|Year : 2016 | Volume
| Issue : 1 | Page : 27-33
Autogenous bone grafts in periodontal practice: A literature review
Nymphea Pandit, Inder Kumar Pandit
Department of Periodontics, DAV (C) Dental College and Hospital, Yamunanagar, Haryana, India
|Date of Web Publication||12-Feb-2016|
Dr. Nymphea Pandit
#9, Professor's Colony, Behind Telephone Exchange, Yamunanagar - 135 001, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
To improve the long-term prognosis of teeth, the treatment of periodontal diseases has evolved from resection to regeneration. Regeneration of the supporting structures of the teeth involves the use of a variety of materials of natural and synthetic origins. The ultimate aim of a true connective tissue attachment to the cementum, however, is difficult to achieve and a few of the materials have shown promising results. Autogenous bone graft obtained from the same individual has always been considered the gold standard because of its high osteogenic potential and virtually nil side effects. The present paper describes the use of autogenous grafts in the periodontal practice. The compilation of the data was done by PubMed search since the first use of the graft in periodontics.
Keywords: Autogenous graft, periodontics, regeneration
|How to cite this article:|
Pandit N, Pandit IK. Autogenous bone grafts in periodontal practice: A literature review. J Int Clin Dent Res Organ 2016;8:27-33
|How to cite this URL:|
Pandit N, Pandit IK. Autogenous bone grafts in periodontal practice: A literature review. J Int Clin Dent Res Organ [serial online] 2016 [cited 2019 Apr 18];8:27-33. Available from: http://www.jicdro.org/text.asp?2016/8/1/27/176247
| Introduction|| |
Increasing probing depths with the increasing severity of the periodontal disease has been consistently associated with the infrabony defects. Clinical studies have proven that residual pockets often persist after nonsurgical periodontal therapy or the use of access flaps, and resective techniques are associated with substantial loss of attachment and increases in soft tissue recession. Along with this, such techniques are characterized by repair (i.e., formation of long junctional epithelium) rather than regeneration (i.e., formation of root cementum with functionally oriented inserting periodontal ligament fibers connected to a new alveolar bone).
To achieve predictable periodontal regeneration, a plethora of different surgical techniques, often including implantation of various types of bone grafts and or substitutes, root surface demineralization, guided tissue regeneration, growth and differentiation factors, and enamel matrix proteins or various combinations thereof have been employed. Overall, the results demonstrated that flap surgery in conjunction with most of the biomaterials evaluated promoted periodontal regeneration to a greater extent than did flap surgery without biomaterials. 
Several types of bone grafts have been studied over the years, and periodontists continue to search for ideal materials. The two most common types of graft material used in periodontics today are autogenous and allogenic.
Autogenous grafts are considered the gold standard as they retain the viability of cells and do not evoke any immunological response in the patient. These grafts contain live osteoblasts and osteoprogenitor stem cells and heal by osteogenesis. They constitute all the three components for tissue engineering, namely, scaffold, cells, and signaling molecules as an additional benefit.
In the presence of adequate vascularization, osteoprogenitor cells (or preosteoblasts) proliferate and bridge the gap between the graft and the recipient bone. The preosteoblasts also generally form the first deposits of new bone. Transplanted osteocytes usually die in response to anoxia and the surgical injury. Transplanted osteoclasts, however, can survive transplantation and these may initiate the resorption of the graft.
The microanastomoses form and restore the circulation and are vital for the survival of osteoprogenitor cells and the formation of new products by the cells. New bone is formed initially by the surviving cells in the graft and later on by the osteoinduction of the cells of the surrounding host bone. The area of new bone interdigitation and the quantity of donor bone that is resorbed are higher for cancellous bone grafts compared with cortical grafts. 
Autogenous bone grafts have been used for a long time. Because of many limitations and crude methods of procurement of the graft, it was not one of the most preferred methods for regeneration of the periodontal osseous defects. It has gained popularity in recent times because of the development of better techniques and consequently lesser morbidity. This review includes the development of the graft and the search has included all the articles related with its use in the specialty of periodontics and oral implantology.
| Historical Background|| |
In 1923, Hegedus used autogenous tibial grafts for the reconstruction of the deficient alveolar ridges as a result of "pyorrhea alveolaris." In his report in "Dental Cosmos," he reported successful osteogenesis in the fourth week.  Until the 1960s, many reports suggested the use of autogenous bone but they were from a heterogeneous origin. As histological studies till this time were inconclusive, Linghorne in his detailed histological report proved autogenous grafts to be beneficial in bone repair in comparison to open flap debridement (OFD).  Burwell studied the origins and conditions of osteoblastic differentiation, and reported that a part of the material has to degenerate and the RNA released could induce the bone cells. 
