Dental Bone Graft types and materials

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Types of bone grafts in dentistry

The primary aim of using a bone graft in dentistry is to improve the quality or quantity of the alveolar bone where tooth replacement is anticipated. Additionally, bone grafts can be used during surgeries where large portions of jaws are amputated during the removal of large lesions. 

Four main types of dental bone grafts, according to application, include:

1. Ridge Augmentation Graft: When a tooth is lost, the alveolar bone in that region undergoes resorption and becomes thinner than before. Ridge augmentation increases the width and volume of the jawbone, providing a stable foundation for implants or other restorative options.
2. Socket Preservation Graft: After tooth extraction, the remaining tooth socket consists of bone and soft tissues. Due to different healing rates of hard and soft tissue, soft tissues may fill the socket instead of bone, causing issues when tooth replacement is needed. A bone graft can be placed in the socket immediately after tooth extraction to help heal the bone properly and prevent the socket’s sides from caving in. This type of graft is also called a ridge preservation graft.
3. Sinus Lift Graft: The maxillary sinuses are located just above the maxillary posterior teeth. When posterior teeth are lost, the sinuses may drop down and occupy the space where the roots of the maxillary teeth were. In this scenario, implant placement is not possible because they would penetrate the sinus membrane. To address this issue, a sinus lift procedure can be performed. During this procedure, the sinus is raised back to its proper position, and a dental bone graft is placed underneath the sinus, creating a solid foundation for dental implants later on.
4. Periodontal Bone Graft: Infections from gum disease can erode the bone that supports the teeth, causing them to become loose. A periodontal bone graft is placed around an existing tooth to reduce mobility and provide additional support.

Dental bone grafts are also categorized according to the source of the graft:

1. Autogenous graft: This type of bone graft is harvested from the patient’s own body, ensuring perfect compatibility and minimal risk of rejection.
2. Allograft: Bone graft material is sourced from a human tissue bank, providing a safe and biocompatible option for patients.
3. Xenograft: Derived from an animal tissue bank, this bone graft material is processed to ensure safety and compatibility with human tissues.
4. Alloplastic graft: In some cases, synthetic bone graft materials can be used, offering a non-biological option that is biocompatible and aids in bone regeneration.

Another way to differentiate between dental bone grafts is the organ it was harvests from, and/or it’s composition. For example:

1. Dentin graft – Derived from human (autogenous) or animal teeth (xenografts) and considered as superior grafts
2. Osteo graft – Harvest from human or animal bones – the most common allograft and xenografts
3. Mineral graft – Sourced from materials like corals, and typically regarded as an inferior graft
   

Recent research indicates that dentin autograft (harvest from patients’ extracted teeth that are grinded with a dedicated dentin grinder) followed by dentin xenograft (harvest from porcine teeth) provide the best dental bone grafting outcomes. Dentin grafts support both osteoconduction and osteoinduction, and therefore lead to more osteogenesis (bone creation). In addition, Dentin is known to directly undergo ankylosis, fusion to the surrounding bone, thus it excels for example in Periodontic treatment.

What is a dental bone graft made of?

Dental bone grafts can be made from various materials, including natural and synthetic sources. Here are some examples of bone graft types based on their composition:

• Autograft: Autografts are considered the gold standard for bone grafting. They can be in the form of teeth granules (Dentin graft) or bone powder or a bone piece (Osteo-grafts) taken from the patient’s own body, typically from the hip, chin, or jaw. Autografts in general, and especially dentin ones, have a very high success rate and are well-tolerated by the body.
• Allograft: An allograft is a bone graft taken from another person’s body or a cadaver. Allografts are extracted from a donor’s body, treated to remove all cellular material, and then freeze-dried or irradiated to preserve their structural integrity. They have a high success rate and are widely used in dental bone grafting procedures.
• Xenograft: A xenograft is a bone graft material derived from an animal source, such as bovine or porcine bone or teeth. Xenografts are typically processed to remove all cellular material and sterilized for use in dental procedures. They are a popular choice for dental bone grafting because they are readily available and cost-effective.
• Synthetic materials: These materials are designed to mimic the structure and composition of natural bone. Synthetic bone graft materials, such as calcium phosphate ceramics, are often used in combination with other bone graft materials to improve their strength and effectiveness.

The choice of graft material depends entirely on the type of procedure involved and the clinician’s preference.

What does a dental bone graft look like?

