Defectos Óseos - Diagnóstico Radiográfico"

Presented by:
Dr. Sapna K Vadera

(P.G. Student)
Guided by:
Dr. S.R.Shenoi
(Prof, Guide and H.O.D)
Dept Of Oral and Maxillofacial Surgery VSPM’S Dental College, Nagpur

Contents
• Definition
• Introduction
• What is a bone graft?
• History of bone graft
• Uses of bone graft
• Principles of bone grafting
• Risk factors for bone grafting
• Mechanism of bone regeneration and augmentation
• Types of bone grafts
• Sinus lift surgery
• Conclusion
• References
Definition...
Graft-
“is a piece of living tissue, organ etc transplanted
surgically”
-Oxford Dictionary.
“any tissue or organ for implantation or transplantation”

- Dorland’s Medical Dictionary 27th edition.
Definition...
• Graft is a tissue that is detached from its own blood
supply and is placed in a new area (recipient site) with
a new blood supply i.e it does not maintain its original
blood supply.
• Flap is a tissue used for reconstruction or wound

closure that retains all or part of its original blood
supply after the tissue has been moved to the
recipient site i.e it maintains original blood supply.
Craig M. Misch,autogenous bone grafting for dental implants, Raymond J Fonseca; Oral
and maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
Introduction
Bone, which has been lost as a result of excision,

Forresorption
Bone agrafts or sequesterization,
successful
have regeneration,
been employed bonewill not
forgraft repair
when
repair by
forapplied
more
should
than heal,normal
a hundred become process
years.It of healing.
incorporated,
is a dynamic revascularise
process and and
is
eventually
extensively usedassume the desired form.
in reconstructive surgery.
So they are to be replaced by means of alloplast, bone

grafts or its substitutes.
Kiokkevold R Perry , Localized bone augmentation and implant site development; Newman
Michael et al, Carranza’s Clinical Periodontology,12th edition: 2015; saunders an imprint of
elsevier inc.
Introduction
To satisfy the ideal goals of implant dentistry, the hard and

soft tissues need to present ideal volumes and quality.
Because of an improved understanding of biomechanics,
requirements for long term prosthesis survival and the
increasing use of implants in esthetic restorations, ridge
Thereconstruction before
alveolar process implantso
is affected placement hastooth
often after become
loss,a
necessary procedure
augmentation for aindicated
is usually number ofto edentulous patients.
achieve optimum
results.
Kiokkevold R Perry , Localized bone augmentation and implant site development; Newman
Michael et al, Carranza’s Clinical Periodontology,12th edition: 2015; saunders an imprint of
elsevier inc.
What is a Bone Graft???
History of bone graft
• The earliest known repair of cranial and facial defects is by
use of alloplast. Neolithic Peruvians used hammered gold
and silver plates over frontal bone defect.
• In 1889,Seydel was first surgeon to use autogenous bone

graft in facial region. He used autogenous bone from tibia.
• In 1978 & 1982 ,Bradley reported a two-stage procedure for

reimplantation of ‘autogenous freeze treated mandibular
bone.
Craig M. Misch,autogenous bone grafting for dental implants, Raymond Fonseca; Oral and
maxillofacial surgery;2nd edition:2009;saunders an imprint of elsevier inc.
• In 1989,McCarthy first applied the principle of distraction in
maxillofacial region.
• In 2008, R. Gutta and P.D. Waite described an extraoral

approach for cranial bone grafting with simultaneous implant
placement to the atrophic mandible.
• In 2010,Amrani et al. evaluated the utility of autogenous

