Tooth Allografts as Natural Biocomposite Bone Grafts: Can They Revolutionize Regenerative Dentistry?

Abstract

For decades, regeneration of alveolar bone defects has depended on traditional grafting options, such as autogenous/allogenic grafts or allografts. Recently, extracted teeth was introduced as an alternative graft source. Tooth autografts are being used and have gained significant attention due to their biocompatibility, osteoconductivity, osteoinductivity, and osteogenic properties. Furthermore, tooth allografts have potential to act as natural biocomposites for oral regeneration procedures and might be advantageous options in near future. Recent advances in tooth banking, including cryopreservation, can serve to maintain bioactivity and to improve the safety, viability, and regenerative potential of teeth. They might be revolutionary in oral surgery, offering a more sustainable solution to the growing demand for bone regeneration procedures. Nevertheless, challenges such as immunogenic responses, ethical issues, and regulatory constraints persist. Ongoing research and technological innovation continue to address these problems. To date, the success rates of tooth autografts are promising, and they are regarded as a reliable option in clinical practice, with predictable outcomes in alveolar ridge preservation, sinus augmentation, periodontal regeneration, guided bone regeneration (GBR), and endodontic surgery by providing natural scaffolds for cell integration and bone remodeling. However, the scientific literature on tooth allografts is lacking. Therefore, this review aimed to comprehensively evaluate the scientific literature for comparing the properties of tooth grafts with other grafting options, in terms of processing techniques, and various clinical applications, positioning them as versatile biocomposites for the future, bridging material science and regenerative dentistry. Furthermore, possible applications of allogenic tooth grafts and overcoming current limitations are also discussed.

1. Introduction

Currently, edentulism is a common clinical problem caused by various factors such as trauma, dental caries, periodontal disease, congenital anomalies, poor oral hygiene, malocclusion, systemic diseases, polysubstance use like alcohol, iatrogenic factors, and aging [1]. Partial or total edentulism results in aesthetic, functional, and phonetic issues, affecting the biological, physiological, social, and psychological well-being of the individual, and can lead to a critical resorption of the jawbones [1,2]. As a result of bone resorption, alveolar bone volume significantly decreases, which can cause alveolar bone fractures or make dental implant placements challenging. To address this issue, a variety of graft materials are available, each derived from different sources and exhibiting distinct properties [

Table 1. Bone grafting materials derived from various sources with different properties [3,4,5].

Graft Type	Source	Key Features
Alloplast (synthetic)	Lab-made materials (e.g., calcium phosphate, hydroxyapatite)	Biocompatible. Osteoconductive. Customizable properties. No risk of disease transmission.
Autograft	Patient’s own bone or tooth (e.g., bone taken from chin, hip, jaw)	Gold standard (bone autograft). Osteogenic, osteoinductive, and osteoconductive. No immune rejection. Slower resorption rate when mixed with alloplast compared to other alternatives.
Allograft	Human donor bone or tooth (Usually cadaveric)	Processed to reduce immune response. Osteoconductive. Osteoinductive potential if dentin is demineralized. Risk of disease transmission. No additional donor site surgery needed.
Xenograft	Animal bone or tooth (e.g., from bovine, porcine, or camel teeth)	Widely available. Osteoconductive scaffold. Safe after processing. Relatively slow resorption. No osteogenic cells.
Growth and Differentiation Factors	Biologically active proteins (e.g., Bone Morphogenetic Proteins)	Used adjunctively to stimulate bone formation. Often combined with graft materials.

] [3,4].

The concept of bone grafting started around 2000 B.C., with evidence of animal bone used for human skeletal repair [6]. The first well-documented modern bone grafting procedure was performed in 1668 by Jacob van Meekeren, who implanted dog bone into a soldier’s skull, demonstrating the potential for bone regeneration [7]. By 1821, the concept of bone autograft was presented in Germany, marking a significant milestone in surgical practice [7,8,9]. In the 20th century, synthetic graft materials were introduced, and with the discovery of bone morphogenetic proteins (BMPs) in the 1960s, bone regeneration strategies were furtherly enhanced [10].

