Human Bone & Bone Graft Material in Dentistry

Sam Khoury - January 2009

One of the most important success criterions in dental implantology is the volume of
bone around the fixtures to support the osseointegration. In the opposite case, the
surgeon will go for bone augmentation. The word “graft” means to add or to
transplant. So the bone graft procedure consists of grafting or adding natural or
synthetic bone to the jaw, and waiting for the grafted material to integrate with the
existing bone (usually it takes up to 6 month).

In this current paper, we will talk about the composition of bone in general; the types
of bone, the bone cells and the natural bone cellular formation. We will present as
well the anatomy of the human jaw then the bone grafting process and material in
dentistry.

I. Bone Components

Bone is composed of proteins and minerals. Approximately 60% the weight of the
bone is mineral, mainly calcium and phosphate. The rest is water and matrix, which is
formed before the mineral is deposited, and can be considered the scaffolding for the
bone. About 90% of the matrix proteins are collagen, which is the most abundant
protein in the body:

- The organic matrix is composed primarily of collagen providing flexibility.

10% of adult bone mass is collagen.
- The mineral component is composed of hydroxyapatite, which is an insoluble
salt of calcium and phosphorus. About 60% of adult bone mass is
hydroxyapatite.
- Bone also contains small amounts of magnesium, sodium, and bicarbonate.
- Water comprises approximately 25% of adult bone mass.

II. Types of Bone

In the human body, we have 2 major types of bones. Cortical bone, also known as
Compact bone. Cortical bone is dense and forms the surface of bones, contributing
80% of the weight of a human skeleton. It is extremely hard, formed of multiple
stacked layers with few gaps. It has a high mineral content (approximately 60 to
70%).

The other major type of bone is Trabecular or Cancellous bone; it is spongy and
makes up the bulk of the interior of most bones, including the vertebrae. Its main
function is to support the body, protect organs, provide levers for movement, and store
minerals. It is filled with haemopoetic marrow, fat containing marrow, or blood
vessels.
In the jaw, 4 different types of bone quality are defined. Bone Quality relates to the
degree of bone density. Type 1, comparable to oak wood, is very hard and dense, and
provides great cortical anchorage, but limited vascularity. Type 2 bone is the best
bone for osseointegration of dental implants. It provides good cortical anchorage for
primary stability, yet has better vascularity than Type 1 bone. Figure 1 presents the
different done quality types.
Types 3 and 4 are soft bone textures with the least success in Type 4 bone (compared
to Styrofoam)

Figure 1: Bone Quality (Source: Implant Dentistry of Washington)

It’s worth to mention that many references categorize the bone in different other ways,
for example by shape, we have 5 types of bones: long, short, flat, irregular and
sesamoid.

Before we go through the stimulated bone formation, we will talk about the bone cell
and the natural bone formation.

III. Bone Cells and Bone Formation

There are three kinds of bone cells. OSTEOBLASTS, OSTEOCLASTS and

OSTEOCYTES (Osteo in Greek means bone).

Bone is a dynamic tissue constantly regenerated by osteoblasts (which build or form

bone) and osteoclasts (which resorb bone, or break it down). Osteoblast cells tend to
decrease, as an individual gets older with age, thus decreasing the natural renovation
of the bone tissue. The bone mass is maintained by a balance between the activity of
osteoblasts and osteoclasts. Normally, bone formation and bone resorption are closely
coupled processes involved in the normal remodelling of bone.

The Bone Marrow is a soft fatty substance in the cavities of bones, in which blood
cells are produced.
 Fig. 2: Human Bone (Photo courtesy of Russ Turner)

III.1 Osteoblasts

This is a mononucleate cell that is responsible for bone formation. Osteoblasts are
formed mainly by Type I Collagen.
The function of those cells is to make the proteins that will form the organic matrix of
bone and to control mineralization of the bone.
They have receptors for hormones such as vitamin D, estrogen, and parathyroid
hormone and they secrete many factors such as:
- Activators of osteoclasts (RANK-ligand) and other factors that communicate with
other cells.
- A protein called PHEX that helps regulating the amount of phosphate excreted by
the kidney.

When the teaming of osteoblasts has finished, the cells become flat. They line the
surface of the bone. These old osteoblasts are now called Lining Cells. They regulate
passage of calcium into and out of the bone, and they respond to hormones by
differentiating into special proteins that activate the osteocytes trapped inside the bone
matrix. The rest undertake apoptosis (known as cell suicide) and disintegrate.

