Bone Grafting in Dentistry: From Autografts to Emerging Naturally Derived Biomaterials

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Abstract
A bone graft is defined as a material capable of promoting bone healing, which has been transplanted into a bony defect, either alone or in combination with other materials.[1] The earliest documented bone graft dates to 1682, when a cranial bone was repaired using bone from a deceased dog. In 2024, the global bone grafts and substitutes market was valued at USD 3.16 billion and is projected to reach USD 4.60 billion by 2030, with a growth rate of 6.6%.[2] After tooth loss, alveolar bone resorption is irreversible, leaving the area without adequate bone volume for future successful implant treatment. Despite the widespread use of bone grafting materials globally, limitations in these materials remain, highlighting the need for continued innovation. Autografts are the gold standard in bone grafting materials. These are sourced from intraoral and extraoral sites in the same individual, such as the mandibular symphysis, mandibular ramus, external oblique ridge, iliac crest, proximal ulna or distal radius, as these are good sources of cortical and cancellous bone.[3] [4] For dental applications, autografts are commonly used for the management of localized alveolar bony defects, maxillary sinus bone grafting, and alveolar ridge augmentation procedures. However, autografts are limited by graft tissue availability, associated donor-site pain and morbidity, higher surgical costs, greater surgical risks, and the need for two operative sites and procedures.[5] [6] Consequently, allografts from a compatible living donor or cadaveric bone are a more acceptable alternative to autografts. Allograft materials are available in three primary forms: fresh, frozen, or freeze-dried. Fresh and frozen allograft materials possess superior osteoinductive properties; for example, demineralized bone matrix (DBM), which contains osteoinductive growth factors, is available in different forms, such as putties, moldable pastes, and moldable blocks, with clinically relevant handling properties.[3] In dental applications, allografts have been used to treat periodontal, maxillary, and mandibular defects. However, allografts are subject to potential risks such as rejection and disease transmission, and require thorough sterilization to eliminate disease potential.[3] In recent years, there has been a shift toward novel bone grafting materials, such as xenografts and synthetic bone substitute products, despite limited evidence-based research on their indications and safety. The primary role of bone grafts is to provide a scaffold that stimulates new bone growth and to display biological properties such as osseointegration, osteogenesis, osteoconduction, and osteoinduction, which play a vital role in this process.[3] Furthermore, material properties such as biocompatibility, resorbability, sterility, structural integrity, adequate porosity for angiogenesis, ease of handling, cost, and compressive strength influence the success rate of bone grafts.[7] To address some of these limitations, novel bone substitutes have been developed to enhance osteogenic, osteoconductive, and osteoinductive properties by creating a more favorable bone microenvironment.[3] Xenografts are graft materials derived from a species that is genetically unrelated to the host.[8] The most common source of xenograft material in the dental field is defatted, deproteinized bovine bone, which is commercially available as BioOss, and contains the mineral hydroxyapatite (HA).[3] HA is present as the inorganic component of bone and teeth, and therefore provides an ideal bone grafting material.[4] Notably, synthetically produced HA lacks the trace amounts of Na+, Mg2+, K+, and Sr2+, which are found in naturally derived HA, such as in bovine bone, and these ions facilitate various biochemical reactions that enhance osteogenesis. Furthermore, synthetic HA does not possess the microporous structure observed in natural bovine-derived HA.[4] The porous structure of BioOss provides good mechanical support and stimulates bone regeneration via angiogenesis, cell migration, and differentiation. Studies have found that maxillary sinus defect sites grafted with BioOss resulted in 39% new bone formation after 6 months, which was comparable to 40% new bone formation following autograft bone grafting at the same time point. Furthermore, it was found that 31% of grafted BioOss remained at the graft site, compared with just 18% of autograft bone,[9] suggesting that the efficacy of BioOss in stimulating new bone formation closely matches, if not exceeds, that of autograft bone. A 5-year prospective follow-up study conducted by Özkan et al found that sufficient bone quality and volume, allowing for predictable simultaneous implant placement, resulted from the use of bovine bone grafts in one-stage maxillary sinus augmentation procedures.[10] Clinically, BioOss has proven to be a valuable grafting material, consistently providing high-quality new bone and exhibiting promising long-term survival rates in dental surgery.[11] OsteoGraf and Cerabone are other commercially available bovine bone grafts produced by high-temperature treatment, which eliminates all organic components. Recent studies conducted by Ratnayake et al have developed bone graft material from bovine bone and teeth using a sustainable, green, and cost-effective method.