Nabers, O'Leary and Robinson used bone chips, which according to them had to resorb completely before new bone formation could take place. 
Rivault et al. in 1971 laid down the requirements of successful grafting. They proposed that the bone graft should be completely covered by soft tissue flaps for adequate blood supply, the size of the graft particles should be less than 100 microns, it should be kept in contact with the host bone, and the irritation factors of the grafted area should be kept under control. 
Over a period of time, clinical experience and histological studies showed that autogenous cancellous bone with hematopoietic marrow  has the maximum osteogenic potential. Apart from this, autogenous bone has the least chance of host rejection and the porous consistency of cancellous bone increases the potential for rapid revascularization and subsequent graft survival. 
Schallhorn has used autogenous cancellous bone with hematopoietic marrow from the iliac crest in the treatment of periodontal osseous lesions.  Sullivan et al. reported a high incidence of root resorption and subsequent ankylosis in beagle dogs.  In a histological study of four cases, Dragoo and Sullivan reported external root resorption. The histological sections showed an association between inflammation and root resorption, which may be the result rather than the cause of resorption. The resorption of the root may be initiated by the resorption of sequestrated bone, or by fresh marrow, which contains many undifferentiated cells, or by proteolytic activity of polymorphonuclear leukocytes macrophages and other chronic inflammatory cells. 
Schallhorn et al. reported no ankylosis or root resorption with fresh intraoral donor material and with frozen iliac autografts or allografts. Root resorption was noted in two cases treated with nongraft methods and in 16 of the 275 sites treated with fresh iliac autograft material. 
Hiatt and Schallhorn in 166 transplants from tuberosity reported an average fill of 3.44 mm, which compares favorably with iliac autografts. 
Froum et al. in 1975 reported a 73% fill with osseous coagulum and 60.7% fill with hip marrow in a study conducted on 23 patients having 32 defects, which depended on the available osseous surface rather than the number of walls of the defect.  In 1976, in a study by the same author, autogenous graft was found to be consistently better than the open flap debridement.  A histological study by Moskow et al. found the downgrowth of the epithelium and no new cementum formation and concluded that bone grafting did not necessarily lead to periodontal regeneration [Table 1]. 
| Sources of Autogenous Grafts|| |
Autogenous bone can be harvested from intraoral donor sites (mandibular symphysis and ramus, maxillary tuberosity, edentulous areas, tori) or extraoral sites (iliac crest, tibia, calvaria).  Although the iliac crest is one of the most preferred sites, it is not always recommended due to its associated problems such as postoperative infection, exfoliation and sequestration, varying rates of healing, root resorption, and rapid recurrence of defects. In addition to patient expense, patient morbidity, altered ambulation, difficulty in procuring the donor material, and need for hospitilization were the limiting factors. ,
These disadvantages, along with the fact that the alveolar defects do not demand large amounts of bone, led to the growing use of intraoral grafts. The intraoral donor sites also have the benefit of conventional surgical access, proximity of donor and recipient sites, which reduces operative time and anesthesia time, discomfort to patients, and less morbidity compared to extraoral location, making it ideal for outpatient periodontal surgery.
Although a number of donor sites have been described, there is no clear preference indicated in the literature for any specific donor site.
| Types of Autogenous Bone Graft|| |
There are several types of autogenous bone grafts that have been or are being used clinically. They include bone chips, osseous coagulum, bone blend intraoral, and extraoral cancellous bone and marrow.
