Bone substitutes: a review of their characteristics, clinical use, and perspectives for large bone defects management

Abstract

Bone replacement might have been practiced for centuries with various materials of natural origin, but had rarely met success until the late 19th century. Nowadays, many different bone substitutes can be used. They can be either derived from biological products such as demineralized bone matrix, platelet-rich plasma, hydroxyapatite, adjunction of growth factors (like bone morphogenetic protein) or synthetic such as calcium sulfate, tri-calcium phosphate ceramics, bioactive glasses, or polymer-based substitutes. All these substitutes are not suitable for every clinical use, and they have to be chosen selectively depending on their purpose. Thus, this review aims to highlight the principal characteristics of the most commonly used bone substitutes and to give some directions concerning their clinical use, as spine fusion, open-wedge tibial osteotomy, long bone fracture, oral and maxillofacial surgery, or periodontal treatments. However, the main limitations to bone substitutes use remain the management of large defects and the lack of vascularization in their central part, which is likely to appear following their utilization. In the field of bone tissue engineering, developing porous synthetic substitutes able to support a faster and a wider vascularization within their structure seems to be a promising way of research.

Keywords: Synthetic; cyst; dentistry; orthopedics; porosity; spine; vascularization.

Figure 1.

Various origins of bone defects: (a) Panoramic X-ray. Bone defect of the mandible right body corresponding to an osteonecrosis of the jaw in relation to denosumab taking. (b) 3D-reconstructed view of upper jaw. Bilateral bone defect of premolar regions associated to tooth agenesis in a young adult presenting a WNT10A gene mutation. (c) Panoramic X-ray. Bone defect (radiolucency, *) of the mandible right ramus corresponding to an ameloblastoma, an odontogenic aggressive benign tumor. (d) Panoramic X-ray. Bone defect (radiolucency, arrows) of upper and lower jaws corresponding to a trauma. (e) Panoramic X-ray. Bone defect (arrow) of upper jaw after resection surgery of a gingival squamous cell carcinoma (clinical view, left corner). (f) Reconstruction of the mandible by autogenous bone (fibula) following an invasive squamous cell carcinoma of the gingiva.

Figure 2.

(a) Radiographical view of a right fibula bone loss, after a road traffic accident in a 24 year-old woman, with an external fixator. (b) Surgical procedure with the use of allogeneic bone chips. (c) Radiographical view 4 months later (courtesy of Dr D. Brinkert).

Figure 3.

Use of DBM in oral procedures: (a, b) DBM used to fill buccal bone defect (arrow) after implant placement. (c, d) Panoramic X-rays of a maxillary right sinus before (c) and after sinus floor elevation (d) filled with DBM and dental implants placement.