showed pocket
reduction, attachment gain, and bone level gain. The materials
have also been studied in conjunction with membranes, with
19

good results. Both materials have demonstrated microscopic

cementum and bone formation, but their slow restorability or
lack thereof has hindered clinical success in practice.
Grafts in combination with other procedures
During the 1989 World Workshop in Clinical Periodontics,
the

consessus

was

that

research

should

be

directed

at

combination treatments for periodontal regeneration, involving

bone

grafts

in

conjunction

with

barrier

membranes,

root

demineralization and others. Since then, several human studies

have been undertaken, with most involving GTR plus allografts.
Guided Tissue Regeneration
GTR involves the use of a barrier membrane to seal off a
defect site during healing. This barrier, which is sutured in a
tension-free fashion between the defect and thick reflected flaps,
deters undesirable tissues that have no osteogenic potential, such
as epithelium and soft connective tissue, from invading the
wound site during healing. The theory is that this, in turn, allows
space for periodontal ligament cells to grow umimpeded and to
form a new attachment apparatus.
Since its development over the last decade, GTR has been widely
used to treat a variety of periodontal defects successfully. Threewalled

defects

respond

best

to

GTR

treatment,

typically

experiencing substantial bone fill. Other defects that have been

shown to respond well include combination two-walled and
20

three-walled defects, funnel shaped defects with definite osseous

stops, and class II furcations with vertical components. When
treating maxillary molars with class II defects, however, only
buccal sites have shown positive responses. Any defect treated
with GTR should be at least 5mm deep.
Root Conditioning
Because the altered root surface can inhibit regeneration
and new attachment, some studies have investigated whether root
conditioning with citric acid or tetracycline to demineralize the
root surface might be a useful adjunct to GTR and grafting
procedures. The theory is that this treatment may expose the
collagen fibrils in the cementum and make the root more
amenable to attachment. This technique is commonly used as part
of other regenerative procedures.
Although animal studies have shown good results, though of
human trials thus far are controversial, particularly pertaining to
tetracycline. Histologic evidence seems to suggest that root
surface demineralization may lead to new connective tissue
attachment and limited regeneration. This conclusion has not
been universal, however, and demineralized root surfaces have
not proven to provide a clinically improved outcome over roots
that were not demineralized.
What to conclude about combination procedures
In reviews of clinical studies investigating combination
periodontal treatment, Schallhorn and McClain and Garrett and
21

Bogle noted that the evidence seems to indicate that when both
furcation and intraosseous defects are treated with ePTFE
barriers, adding bone grafts may improve clinical results,
including bone fill and clinical parameters.
Garrett, however, noted that further research is necessary to
evaluate GTR plus bone grafts and to compare the benefits of
each individually in treating intraosseous defects. Few histologic
studies have been done on combined procedures thus far,
however, Stahl and Froum did report evidence of limited
cementogenesis in two of four defects treated with both GTR and
DFDBA

and

osteogenesis.

associated
New

osseous

connective

remodeling
tissue

and

crestal

attachment

was

histologically detected in two of four calculus notches.

Combined Techniques
The combination of barrier techniques with bone grafts and other
methods has tMlen suggested and proce dures following these
ideas proposed by several au thors. The following technique has
been described by Schalihorn and McClain
1. Perform a regenerative type flap. If recession has occurred
and/or coronal flap positioning is required for membrane
coverage, periosteal__separation is performed.
2. The defect is debrided of all granulation tissue and the root
surface is planed to remove all remnants of plaque, accretions
and other root surface alterations (grooves, notches, caries)
employing ultrasonic! sonic, hand, and/or rotary instrumentation.
3. Odontoplasty and/or osteoplasty are performed if required for
adequate

access

to

the

defect
22

including

intraradicular

or

furcation

hindus

concavities

and/or

reduction

of

enamel

projections.
The bone graft (typically DFDBA)is prepared in a dap pen dish,
hydrating it with sterile saline or local anesthetic solution, and if
there is no contraindication, is combined with tetracycline (125
mg/O.25 g of DFDBA). After mixing, the dappen dish is covered
with a sterile, moistened gauze to prevent drying of the graft. .
5.The

area

is

thoroughly

cleansed

and

isolated,

and

the

regenerative site root surface is treated with cot ton pellets

soaked in citric acid pH 1 for 3 minutes, taking care that the
solution does not go beyond the root and bone surface. The
pellets are removed and the site inspected for any residual cotton
fibers prior to flushing the site with sterile water or saline.
6.If a sclerotic bone surface exists in the graft site, intra marrow
penetration is performed with a round but.
7.The ligament surface is scraped with a periodontal probe to
remove any eschar and stimulate bleeding.
8. The DFDBA is packed firmly in the defect using an overfill
approach, covering the root trunk and com bination or confluent
vertical dehiscence or horizon tal osseous defects.
9. The custom-fitted membrane is placed over the graft and
secured as appropriate.
10. The area is rechecked to ensure that adequate graft material
remains in the desired area, and the flap Is positioned to cover
the membrane and secured with nonabsorbable sutures.