Osteoid is the organic portion of the matrix of bone tissue. Osteoblasts begin the
process of forming bone tissue by secreting the osteoid as several specific proteins.
When the osteoid becomes mineralized, it and the adjacent bone cells have developed
into new bone tissue.

III.2 Osteoclasts

An “Osteoclast” is a large cell containing multiple nuclei and a cytoplasm with a

homogeneous, foamy appearance. This appearance is due to a high concentration of
vesicles and vacuoles.
A mature Osteaclast is formed by the fusion of many precursors (Pre-Osteoclasts).
The fusion of the precursors is activated by the RANK-ligand (which is formed by the
Osteoblasts as mentioned above). Osteoprotegerin (OPG) is anotehr factor in the
marrow bone which also binds RANK-ligand, so it can help to regulate the Osteoclast
activation.

Pre-osteoclasts around the Linen Cells are activated by RANK-ligand and OPG, and
then they fuse with each other and with some Lining Cells to form the mature
Osteoclasts.

The Osteoclasts resorb the bone. They form sealed compartments next to the bone
surface and secrete acids and enzymes, which degrade the bone.

After they finish resorbing bone, they undergo apoptosis.

Figure 3: Illustrated cross-section of an activated Osteoclast

III. 3 Osteocyte

An “Osteocyte” is a star-shaped cell; the most abundant cell found inside the bone.
Cells contain a nucleus and a thin ring of cytoplasm. Osteocytes are networked to
each other via long cytoplasmic extensions that occupy tiny canals called canaliculi,
which are used for exchange of nutrients and waste.
 Figure 4: Osteocyte Cell (Image from van der Plas and Nijweide, J Bone Mineral Res 1992, 7:389-96)

IV. The Human Jaw

In this section we will present the anatomy of the mandible and the Maxilla.

IV.1 The Mandible

This is the lower jaw of the human being. It has U shape reaching ears from both
sides. The below picture shows the different part of the mandible.

The Ascending The Condyle

Ramus Figure 5. Human lower jaw

The Coronoid
Process

Body of the
Mandible
The Ascending
Ramus

A- The Body of the Mandible supports all the lower teeth.

B- The Condyle is the rounded end of bone that fits into the movable joint between
the mandible and the cranium.
C- The Coronoid Process is the name for a triangular projection from the mandible,
which joins one of the chewing muscles to the cranium.
D- The Ascending Ramus is the flatter, straighter part on the sides of the lower jaw,
which joins the body of the mandible to the coronoid processes and the condyles.

IV.2 The Maxilla

Figure 6. Human upper Jaw

Anterior Nasal The Zygomatic
Spine Process

The plate

Maxillary Antrum or
Sinus

A- The Maxillary Sinus is the name for the air filled space that sits just under the
cheekbone, and just above the plate of the mouth. There is one on each side of the
face.
B- The Anterior Nasal Spine is a bit of bone, which protrudes from the maxilla at the
lower end of the nose.
C- The Zygomatic Process is a curved piece of bone, which extends outwards from
the maxilla and forms part of the cheekbone.
D- The palate is the roof of the mouth, it separates the nose and the mouth: the hard
part is called the “Hard Palate” and is towards the front of the mouth, and the softer
part or “Soft Palate” at the back near the throat is the soft palate.

IV.3 The Occlusion

The relationship between the mandibular and maxillary teeth (when they approach
each other, as when chewing, or in a resting position) is called “Occlusion”. It’s he
contact between the teeth.

The occlusion is influenced by three primary components: The teeth, the nerves and
muscles and the bones.

“Centric Occlusion” is the normal or relaxed position of closure of the jaws. It occurs
when the cups of the lower and upper teeth inter-position themselves. The below
picture will the described position in maximum intercuspation.
 Figure 7. Centric Occlusion of Human jaws

To make sure, the bite is well guided, we place the front teeth together on their biting
edges and we check the posterior teeth: they should not touch.

V. Bone Grafting

So as we mentioned up till now, “Bone Graft” is bone transplanted from a donor site
to a recipient site, without anastomosis of nutrient vessels; bone can be transplanted
within the same person (i.e., autograft) or between different people (i.e., allograft).
Bone Graft Material is the material other than the human bone placed into spaces
between or around broken bone (fractures) or holes in bone (defects) to aid in healing;
such as bovine or synthetic bone.