extended mandibular ramus and coronoid process bone
grafts for maxillofacial reconstructive surgery.
• In 2013,Kolerman et al. conducted a study to evaluate the
regenerative potential of a fully synthesized homogenous
hydroxyapatite β-tricalcium phosphate alloplast material in
sinus lift procedures.
Uses of Bone graft
To repair
encourage
restore
improve congenital
continuity
reconstruct
fill
augment facial
cavities healing
contour
alveolar defects.
of
ofcyst
following bone
non
forenucleation.
posttraumatic
bone. united
cosmetic
following
fractures.
deformity. purpose.
tumour excision.
Garg K Arun, Bone biology, Osseointegration, and Bone grafting, Implant Dentistry; 2nd
edition: 2010; an affiliate of elsevier inc.
Principles of Bone grafting
• Harvest bone from areas familiar.
• Contour bone graft to fit the defect.
• Fix the bone graft to the defect in a tension free manner.
• Ensure absolute immobilisation.
Principles of Bone grafting
• Avoid contaminated sites.
• Do not have graft exposed.
• Ensure adequate blood supply to the graft.
• Assess “graft take” periodically.
Risk factors for Bone grafting
Mechanisms of bone
regeneration and augmentation
• Osteogenesis
• Osteoinduction
• Osteoconduction
Osteogenesis
• Osteogenesis refers to thefrom
New bone is regenerated growth
of bone
endosteal from viable andcells
osteoblasts
transferred
marrow stem within
cellsthetransferred
graft.
with the graft.
Osteogenesis
Examples-
• Autografts
Osteoinduction
•• Osteoinduction
Capable of involves
inducingnewbone
bone
formation
formationin from
a non-bony
osteoprogenitor
site by
recruiting
cells derived
and inducing(pluripotent)
from primitive
cells
mesenchymal
to become osteoblasts
cells under the
influence of one or more inducing
agents that arise from the bone
matrix.
Osteoinduction
• The most commonly used
osteoinductive materials in
implant dentistry are bone
allografts and autografts.
• Frozen bone
• Freeze – Dried (FDBAs) and
• Demineralized freeze – Dried
(DFDBAs)
Osteoconduction
• Osteoconduction characterizes bone
growth by apposition from the surrounding
bone.
• Biocompatible material that provides a

physical structure into and along which
bone may grow
Osteoconduction
• The most common osteo-

conductive bone grafting
materials used in implant
dentistry are alloplasts and
xenografts.
Types of Bone grafts
Bone grafts can be classified:
1. Based on nature of bone (Graft anatomy).

2. Based on source of donor.
3. Based on form of grafts.
4. Based on grafting techniques.
5. Based on donor site.
Craig M. Misch Maxillary Autogenous Bone Grafting Oral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2 (May 2011) - Copyright © 2011 Saunders, An Imprint of Elsevier.
• Nature of the bone:
3.
2. Cortico-cancellous
Cancellous
1. Cortical
• Source of the donor:
1. Autogenous bone graft

2. Allograft
3. Isogenic bone graft
4. Xenografts
5. Composite grafts
6. Alloplastic materials (synthetic).
Characteristics:
• Historical standard of bone

grafting.
• ‘Gold Standard’
• Mechanisms:
- osteoconduction,
- osteoinduction, and
- osteogenesis
Considerations:
• Time of overall surgical procedure
• Second site surgery to procure

autograft
• Limited quantity of 50-55 cc
Complications:
• Infection
Blood loss
•• Fracture
Hematoma andand
pelvic instability
arterial injury
• Cosmetic defects
• Nerve injury and numbness
• Chronic pain at donor site
• Hernia formation
Proposed Mechanism of Action:
Presence of osteoblasts provides direct osteogenesis,

presence of growth factors permits osteoinduction,
bone tissue allows osteoconduction.
2. Allograft
• Characteristics
• Cortical allografts may provide

structural support and may be
immediately load bearing.
• Various geometric and shapeable

forms.
2. Allograft
ADVANTAGES:
• It reduces additional surgery and the

resultant morbidity.
• Operating time is reduced.
• All the bone required is readily

available
2. Allograft
DISADVANTAGES:
• Graft rejection
Chances due to
for disease immune
transmission.
reaction.
• Difficult storage of graft.
• Reputed tissue bank required.
• Loss of viable osteo-progenitor

cells.
2. Allograft
Primarily acts through osteoconduction. Cancellous

allograft may have some osteoinductive potential but it will
vary depending on the source and how it was processed and
sterilized.
A. Allograft Sub-set
Cortical bone with mineral removed (via

acid extraction) leaving collagenous and
non-collagenous proteins with a low
concentration of growth factors.
Characteristics:
• Contains type I collagen,non-collagenous proteins,and a

low concentration of growth factors (BMP) which may
impart osteoinductivity.