[6] [8] In vitro studies showed that the bone graft materials were non-toxic and supported the proliferation and differentiation of osteoblast-like cells. In addition to bovine sources, other xenogeneic sources have also been explored. For example, bone and teeth sourced from Saudi Arabian camels are currently being investigated for the development of bone grafts, with in vitro biocompatibility studies showing promising results.[12] [13] Nevertheless, future studies should focus on in vivo studies and clinical trials to assess the clinical feasibility of these emerging xenograft materials. Other promising xenograft materials include chitosan, which is a naturally occurring polymer composed of glucosamine and N-acetylglucosamine, derived from crustacean exoskeletons.[7] [14] Chitosan has been widely investigated as a xenograft material due to its antimicrobial and biocompatible properties. It is available in a variety of forms, including beads, films, hydrogels, and more complex structures, such as porous scaffolds.[14] Due to chitosan's poor mechanical strength, it is often combined with other materials, such as calcium phosphates (HA), gelatin, and bioglass, to impart more desirable mechanical properties.[14] Furthermore, chitosan-based grafting materials also possess other beneficial properties, such as low immunogenicity, fibrous encapsulation, structural versatility, and a hydrophilic surface that promotes cell adhesion and proliferation.[14] Recent studies in the dental field have reported the successful application of chitosan-based materials as membranes for guided bone and tissue regeneration, as coating agents for implant surfaces, for periodontal regeneration, and for the restoring alveolar bone height. Silk is a natural biopolymer derived from the silkworm Bombyx mori and is predominantly composed of fibroin and sericin. After removal of sericin through degumming, silk fibroin (SF) is commonly used as a bone scaffold in sponge, film, and hydrogel forms. SF demonstrates excellent biocompatibility, degradability, tissue integration, oxygen and water permeability. Recent research has shown that these favorable biological properties enable its use as a membrane for guided bone regeneration (GBR), despite its poor mechanical properties and difficulties in use.[15] [16] SF has been used as a GBR membrane following tooth extraction, cyst/tumor excision, and in cases of deficient alveolar bone for implant placement. Furthermore, SF-based membranes have exhibited excellent tensile strength, good osteogenic potential, and good mechanical properties in several in vivo studies.[16] [17] Phytogenic materials are bone-analogue grafting materials derived from plant sources, such as Gusuibu, coral-based bone substitutes, and marine algae. Gusuibu is a traditional Chinese herbal medicine widely used to treat patients with bone fractures and osteoarthritis in Chinese patients and has shown osteoinductive properties, increased alkaline phosphatase activity, and thus promotes bone calcification and remodeling processes.[18] In dental applications, gusuibu has been shown to accelerate bone remodeling following orthodontic tooth movement by promoting osteoblastic activity, and in vitro, it has been shown to mediate bone remodeling by regulating osteoclastic and osteoblastic activity.[19] AlgiPore is a naturally occurring HA derived from marine algae that has been clinically used as a bone grafting material since 1988. AlgiPore is a very favorable grafting material for bone filling due to its excellent biocompatibility, low immunogenicity, biodegradability, and bone-bonding capacity. Clinically, Algipore is primarily used as a space filler, often in combination with other grafting materials, following tooth extraction to prevent ridge deformities.[20] Despite the establishment of criteria defining the ideal bone grafting material, autografts remain the gold standard and the only material that possesses all four fundamental biological properties. However, their limited availability and other associated limitations have driven a shift toward the development of alternative grafting materials. Synthetic options can be expensive and lack the full spectrum of biological properties necessary for bone grafting, and clinicians must consider the limitations of these new technologies. Therefore, there is a growing need to investigate these innovative biomaterials derived from natural, sustainable sources, capable of producing novel dental bone grafts with the necessary porous structure, mechanical stability, controlled degradation, and a rate of new bone formation that matches the rate of graft resorption. Presently, 3D (three-dimensional) bioprinting is widely explored, involving the printing of biomaterials that integrate biological materials, such as cells and growth factors, to mimic the structure of targeted tissues while maintaining cell viability during and after printing.[21] These developments are being performed in a hydrogel or a 3D scaffold to develop new therapies for bone regeneration.[21] Such strategies could allow natural biomaterials to more closely imitate the multifaceted biological microenvironment of natural bone, representing a key area of future research. Article published online: 22 May 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical and Scientific Publishers Private Limited A-13A, Graphix Tower 1, 6th floor, Sector 62, Noida 201309, Uttar Pradesh, India

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