V.1 Types of Bone Graft Material

We can divide the bone graft material into different categories, either by nature or by
shape and others, like Laurencin et al (2006) have suggested a classification scheme
of material-based groups:

· Allograft-based bone graft substitutes involve allograft bone, used alone or in

combination with other materials: Allograft tissue is treated by tissue freezing,
freeze-drying, gamma irradiation, electron beam radiation, ethylene oxide, etc, but
still the risk of disease transmission from donor to recipient is not completely
removed.

•Factor-based bone graft substitutes are natural and recombinant growth factors, used
alone or in combination with other materials such as transforming growth factor-
beta (TGF-beta), platelet-derived growth factor (PDGF), fibroblast growth factor
(FGF), and bone morphogenetic protein (BMP).

•Cell-based bone graft substitutes use cells to generate new tissue alone or are seeded
 onto a support matrix (e.g. Mesenchymal stem cells).

•Ceramic-based bone graft substitutes include calcium phosphate, calcium sulfate,

and bioglass.

· Polymer-based bone graft substitutes, degradable and non-degradable polymers,

are used alone or in combination with other materials,

By shape, we can divide the bone grafting material into granules, cement, membranes
and blocks. By nature, we can divide it into:

 The Autogenous bone grafts, taken from the patients themselves, from their chins,
calvaria, or hips.

 Human Bone or Allograft. We talked already about this type of material in the
above paragraph.

 Bovine (animal) also called Xenograft. It’s bone healing capacity is inferior
compared to that of autografts and allografts

 Synthetic bone: it may be classified into three primary groups: Demineralized

bone matrix, ceramics and composite materials.

V.1.1 Demineralized bone matrix is created from cortical or corticocancellous bone

through an acid extraction process that produces a composite of noncollagenous
proteins, bone growth factors, and collagen (18). Demineralized bone matrix implants
act in an osteoinductive manner to stimulate bone healing in 3–6 months and have
been reported to show no significant resorption in patients 7 years after implantation.
Disadvantages of demineralized bone are the loss of structural rigidity (because of
processing) and the inability to visualize the material radiographically (because of its
inherent radiolucency).

V.1.2 Ceramics: The majority of ceramics currently used are synthetic and composed
of calcium sulfate, hydroxyapatite, tricalcium phosphate, or a combination of
hydroxyapatite and tricalcium phosphate. Ceramics provide an osteoconductive lattice
on which host osteogenesis can take place. The design of these products allows for
involves the resorption of the ceramic and its replacement by bone during the healing
process.

V.2 Interaction between Bone and Bone Graft Material

There are three ways in which a bone graft can help repair a defect.
The first is called “Osteogenesis”; the formation of new bone by the cells contained
within the graft.

The second is “Osteoinduction”: a chemical process in which molecules contained

within the graft (bone morphogenetic proteins) convert the patient's cells into cells
that are capable of forming bone.

The third is “Osteoconduction”: a physical effect by which the matrix of the graft
forms a scaffold on which cells in the recipient are able to form new bone.
Refrences:

American Society for Bone and Mineral Research, Bone Curriculum.

Bauer, Thomas W. MD, PhD and Muschler, George F. MD: Bone Graft Materials: An
Overview of the Basic Science. Clinical Orthopaedics & Related Research, February
2000.

British Dental Journal, Vol. 186, No. 5,: “Tooth surface loss; Part 3: Occlusion and
splint therapy”.

Laurencin C, Khan Y, El-Amin SF. Bone graft substitutes. Expert Rev Med
Devices. Jan 2006.

Lind M, Bunger C. Factors stimulating bone formation. In: Gunzburg R, Szpalski M,

Passuti N, Aebi M, eds. The use of bone substitutes in spine surgery. Berlin,
Germany: Springer-Verlag, 2002.

Netter, Frank H. (1987), Musculoskeletal system: anatomy, physiology, and metabolic

disorders. Summit, New Jersey: Ciba-Geigy Corporation

T. Tuominen, T. Jämsä, J. Tuukkanen, A. Marttinen, T.S. Lindholm, P. Jalovaara,

Bovine bone implant with bovine bone morphogenetic protein in healing a canine
ulnar defect.

Websites:

http://www.3dmouth.org

http://www.teeth-usa.com

http://www.seattle-implants.com

This paper is researched and prepared by Sam Marcel Khoury, Managing Director -
Kuwait & Business Development Manager – Dental Division.