During a dental bone graft procedure, the graft material is typically placed in the area where bone loss has occurred and may be stabilized with a dental bone graft mesh. Over time, the graft material will integrate with the patient’s natural bone tissue, resulting in a stronger, healthier jawbone.

The appearance of a dental bone graft will depend on the specific type of graft material used. Dental bone graft materials are available in various forms, such as granules, putty, and blocks.

• Bone graft granules: These are typically small, irregularly shaped particles that vary in size from less than 1mm to several millimeters. They can be white or off-white and have a grainy texture.

• Bone graft putty: This is a more viscous material that is often used for smaller defects. It has a smoother texture and can be molded into a shape.

• Bone graft blocks: These are larger pieces of graft material that are used for larger defects. They can be rectangular or square and may be cut to size during the procedure.

Dental bone graft material

Bone tissue can regenerate completely if provided the space into which it has to grow. Bone grafting is a surgical procedure in which the area where the bone is missing is filled with material from the patient’s own body, an artificial, synthetic, or natural substitute. After the graft is placed, the natural bone grows, generally replacing the graft material completely, resulting in a fully integrated region of new bone.

The following classification of bone grafts is based on material groups:

• Dentin-based bone graft: This type involves the use of autologous or xenograft teeth, grinded and cleansed, alone or in combination with other materials (e.g., growth factors).

• Allograft-based bone graft: This type involves the use of allograft bone alone or in combination with other materials (e.g., Grafton, OrthoBlast).

• Factor-based bone graft: This graft uses natural and recombinant growth factors, which may be used alone or in combination with other materials, such as transforming growth factor-beta (TGF-beta), platelet-derived growth factor (PDGF), fibroblast growth factors (FGF), and bone morphogenic protein (BMP).

• Cell-based bone grafts: These grafts use cells to generate new tissue alone or are added onto a support matrix, for example, mesenchymal stem cells.

• Ceramic-based bone graft: This type uses substitutes like calcium phosphate, calcium sulfate, and bioglass alone or in combination; for example, OsteoGraf, ProOsteon, and OsteoSet.

• Polymer-based bone graft: These grafts use degradable and nondegradable polymers alone or in combination with other materials, for example, open porosity polylactic acid polymer.

What is the best dental bone graft material?

The best dental bone graft material for a patient depends on their individual needs and circumstances, as each type of bone graft material has its unique advantages and disadvantages.

• Dentin bone grafts are currently regarded as the new gold standard for dental bone grafting, since they better support both osteoconduction and osteoinduction, and therefore lead to more osteogenesis (bone creation). In addition, Dentin is known to directly undergo ankylosis, fusion to the surrounding bone, thus it excels for example in Periodontic treatment. Dentin bone graft can originate from grinded and cleansed teeth extracted from the patient (Autograft) or from animal (Xenograft). Either way, Dentin grafts also eliminates the need for a separate surgical site to harvest bone tissue from the patient’s body.
• Autograft bone, taken from the patient’s body, is regarded as the second-best option for dental bone grafting, due to its biocompatibility and ability to stimulate new bone growth. However, it requires a separate surgical procedure to harvest the bone, which may result in more post-operative discomfort.
• Allograft bone offers various advantages over autografts, such as eliminating the need for a separate surgical site to harvest bone tissue, and it is readily available. This type of bone graft material can be obtained from a cadaver and is processed to remove any cells or materials that could cause an immune response. However, there is a small risk of disease transmission with this type of bone graft material.
   
• Xenograft bone, derived from animal sources like cows or pigs, is readily available and eliminates the need for a separate surgical site to harvest bone tissue from the patient’s body. The graft is processed to remove all organic material and sterilized before use. However, there is a small risk of allergic reactions with this type of bone graft material.
• Synthetic bone graft materials are readily available and eliminate the risk of disease transmission associated with allograft or xenograft bone. However, they may not be as effective at stimulating new bone growth as any of the organic grafts mentioned above. 

By evaluating various factors, including the extent of bone loss, the location of the graft site, the patient’s overall health and the available budget, the best-suited material for grafting can be determined.

Dental bone graft granules

Dental bone graft granules are small particles typically made from materials such as hydroxyapatite, tricalcium phosphate, or a combination of both. Different types of calcium phosphates, including tricalcium phosphate, synthetic hydroxyapatite, and coralline hydroxyapatite, are available in various forms, such as pastes, putties, solid matrices, and granules.