Primarily acts through osteoconduction.
Studies reports that the presence of growth factors

(e.g. BMP) imparts osteoinductivity.
B. Growth Factor Based
Growth factors bind to receptors

on cell surfaces stimulating the
formation of proteins to be used
inside the cell or externally (e.g.
formation of extracellular
matrices like bone tissue)
Bone MorphogeneticProteins (BMPs)
(aka recombinant human bone
morphogenetic protein or rhBMP)
Fibroblast Growth Platelet Derived Growth

Factor (FGF) Factor (PDGF)
Growth
Factors
Insulin-Like
Transforming Growth Growth Factor 1 & 2
Factor Beta (IGF-1), (IGF 2)
(TGF-β)
Considerations:
• Most common complications include osteolysis,

swelling/ edema, heterotopic bone formation, and
antibody reaction.
Acts via osteoinduction.

BMP binds to mesenchymal stem cell receptors resulting
in proliferation and differentiation into osteoblasts.
C. Cellular Based:
PRP
Platelet Rich Plasma (PRP) is obtained by fractioning

whole autologous blood by centrifugation
C. Cellular Based:
PRP
Characteristics:
• PRP contains PDGF, EGF,
and FGF-2 which stimulate
proliferation of osteoblast
progenitors.
• Also contains TGF-β which
increases type I collagen
synthesis.
C. Cellular Based:
PRP
Considerations:
• Outcome is donor dependent and varies with preparation

technique.
• Proteases present in the platelet fraction may degrade

some of the growth factors.
C. Cellular Based:
PRP
Platelet gels provide a rich source of growth factors

that direct mechanisms involved in bone healing and
subsequent osteogenesis.
3. Alloplastic materials
Alloplastic material:
A. Ceramic based
B. collagen based
3. Alloplastic materials
CERAMICS COLLAGEN BASED MATERIAL
• Calcium Sulfate • Typically composites

• Calcium Phosphate with ceramic materials.
• Synthetic Hydroxyapatite
• Tricalcium Phosphate (TCP)
A.Ceramic Based
Characteristics:
• Osteoconductive
• Can be used in the presence of infection
• Resorption (5-7 week period)
A.Ceramic Based
Considerations:
• Mechanical properties variable, due to high dissolution
rate.
• Implantation should be limited to confined defects.
• Calcium sulfate – complications associated with

inflammatory reactions.
A.Ceramic Based
Calcium sulfate serves as an osteoconductive matrix for

the ingrowth of osteogenic cells.
B.Collagen Based
Characteristics:
• Collagen is the most abundant

protein found in bone tissue
• Osteoconductive matrix with a

favourable physical and
chemical matrix for bone
regeneration
B.Collagen Based
Considerations:
• Weak structural and mechanical properties

• Collagen is usually coupled with other bone
substitutes (HA, β-TCP, bone marrow, etc.)
B.Collagen Based
• Primarily acts through osteoconduction and/ or via

mechanisms from the component that is added to
it.
• Form of graft:
1. Bone blocks
2. Particulate bone
3. Bone slurry
4. Bone paste
1.Bone Blocks
2. Particulate Bone
3.Bone Slurry
4.Bone Paste
• The Grafting technique:
Clothes
Dowel
Onlay
Inlay
Strut pin
grafts
(H grafts)
grafts
grafts
• Donor site:
• Intra oral sites

• Extra oral sites.
Intra oral
Patrick J. Louis, Bone Grafting the MandibleOral and Maxillofacial Surgery Clinics of North
America;Volume 23,Issue 2 (May 2011).Copyright © 2011 Saunders, An Imprint of Elsevier.
Extra oral
DONOR SITE MAXIMUM VOLUME
Posterior iliac crest 140 ml
Anterior iliac crest 70 ml
Tibia 20-40 ml
Cranium 40 ml
Ascending ramus 5-10 ml
Mandibular symphysis 5 ml
Maxillary tuberosity 2 ml
The main donor sites are:
1. Mandibular Symphysis
2. Mandibular Ramus
3. Maxillary Tuberosity
The miscellaneous sites are:
1. Residual ridge crest area