| Cortical Bone Graft|| |
Autogenous cortical bone graft, which provides an osteoconductive medium with minimal osteoinductive and osteogenic properties, is best suited for structural defects for which immediate mechanical stability is required for healing. The dense cortical matrix results in relatively slow revascularization and incorporation, as resorption must occur before the deposition of new bone, and limited perfusion and donor osteocytes make this option poorly osteogenic. ,
For periodontal defects, Nabers and O' Leary (1965) have reported a coronal increase in bone height by using cortical bone chips, removed by hand chisels during osteoplasty and ostectomy. Cortical bone chips due to their relatively large particle size 1,559.6 × 183 um and potential for sequestration were replaced by autogenous osseous coagulum and bone blend.  The literature indicated a broad range when considering the influence of particle size for autologous bone grafts. Values from 125 μm up to 2 mm were reported as preferable. A critical minimum value was reported stating that particles less than 75-125 μm are rapidly resorbed, and do not participate in effective osteogenesis.
| Cancellous Bone Graft|| |
Cancellous bone graft is the most commonly used source of autogenous graft. It provides an osteoinductive, osteoconductive, and osteogenic substrate, and the porous trabeculae are lined with functional osteoblasts, resulting in a graft that is highly osteogenic.
After implantation, a portion of the donor osteocytes survives, and these osteocytes, combined with graft porosity and local cytokines, promote angiogenesis and host mesenchymal stem cell recruitment. 
| Corticocancellous Bone Graft|| |
Corticocancellous bone grafts intuitively offer the advantages of both cortical bone and cancellous bone: An osteoconductive medium and immediate structural stability from cortical bone, and the osteoinductive and osteogenic capabilities of cancellous bone.
| Intraoral Cancellous Bone and Marrow|| |
Intraoral cancellous bone and marrow can be obtained from healing extraction sockets, mandibular retromolar areas, and maxillary tuberosity areas. A mean bone fill of 3.65 mm and >50% bone fill has been obtained on a predictable basis. 
| Extraoral Cancellous Bone and Marrow|| |
This material is obtained from either the anterior or the posterior iliac crest predictable bone growth ranging 3.53-4.36 mm and even complete eradication of furcation involvement and interdental craters have been reported by various authors. ,,,
| Osseous Coagulum and Bone Blend|| |
Intraoral bone, when obtained with high or low speed round burs and mixed with blood becomes a coagulum. ,, It was subsequently demonstrated in monkeys that small bone particles of 100 um could provide an earlier and greater osteogenic activity than particles 10 times as large. 
The bone blend technique was designed to overcome some of the disadvantages of osseous coagulum including inability to aspirate during the collection process and unknown quality and fluidity of the material. Bone blend is cortical or cancellous bone that is procured with a trephine or rongeurs, placed in an amalgam capsule and triturated to the consistency of a slushy osseous mass. The resultant particle size is in the range of 210 × 105 um.  Froum et al. reported that the osseous coagulum bone blend type of grafts provided 2.98 mm coronal growth of the alveolar bone, compared with 0.66 mm obtained when open flap debridement alone was used. ,,
| Block Grafts|| |
Bone blocks have the inherent advantage of stability and resistance to deformation. They can be used for the horizontal augmentation of alveolar bone defects for periodontal regeneration as well as reconstruction of the alveolar bone for implants and as a preprosthetic surgery for jaw reconstruction. Alveolar ridge augmentation is a necessity in many cases, which present in clinical practice to facilitate adequate bone volume for implant placement. The stabilization and intimate contact of these block grafts to the recipient bed have been considered crucial to a successful outcome. This can be achieved with the use of bone fixation screws or the simultaneous placement of dental implant. Aggressive recipient bed preparation with decortication, intramarrow penetration, and inlay shaping also has been supported because of increases in the rate of revascularization, the availability of osteoprogenitor cells, and the increased rate of remodeling. The healing of autogenous block grafts has been described as "creeping substitution" where viable bone replaces the necrotic bone within the graft, and is highly dependent on graft angiogenesis and revascularization.
Block grafts are harvested as corticocancellous or cortical bone autografts. The revascularization of corticocancellous block grafts takes place at a much faster rate than in cortical bone autografts and at a slower rate than particulate autografts. Revascularization of block grafts enables the maintenance of their vitality and hence, reduces chances of graft infection and necrosis. ,
Autogenous bone block can be harvested from the mandibular symphysis,  ramus, or external oblique ridge, and in areas beyond the root apices. It can be procured either by bone mill or by osteotomy procedures. However, cell viability seems to be significantly influenced by the harvesting technique. Conventional osteotomy or milling procedures have some limitations such as overheating of bone when contaminations of bone, which lead to possible structural bone changes and toxic effects on living cells. In order to overcome some of these problems, a newly developed piezoelectric device has been used for harvesting the autogenous bone block. Piezoelectric bone surgical technique has an advantage of low surgical trauma, exceptional control during surgery, and fast-healing response of tissues.