These biocompatible materials are used in dental procedures to help regenerate or rebuild bone tissue. Various types of dental bone graft granules are available, each with unique characteristics and benefits. Most bone grafts involve ceramics, either alone or in combination with another material (e.g., calcium sulfate, bioactive glass, and calcium phosphate).

Calcium phosphate products include Bio-Oss and OsteoGraft, which both use hydroxyapatite as either a particulate (Bio-Oss) or as blocks and particulates (OsteoGraft). When combined, such as calcium hydroxyapatite, they work as osteoconductive, osseointegration, and in some cases, osteoinductive materials. High temperatures are required for scaffold formation.

OsteoSet is a calcium sulfate tablet used for bone defect sites, while Allomatrix combines calcium sulfate and demineralized bone matrix (DBM) to form an injectable paste or pliable putty.

Bioactive glass (bioglass) is a biologically active silicate-based glass with a high modulus and brittle nature. It is used in combination with polymethylmethacrylate to form bioactive bone cement. Pro-Osteon, a unique product based on sea coral, is converted from calcium carbonate to calcium hydroxyapatite. The advantage of this material is its structure, similar to that of trabecular bone.

During a dental bone graft procedure, the granules are placed in the area where bone loss has occurred. Over time, the granules will fuse with the patient’s existing bone tissue, promoting the growth of new bone cells and ultimately resulting in a stronger, healthier jawbone. The surgeon can decide the type of graft granules needed based on the procedure and the extent of bone loss that has occurred.

Dental bone graft mesh

In dentistry, a dental bone graft mesh is typically a small, mesh-like sheet used to contour the area where bone loss has occurred, providing support for bone grafting materials. During the bone grafting procedure, the mesh is placed over the bone graft material, acting as a barrier to keep the graft in place, promoting better healing. Additionally, the mesh offers a scaffold for new bone growth, encouraging osteo-regeneration and osteo-integration of the graft.

Made of biocompatible materials such as titanium or other metal alloys, dental bone graft meshes are commonly used in procedures where precision is of the utmost concern. Examples of such procedures include ridge augmentation, where minimal bone is left to work with; sinus lifts, where positioning is critical and requires precise control; and guided bone regeneration. Dental bone graft meshes can also be used in combination with other dental implants, such as dental crowns or bridges, to provide additional support and stability.

Dental bone graft companies

Numerous companies manufacture dental bone graft materials for use in dental procedures. Here are a few examples:

• Zimmer Biomet Dental: Zimmer Biomet offers a range of dental bone grafting products, including its Trabecular Metal Dental Implant system, designed to mimic human bone’s structural properties.
• Geistlich Pharma: A leading manufacturer of dental biomaterials, Geistlich Pharma produces the well-known Bio-Oss product line, made from bovine bone and widely used in dental bone graft procedures.
• Dentsply Sirona: This US-based company offers a range of dental implant and bone grafting products, including its Ankylos and Xive implant systems, as well as the OsseoGuard bone graft material.
• Straumann: A Swiss-based company, Straumann produces various dental implants and biomaterials, including its BoneCeramic product line, made from a synthetic material that mimics natural bone’s properties.
• Osteogenics Biomedical: Specializing in bone grafting and implant products, this US-based company offers its Cytoplast TXT-200 barrier membrane and GEM 21S growth factor product.
• Johnson & Johnson: This US-based company produces the chronOS® Bone Graft Substitute (BGS), a synthetic β-tricalcium phosphate bone void filler that is radiopaque, resorbable, and osteoconductive.
• NovaBone: Another US-based company, NovaBone’s Dental Putty bone graft accelerates bone formation and features a unique cartridge delivery system for easier manipulation.
• Ivory graft: offering the first ever commercial and CE approved Dentin Xenograft, thus making the dentin advantages available to all dentists. 

These companies, among others, provide various bone graft products available in the market. The selection of bone graft material depends on the type of procedure being performed and the clinician’s preference.

Dental bone graft codes

Dental bone grafts are typically assigned codes within the Current Dental Terminology (CDT) coding system. The specific code used depends on the type of bone graft procedure being performed. 

Here are a few examples:

• D4263: Bone replacement graft for a retained natural tooth, each additional site in a quadrant.
• D4264: Bone replacement graft, first site in a quadrant.
• D7953: Bone replacement graft for ridge preservation, per site.