23

11. A periodontal dressing is passively applied over the surgical

area, with Surgical covering the sutures.
Typical

pre-

and

postoperative

medication

regimens

include, if not contraindicated, 7 to 10 days of antibiotic

coverage, which is subsequently extended with doxycy dine, 100
mg

daily

for

to

weeks;

steroid

therapy

such

as

methyiprednisolone dosepak; and analgesic agents.

Sutures are removed if and when they become loose or no longer
aid in tissue position or wound closure. The patient is seen for
monitoring and local debridement as needed every 1 to 2 weeks.
If a nonresorbable membrane has been used, it is removed 6 to 8
weeks after the operation.
Several studies and case reports have shown excellent results
with the combined technique.
SUCCESSFUL OUTCOME
Factors adversely affecting outcomes were assessed in the 1996
world Workshop in Periodontics. These included the following:
inadequate plaque control
Poor compliance with supportive periodontal therapy
Smoking
Other factors such as flap design, defect and root
morphology, material employed, flap position, and post operative
management
Other factors possibly influencing outcomes but which lack
conclusive

evidence

at

this

time
24

include:

age,

systemic

conditions,

and

use

of

membranes

irs

patients

requiring

prophylactic medication.
Other reports have also attempted to delineate variables for
case/site selection and management. These included: therapist
considerations
(systemic

(training

conditions,

and

stress

experience),
level,

smoking

patient

factors

habits,

plaque

control, patient compliance, tissue response to presurgical

therapy,

and

tooth/defect

age),

defect

anatomy,

factors

space

(bone

maintenance

height,
of

access,

membranes

employed, and tooth stability), surgical considerations (flap

design/management,

root

preparation

biomodification,

regenerative

materials

control,

postsurgical

management,

etc.),

and

employed,
and

possible
infection
supportive

periodontal therapy after completion of active therapy.

Requirement for a successful graft

Patient selection

Material selection

Proper flap reflection and Wound stability

Revascularization

Root debridement

Post-surgical care

Keys to success in bone grafting

Patient selection medical/dental

25

Graft placement

Elimination of all etiologic factors

Soft tissue coverage

and

adaptation
Flap design

Suturing technique

Root preparation and removal of

Appropriate

granulation tissue

medication
Postoperative care

GROWTH

FACTORS,

CYTOKINES&

BONE

MORPHOGENETIC PROTIENES:
Investigators are currently studying the potential
therapeutic

effects

of

growth

factors

&

cytokines

for

regenaration of alveolar bone. Many of these factors stimulate

regeneration of bone & tissue & influence bone growth &
resorption. Thus may be of benefit in the regeneration process.
Bone

morphogenetic

proteins

are

osteoinductive

compounds that induce new bone formation at the site of

implantation ; growth factors & cytokines , in contrast, change
the growth rate of preexisting bone. Studies have shown that
growth factors & BMPs are responsible for normal remodelling ,
healing and repair of bone. Their potential as theraputic
modalities for dentoalveolar reconstruction has been studied.
In an experimentally fractured rabbit mandible , it was
shown that BMP and PDGF are released in to fracture gap
subsequent to the fracture. These findings suggest that these

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substances

act

as

transcription

factors

to

regulate

the

proliferation & differntiation of mesenchymal cells .

various annimal studies have been indicated that
recombinant

human

BMP-2

and

PDGFmay

have

excellent

theraputic potential in ridge augmentation and replacement of

lost alveolar bone .Determination of full potential of BMP will
require further clinical studies.
The early wound healing events of bone were studied
around press-fit titanium implants with and with out the
application of a combination of PDGF and insulin like growth
factors (IGF-1)An increased amount of bone fill was found in the
(PDGF,IGF-1 sites) with prolonged effects seen with larger bone
defects.
Biology of bone healing
Bone heals in a unique way compared with other connective
tissues. Rather than developing scar tissue, it has the ability to
regenerate itself completely. In fact, bone is constantly being
resorbed and remodeled a delicate balance coordinated by a
rather complex cascade of cellular events that researches are still
working to dissect.
The bone repair process begins with an inflammatory
response that prompts granulation tissue to profilerate in the
wound

site.

This

granulation

tissue

brings

in

capillaries,

fibroblasts, and osteoprogenitor cells.

Osteoblasts,

which

are

the

bone-producing

cells,

are

produced by the osteoprogenitor cells in the granulation tissue,

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and they begin to make the organic matrix of woven bone and to
initiate mineralization. This healing mass of new tissue is called
the callus, and it is an architecturally disorganized mass.
Over time, this woven bone is replaced by lamellar bone as bone
remodeling units invade the healing area. As this replacement is
proceeding, the new bone growth is also being modeled to form
an organized structure.
Osteogenesis, or the process of bone formation, begins with
either osteoblasts in the patients natural bone or from the
surviving cells in the bone graft that is placed. Through a gradual
healing process that begins with inflammation, bone grafts are
incorporated into the patients natural oral bone structure over
time. The process of bone formation in relation to various types
of grafts is discussed later.

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