Bone graft integration is a complex and multifaceted process that involves multiple cellular and molecular events. Understanding this mechanism is essential for optimizing clinical outcomes in periodontal regenerative therapy. To understand the mechanism of bone graft integration, first we should be aware of three terminologies: Osteoconduction, Osteoinduction and Osteogenesis. Osteoconduction involves providing a physical, three-dimensional scaffold or matrix that facilitates bone repair. Essentially, it acts as a structural framework for bone growth. Osteoinduction refers to the ability of certain materials or factors to induce osteogenesis. In other words, it stimulates the recruitment and differentiation of immature cells (such as mesenchymal stem cells) into preosteoblasts, which eventually form new bone tissue. Osteogenesis refers to the process of bone formation, where new bone material is laid down by osteoblasts. Living osteoblasts within the graft material contribute to bone remodeling. These cells actively participate in the healing process, integrating with the host tissue and gradually replacing the graft.

After a bone graft is placed in periodontal defect, following events take place,

Inflammation Phase

The integration process begins immediately after the graft is placed into the recipient site. This initial phase is characterized by:

Clot Formation:

Upon graft placement, there is bleeding at the graft site, leading to the formation of a clot. This blood clot provides a matrix for incoming cells and cytokines essential for healing. Platelets play a crucial role in clot formation. They aggregate at the site of injury, forming a plug that helps prevent further bleeding. Fibrin forms a meshwork within the clot. It provides structural stability and reinforces the platelet plug. Cross-linking of fibrin strands creates a network that traps blood cells and strengthens the clot.

Recruitment of Inflammatory Cells:

Platelets within the hematoma release growth factors such as platelet-derived growth factor (PDGF) and transforming growth factor-beta (TGF-β), which attract inflammatory cells like neutrophils and macrophages to the site. These cells play a crucial role in cleaning debris and releasing additional cytokines that modulate the healing process. Neutrophils and monocytes (innate immune cells) bind to the activated vascular endothelium, contributing to the initial stages of clot formation. As the thrombus matures, macrophages become more prominent within the clot. Neutrophils facilitate the recruitment of monocytes into the thrombus. Eventually, macrophages become the predominant inflammatory cells present in the thrombus.

Revascularization and Angiogenesis

Adequate blood supply is vital for graft survival and integration. The process of revascularization involves angiogenesis, a process where new blood vessels form from existing ones, facilitated by angiogenic factors like vascular endothelial growth factor (VEGF). This ensures that the graft receives sufficient oxygen and nutrients. Let us discuss the factors involved in angiogenesis,

VEGF (Vascular Endothelial Growth Factor): VEGF is a potent stimulator of angiogenesis. It promotes endothelial cell proliferation and migration, leading to the formation of new capillaries.

Angiopoietins (Ang-1 and Ang-2): These growth factors regulate vessel maturation and stability. Ang-1 promotes vessel stabilization, while Ang-2 destabilizes vessels, allowing sprouting angiogenesis.

FGF (Fibroblast Growth Factor): FGF2 (basic FGF) is involved in angiogenesis by stimulating endothelial cell proliferation and migration.

Chemokines: These signaling molecules attract immune cells and endothelial progenitor cells to the site of angiogenesis, facilitating vessel growth.

Cellular Proliferation and Differentiation

With the establishment of a blood supply, the next phase involves the proliferation and differentiation of cells necessary for new bone formation. MSCs have the capacity to proliferate and differentiate into various cell lineages, including osteoblasts. MSCs can differentiate into osteoblasts, which are responsible for bone formation. Osteogenic differentiation involves the expression of specific genes and the production of bone matrix. Osteoblasts are the primary bone-forming cells. They exhibit relevant cellular activity and provide valuable insights into the effects of biomaterials on bone tissue. Perivascular cells, specifically those in the adventitial niche, participate directly in bone formation and repair. They interact with native skeletal cells and indirectly induce bone repair through paracrine mechanisms. These cells exhibit multipotency, including osteoblastic potential. They release extracellular vesicles (EVs) and other factors that influence osteoprogenitor cell proliferation, migration, and osteogenic differentiation.

Bone Formation (Osteogenesis)

The bone formation in the grafted area occurs in the same way as in any healing area. Osteoblasts actively produce bone matrix. They play a central role in bone healing and graft integration. On the other hand, osteoclasts are responsible for resorbing or breaking down the graft surface. They create space for new bone formation. During graft healing, osteoclasts eat away at the graft surface, while osteoblasts create new bone. It’s a dynamic remodeling cycle where the graft material gradually gets replaced by new bone.

Remodeling Phase

Once new bone is formed, it undergoes continuous remodeling to restore the normal architecture and function of the bone. This phase includes:

Osteoclast Activity:

Osteoclasts resorb the graft material and any damaged bone, creating space for new bone formation. This resorption is regulated by factors such as receptor activator of nuclear factor kappa-Β ligand (RANKL) and osteoprotegerin (OPG).

Osteoblast Activity:

Osteoblasts deposit new bone in the resorbed areas, gradually replacing the graft material with the patient’s own bone. This ensures that the graft integrates seamlessly with the surrounding bone.

Factors Influencing Bone Graft Integration

Several factors can affect the success of bone graft integration:

Graft Type and Quality:

Autografts (patient’s own bone) are considered the gold standard due to their osteogenic, osteoinductive, and osteoconductive properties.

Allografts (donor bone) and xenografts (animal bone) lack live cells but can provide structural support.

Synthetic grafts and composite grafts combine materials to mimic natural bone properties.

Biological Factors:

Age: Younger patients typically have better healing potential due to more robust cellular activity.

Health Status: Conditions like diabetes, osteoporosis, or smoking can impair bone healing.

Mechanical Environment:

Stability: Adequate mechanical stability at the graft site is crucial for successful integration. Excessive movement can disrupt the healing process.

Loading: Appropriate mechanical loading stimulates bone formation through mechanotransduction pathways.

Surgical Technique:

Aseptic Technique: Preventing infection is paramount, as infections can severely impair bone healing.

Graft Handling: Careful handling of the graft to preserve its biological activity is essential.

Use of Adjunctive Therapies:

Biological Agents: Application of growth factors such as BMPs or platelet-rich plasma (PRP) can enhance osteoinduction.

Pharmacological Agents: Drugs like bisphosphonates or teriparatide can modulate bone remodeling.


The integration of bone grafts is a dynamic and intricate process involving a coordinated series of biological events. From initial inflammation and revascularization to cellular proliferation, bone formation, and remodeling, each phase plays a vital role in ensuring successful graft incorporation. Advances in graft materials, surgical techniques, and adjunctive therapies continue to enhance the outcomes of bone grafting procedures, offering improved solutions for patients requiring bone repair and reconstruction. Understanding the detailed mechanisms behind bone graft integration helps clinicians make informed decisions and tailor treatments to optimize healing and functionality.


Periobasics: A Textbook of Periodontics and Implantology

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