2. Canine eminence areas
3. Lateral to the nasal spine
4. Maxillary and mandibular tori and exostosis
5. Particulate bone from implant drills and screw taps.
Mandibular Symphysis
Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial Surgery Clinics of North
Advantages-
• Easy access
• Corticocancellous block
morphology
• More cancellous bone than any other intra oral sites.
Contraindication-
• Mandible with longer anterior teeth
• Inadequate mandibular height or width
• Gross vertical bone loss
• Width augmentation spanning more than four teeth.
Complications-
• Damaged submental and sublingual arteries
• Damage to mandibular tooth roots
• Mental nerve paresthesia
• Temporary altered sensation of lower lip
• Chin ptosis
Mandibular Ramus
Mandibular Ramus
Mandibular Ramus
Mandibular Ramus
Complications-
• Potential damage to inferior

alveolar nerve
• Limitation of size and shape of graft
• Postoperative trismus
• Potential damage to lingual nerve during flap incision
Coronoid Process
Coronoid Process
Coronoid Process
Advantages
• No facial scarring or damage
to teeth.
• Harvesting the bone is relatively
easy.
Complications
• Trismus
• Damage to the buccal branch of the trigeminal nerve.
Maxillary Tuberosity
Kahnberg Karl-Erik, Bone Grafting Techniques for Maxillary Implants, 1st edition:
2005;Blackwell Munksgaard, a Blackwell Publishing company.
Maxillary Tuberosity
Complications –
• Oroantral fistula
• Hematoma formation
from disruption pterygoid
venous plexus.
Kahnberg Karl-Erik, Bone Grafting Techniques for Maxillary Implants, 1st edition:
2005;Blackwell Munksgaard, a Blackwell Publishing company.
Extra Oral Donor Bone Grafts
The Preferred extra-oral donor sites of
autogenous bone include:
1. Tibia
2. Cranium and
3. The iliac crest
4. At a lesser degree rib and fibula
Cranial Bone
Cranial Bone
Cranial Bone
Advantages –
• Slow resorption
• High stability for osteo
integration
• Low morbidity at donor site
• Easy screw fixation
• Harvesting of large grafts
Cranial Bone
Complications-
• Surgical wound infection

• Dural injuries
• Transitory neurological defects
• Epidural hematoma
• Alopecia
Tibia
Tibia
Advantages-
• Minimal
20 to 40postoperative pain and dysfunction.
cu.cm of noncompressed cancellous bone can
• Immediate postoperative
be harvested weightspace.
from the marrow
•• Blood loss is straightforward
Procedure minimal
• Drainage is not required.
• Less surgical time 20-40mins
Tibia
Contraindication-
• Patients younger than 18 years

• Patients with knee injury or knee surgery
• Patients with advanced rheumatoid or degenerative
arthritis
• Patients with metabolic bone disease
Tibia
Complications-
• Potential entrance into joint space

• Post operative edema
• Large/unsightly scar
• Gait disturbance
• Fracture
Iliac Crest
Iliac Crest
Advantages
• excellent source of large segments of cortico-cancellous

grafts or pure cortical or cancellous grafts.
• Sculptured segments can be used for onlay,
interposition or construction in craniomaxillofacial
surgery.
• Iliac cortico cancellous grafts are easily incorporated
into rigid fixation plates and provide immediate
mechanical strength.
Iliac Crest
Complications
• Cosmetic deformity
Perforation of the bowel
•• Injury
Herniato sensory nerves-iliohypogastric nerve,
lateral femoral cutaneous nerve
• Gait disturbance-damage to gluteus medius or
• Fractures
gluteus maximus muscle
Rib
Rib
Advantages-
• Can be harvested in length of 10 to 15cm and then split to
double the surface area of the graft.
• Cortico-cancellous ribs are quite malleable and are easily
fashioned for use in the curved contours of cranio-facial
skeleton.
• Rib regenerate from the ends if the periosteal sheath is
preserved.
Rib
Disadvantages-
• The regenerated bone from the rib is never the same

quality as the original rib.
• Potential for pneumothorax, chest wall depression,
persistent pleuritic pain with exercise.
• The cortices are thinner. So incorporation of implants
are not successful.
• It has minimal cancellous bone
Sinus Lift Procedure Using
Bone Graft
Conclusion
Small
Intra
Moderate
Thereconstruction
oral
Diagnosis,
Choice ofautogenous
Patientstreatment
graft
predictable
to largeshould
should with
bone
be high ofosteogenic
grafts
planning,
according
reconstructions
outcome
be informed and
careful
in to
these
about potential
allografts
execution
osteogenic
defects
procedures
possible (FDBA)
of low is
of to
the
usually
are
moderate done
used
surgical
complications
depends with
in
osteogenic alloplasts
small
ontreatment,
potential the
several defects
ofassociated
site and
potential
biologiclike
withtheanorganic
with
postoperative lowharvest
type
principles
are
bone of
treated bovine
tothat
moderate
follow-up,
defect.
with
must bone
and
asextra
wellbeoral
as
appropriate
autogenous
complications&implant
bonemicroporous
osteogenic
that loading
grafts-iliac
may hydroxyapetite
potential.
followed.are all
develop
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theandgraftedfactors
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site.
achieving success.
Craig M. Misch Maxillary Autogenous Bone GraftingOral and Maxillofacial Surgery Clinics of North
America - Volume 23, Issue 2(May 2011) - Copyright © 2011 Saunders, An Imprint of Elsevier.
References
• Craig M. Misch,autogenous bone grafting for dental implants,
Raymond J Fonseca; Oral and maxillofacial surgery;2nd
edition:2009;saunders an imprint of elsevier inc.
• Kiokkevold R Perry , Localized bone augmentation and implant