Although autogenous bone grafts (as block or particulate form) remain the gold standard for ridge augmentation, donor site morbidity associated with block graft harvest has turned attention to the use of allogenic block graft materials. 
| Techniques and Devices of Procurement of Autogenous Bone Grafts|| |
Many techniques and devices are available to harvest intraoral autogenous bone grafts such as bone scraper, rotary instruments, bone chisels, rongeur pliers, and piezoelectric devices. Berengo et al. (2006) found 100% of nonvital bone cells in bone grafts harvested with the bone scraper.  But at the same time, these findings differ from another histological study of Zaffe and D'Avenia (2007)  where the bone scraper was used and a mean bone viability between 45% and 72% was obtained. Therefore, it remains unclear to what extent particle size and device used can influence the viability of bone cells after harvesting. However, the bone quality of the patient seems to be an important factor, as some studies reported a higher percentages of bone cells when the trabecular bone was harvested (Zerbo et al., 2003; Springer et al., 2004). , These results differ from the histomorphometrical results obtained by Berengo et al. (2006)  and Guillaume et al. (2009)  where they found high percentages of vital bone when block grafts were harvested. However, another study by Zerbo et al. (2003)  evaluated the survival of osteocytes and graft viability after ramus bone block regeneration. They reported that after a healing time of 7 months, 11.1% of nonvital bone was present and that the majority of the osteocytes did not survive the grafting procedure. Recent investigations have reported that osteocytes are involved in sensing mechanical stimuli inside the lacunar-canalicular system (Weinbaum et al., 1994; Klein-Nulend et al., 1995; Guillaum et al., 2009). ,, Therefore, certain forces or vibrations, such as the ones provoked by certain devices or instruments during harvesting, can induce osteocytes to undergo apoptosis or necrosis. The results of many studies have shown that none of the intraoral harvesting methods used (piezoelectric device, rotary instrumentation, and bone scraper) could get viable bone cells after the extraction of bone particles, and higher percentages of apoptosis were found in all samples. Moreover, when cortical bone block was harvested, bone cells also underwent the processes of apoptosis and necrosis. It has minimal morbidity, and is preferred by patients over the conventional high-speed hand piece. Studies are needed to better understand the bone-healing process in grafting procedures. 
| Recommendations|| |
A controversy remains as to whether cortical or spongy bone is the material of choice for autologous bone grafts (Girdler and Hosseini 1992; Schwipper et al. 1997). , Large defects undoubtedly require great amounts of bone that can only be harvested from extraoral donor sites such as the iliac crest (Jin et al. 2004; Kinsel and Turbow 2004; Turunen et al. 2004) ,, and tibia (Jakse et al. 2001; Mazock et al. 2004). , Smaller defects can be treated with limited bone volumes that can be harvested intraorally, also exploiting lower resorption (Smith and Abramson 1974; Zins and Whitaker 1983; Borstlap et al. 1990), ,, enhanced vascularization (Zins and Whitaker 1983),  and better incorporation (Borstlap et al. 1990  ) of bone grafts of membranous origin as compared with endochondral origin. Bone harvesting and treatment may suffer from microbial contamination (Young et al. 2001, 2002a).  Once the bone graft has been procured, it should be transplanted rapidly into the patient. Salivary contamination should be avoided and the recipient site should be appropriately managed. The longer the bone remains exposed to air, the lower the number of viable osteogenic cells that will actually be transplanted with the graft.
| Autogenous Bone Grafts and Dental Implants|| |
Extraction is the most common trauma that results in alveolar bone loss due to atrophy of edentulous alveolar process. In many circumstances, this is a limiting factor to rehabilitation with dental implants due to insufficient bone volume and may be indicated the use of grafts (Pappalardo et al., 2007). 