It is important to note that dental codes may vary by location and insurance carrier. Therefore, it’s always best to consult with your dental provider and insurance carrier to confirm the appropriate code for your particular situation.

Where does dental bone graft come from?

Dental bone grafts can be divided into the following types based on their sources:

• Autograft: An autologous or autogenous bone graft is obtained from the same individual receiving the graft. Autografts are osteoinductive, osteogenic, and osteoconductive. Bone can be harvested from nonessential areas, such as the iliac crest, mandibular symphysis (chin area), or anterior mandibular ramus (coronoid process). Autografts are preferred for block grafting due to a lower risk of graft rejection since they originate from the patient’s body. However, an additional surgical site is required for graft withdrawal, and the associated postoperative pain and complications are the main disadvantages. 
  • Dentin autograft: A superior autograft option is to use patient’s extracted teeth as a dentin autograft source, after grinding and cleansing them with a dedicated teeth grinder. Dentin autograft is more effective – since dentin outperforms bone as a regeneration enhancer, and is also safer – since it does not involve bone harvesting surgery, as it instead uses teeth that were meant to be extracted anyhow.
     
• Allografts: These are derived from humans but harvested from an individual other than the one receiving the graft. Allograft bone can be taken from cadavers and is typically sourced from a bone bank. Allografts are sterilized, and their proteins are deactivated before use. They are fully enriched with bone growth factors, proteins, and other bioactive materials necessary for osteoinduction and successful bone healing. There are three types of bone allografts available: fresh or fresh-frozen bone, FDBA, and DFDBA.
   
• Xenograft: Xenografts are bone grafts from a species other than humans, such as bovine, and are used as a calcified matrix. These are typically harvested from purified animal bones, but superior Dentin xenograft, extracted from animal teeth are recently available on the market. Ivory Graft is the first ever commercial and CE approved Dentin xenograft, using porcine teeth as a source.
   
• Synthetic Variants: These are created from ceramics, such as calcium phosphates (e.g., HA and tricalcium phosphate), bioglass, and calcium sulfate, and are biologically active depending on their solubility in the physiological environment. These materials can be combined with growth factors, ions like strontium, or mixed with bone marrow aspirate to increase biological activity. The presence of elements like strontium can result in higher bone mineral density (BMD) and enhanced osteoblast proliferation.
   
• Growth Factors: They consist of either human growth factors or morphogens (BMPs in conjunction with a carrier medium, such as collagen) and are produced using recombinant DNA technology. The combination and simultaneous activity of multiple factors result in controlled production and resorption of bone. These factors include TGF-beta, insulin-like growth factors I and II, PDGF, FGF, and BMPs.
   
• Cell-based Bone Graft Substitutes: Stem cells are cultured with various additives, such as dexamethasone, ascorbic acid, and β-glycerophosphate, to direct the undifferentiated cells towards the osteoblast lineage. The addition of TGF-beta and BMP-2, BMP-4, and BMP-7 to the culture media can also influence stem cells toward the osteogenic lineage. Mesenchymal stem cells can be seeded onto bioactive ceramics conditioned to induce differentiation into osteoblasts.
   
• Ceramic-based Bone Graft Substitutes: The majority of bone grafts available involve ceramics, either alone or in combination with another material (e.g., calcium sulfate, bioactive glass, and calcium phosphate). Ceramics like calcium phosphates are osteoconductive, promote osteointegration, and in some cases, are osteoinductive. They require high temperatures for scaffold formation and have brittle properties.
   
• Polymer-based Bone Graft Substitutes: These can be divided into natural polymers (such as Healos) and synthetic polymers (such as Cortoss). Degradable synthetic polymers, like natural polymers, are resorbed by the body. The advantage of having the implant resorbed by the body is that the body can heal itself completely, without remaining foreign bodies.
  

Are dental bone grafts from cadavers?

Dental bone grafts can be obtained from cadavers in the form of allograft bone. Allograft bone is a common source of bone graft material used in dental procedures, and it is acquired from donors who have agreed to donate their bone tissue for medical use after death.

Allograft bone is a popular choice for bone graft material because it is readily available, eliminating the need for a second surgical site to harvest bone tissue from the patient’s own body. It is also less expensive than some other types of bone graft materials, such as autogenous bone grafts, which require a separate surgical procedure to harvest bone tissue from the patient’s body.