site development;Newman Michael et al, Carranza’s Clinical
Periodontology,12th edition:2015;saunders an imprint of
elsevier inc.
• Garg K Arun, Bone biology, Osseointegration, and Bone

grafting, Implant Dentistry;2nd edition:2010; an affiliate of
elsevier inc.
References
• Kahnberg Karl-Erik, Bone Grafting Techniques for Maxillary
Implants, 1st edition:2005;Blackwell Munksgaard, a Blackwell
Publishing company.
• Patrick J. Louis, Bone Grafting the Mandible Oral and Maxillofacial

Surgery Clinics of North America - Volume 23, Issue 2 (May 2011) -
Copyright © 2011 Saunders, An Imprint of Elsevier.
• Craig M. Misch Maxillary Autogenous Bone Grafting Oral and

Maxillofacial Surgery Clinics of North America - Volume 23, Issue
2(May 2011) - Copyright © 2011 Saunders, An Imprint of Elsevier.
Thank You......

Defectos Óseos - Diagnóstico Radiográfico"

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Presented by:

Dr. Sapna K Vadera

Dept Of Oral and Maxillofacial Surgery VSPM’S Dental College, Nagpur

“any tissue or organ for implantation or transplantation”

• Flap is a tissue used for reconstruction or wound

Bone, which has been lost as a result of excision,

So they are to be replaced by means of alloplast, bone

To satisfy the ideal goals of implant dentistry, the hard and

• In 1889,Seydel was first surgeon to use autogenous bone

• In 1978 & 1982 ,Bradley reported a two-stage procedure for

• In 2008, R. Gutta and P.D. Waite described an extraoral

• In 2010,Amrani et al. evaluated the utility of autogenous

• Harvest bone from areas familiar.

• Contour bone graft to fit the defect.

• Fix the bone graft to the defect in a tension free manner.

• Ensure absolute immobilisation.

• Do not have graft exposed.

• Ensure adequate blood supply to the graft.

• Assess “graft take” periodically.

with the graft.

• Biocompatible material that provides a

• The most common osteo-

1. Based on nature of bone (Graft anatomy).

1. Autogenous bone graft

• Historical standard of bone

• Time of overall surgical procedure

• Second site surgery to procure

• Limited quantity of 50-55 cc

Presence of osteoblasts provides direct osteogenesis,

• Cortical allografts may provide

• Various geometric and shapeable

• It reduces additional surgery and the

• Operating time is reduced.

• All the bone required is readily

• Loss of viable osteo-progenitor

Proposed Mechanism of Action:

Primarily acts through osteoconduction. Cancellous

Cortical bone with mineral removed (via

• Contains type I collagen,non-collagenous proteins,and a

Proposed Mechanism of Action:

Studies reports that the presence of growth factors

Growth factors bind to receptors

Fibroblast Growth Platelet Derived Growth

• Most common complications include osteolysis,

Acts via osteoinduction.

Platelet Rich Plasma (PRP) is obtained by fractioning

• Outcome is donor dependent and varies with preparation

• Proteases present in the platelet fraction may degrade

Platelet gels provide a rich source of growth factors

• Calcium Sulfate • Typically composites

• Implantation should be limited to confined defects.

• Calcium sulfate – complications associated with

Proposed Mechanism of Action:

Calcium sulfate serves as an osteoconductive matrix for

• Collagen is the most abundant

• Osteoconductive matrix with a

• Weak structural and mechanical properties

• Primarily acts through osteoconduction and/ or via

• Intra oral sites

Posterior iliac crest 140 ml

Anterior iliac crest 70 ml

Ascending ramus 5-10 ml

1. Residual ridge crest area