The success rate of implants placed in onlay graft regenerated ridges ranges 72,8-97% after follow-up periods ranging from 6 months to 10 years, with all the studies but two, reporting a success rate higher than 84% (range 84-97%). The lowest annual failure rate (0.1%) of rough surface implants was observed using autogenous particulated bone graft.
The success rate of implants placed in regenerated areas is very similar to those obtained in case of implants placed in the pristine bone, and suggests that onlay graft augmentation is a quite predictable technique to allow the placement of implants in severely atrophic areas. ,
| Autogenous Bone and Sinus Lift|| |
The maxillary bone atrophy is usually caused by loss of teeth, infections, trauma, tumor resections, and/or developmental abnormalities. Such lesions, apart from not repairing themselves spontaneously, are enhanced by the absence of stimuli, affecting the form and function of the skull (Fontana et al., 2008).  The loss of teeth causes the narrowing of alveolar bone crest width, loss of height, and reduction of cancellous bone. Thus, stimuli that maintain the morphology of the alveolar bone are lost with the teeth absence. 
The posterior region of the maxilla is a difficult area for the installation and maintenance of implants.  Thus, the use of dental implants in this region is a challenge in fixed implant-supported rehabilitation due to pneumatization of the maxillary sinus, inadequate morphology of the alveolar bone crest, and poor bony quality (Haas et al., 2003). 
Rickert et al. found a significantly higher fraction of the autogenous bone group compared to the sole use of β-tricalcium phosphate. The 1-year overall implant survival rate showed no significant difference between implants. Bone substitutes, combined with autogenous bone, provide a reliable alternative for autogenous bone as sole grafting material to reconstruct maxillary sinus bony deficiencies for supporting dental implants after 5 months. Adding growth factors (platelet-rich plasma) to grafting material and the sole use of β-tricalcium phosphate did not promote bone formation. 
Studies have shown that bone grafting with Bio-Oss or Cerasorb may be as effective as autogenous grafts for sinus floor augmentation procedures. 
| Regenerative Effect of Autogenous Bone|| |
A recent review of the effectiveness of autogenous grafts related to the true regeneration has provided mixed results. Of the 10 studies evaluated, five of the studies reported complete regeneration of the periodontal tissues (i.e., the entire defect), three studies noticed a long junctional epithelium coronally and periodontal regeneration apically and two studies observed only long junctional epithelium and osseous repair. Autograft particles were not fully replaced in six studies and were encapsulated in the bone or connective tissue in five studies depending on the healing observation period, graft source, and type of healing. Fifty percent of studies revealed complete defect resolution, and no remarkable inflammation was described. Only two of the 10 studies provided histomorphometric data and included a total of 10 defects; in 80% of the defects, partial or complete regeneration was observed. The main defect fill was 3.0 mm, and both the cementum and bone formation were 1.9 mm when calculated in a linear manner along the root surface. 
| Conclusion|| |
Although a plethora of materials are available for the regeneration of bone, autogenous bone graft remains one of the most frequently used modalities for not only the regeneration of osseous defects but also foe ridge augmentation and sinus floor lift in the discipline of periodontics and implant dentistry. Various techniques and types of the graft can be used depending on the availability and indications.
| Future Directions|| |
Randomized well-controlled studies should be conducted to determine the true potential of the graft and newer equipment can be developed for easier and better procurement of the material from the donor sites.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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| Authors|| |
Dr. Nymphea Pandit, a 1993 graduate from S.C.B Medical College Cuttack completed her M.D.S. in Periodontics (1998) from Government Dental College Ahmedabad. She has received the Best Graduate Award for Excellent Performance in the Four years of Graduate Programme by ICDRO in the year1993. She is also the recipient of Colgate Palmolive Award for highest marks in the subject of periodontology and ISPPD award for highest marks in the subject of Pedodontics and Preventive Dentistry. She is presently working as the Professor & Head, Department of Periodontology, D.A.V Dental College and Hospital Yamunanagar. She has 10 international and 20 national publications and has been a keynote speaker at more than 30 foras at national and State levels. She has authored a book titled " Concise Periodontics" . She is an EC Member of Indian Society of Periodontology and in the Editorial Board of the Journal of Indian Society of Periodontology and many other National Journals. She has been at different posts in the IDA yamunanagar Branch including President in the year 2012. She has been cited in the Marquis Who's Who in the World (2011).