For a long period, the field of bone grafting mostly relied on harvesting bone from the patient’s own body, donors, or synthetic production in laboratories [11]. However, recently, an innovative archetype has been emerging that transformed what was once considered dental waste material into a possible therapeutic gold alternative. At this point, extracted teeth that are routinely collected in dental clinics was introduced as a new method for bone regeneration strategies by recycling and repurposing these discarded teeth to address patients’ oral rehabilitation needs in a sustainable and innovative manner, using a method known as tooth grafting [12]. The history of tooth grafts began in 1967 when Arthur Urist and colleagues demonstrated the osteoinductive properties of demineralized autologous dental matrix, establishing a foundation for using teeth as bone graft material. In 1991, research by Bessho et al. identified BMPs in human dentin, further supporting the potential for bone regeneration [13]. A significant milestone was achieved in 2002, when the first successful clinical application of human tooth-derived material for maxillary sinus lifting was reported in Japan, marking the beginning of its practical use in regenerative dentistry [14].

Teeth share notable compositional similarities with bone tissue, containing comparable inorganic hydroxyapatite matrices (65%) and organic matrices (25%). Both bone and tooth also contain type I collagen and non-collagenous proteins, such as sialoprotein, osteocalcin, osteonectin, and phosphoprotein, which are required for bone matrix formation and mineralization [5]. Furthermore, growth factors like mineralization protein LIM-1 (LMP-1) and transforming growth factor-β (TGF-β) are also present. These components make the tooth a natural biocomposite to be utilized as a bone grafting material [15]. Since biocomposites combine two or more different materials to produce superior properties compared to individual components, this seems beneficial for regeneration [16]. Examples of biocomposites include hydroxyapatite-collagen composites [16,17], calcium phosphate-polymer composites [16], decellularized bone matrix composites [18], and chitosan-based nanocomposites [19]; and recently, tooth autografts [5]. This final option seems to be advantageous and is often preferred due to low costs, reduced immunogenicity, and minimal rejection risk. Scientific research has shown promising outcomes of tooth autografts for ridge augmentation, including faster healing and better functional results [5,20]. However, some limitations exist, such as patient age or tooth availability [11,12,13,20]. In such cases, tooth allografts, among other alternatives, can serve as a viable solution. Tooth allografts are obtained from teeth harvested from living donors or cadavers. They share the same properties as autografts but have different genotypes. Furthermore, recent advances in tissue preservation, sterilization, and processing through tooth banks have made the clinical use of stem cells from allogenic teeth possible [21]. Based on these developments, it is reasonable to anticipate that tooth allografts will be a promising option in the near future for routine bone regeneration operations in dental clinics.

Although scientific evidence supports the successful use of tooth autografts, there are no published studies on tooth allografts in the literature. This narrative review aims to offer a thorough overview of tooth grafts (limited to autografts due to available scientific evidence) compared to other graft types, with the goal of evaluating tooth allografts as a potential future bone graft material in oral and maxillofacial surgery. For this purpose, this review discusses tooth grafts for material properties, tissue banking techniques, and various clinical applications. It critically examines the potential advantages and challenges of tooth allografts in future for regenerative dentistry. The intent is to provide clinicians with a comprehensive synthesis of current scientific data on tooth grafting materials to help them make informed decisions when selecting alternative graft options.

2. Methodology

This narrative literature review aimed to evaluate the use of tooth grafts as biomaterials for bone regeneration. A comprehensive search was conducted across national and international scientific databases including PubMed, Scopus, Web of Science, Google Scholar, and Medline. The search terms used were “tooth graft” or “autogenous dental graft” or “autogenous tooth bone graft” or “allogenic dental graft” or “allogenic tooth bone graft” combined with “bone regeneration”, and only articles published in English were considered.

Inclusion criteria comprised clinical, laboratory, and review studies addressing tooth grafting in implant dentistry or bone regeneration, published in peer-reviewed journals with a focus on clinical aspects in the recent 5 years. Excluded from the analysis were opinion pieces, editorials, conference abstracts, and studies unrelated to the topic, as well as articles focusing on tooth autotransplantation or bone grafts. Article selection was guided by the objectives of this review, ensuring alignment with the study aims. Abstracts, results, and conclusions were thoroughly evaluated. The review process utilized analysis principles described by Mendes Miskulin (2017) (a qualitative data classification technique that identifies significant patterns) [22]. Quality assessment of included studies focused on the clarity of objectives, methodological rigor, and result consistency. Priority was given to studies meeting these standards to ensure the evidence presented was both relevant and of high quality.

3. Tooth Grafts

3.1. Bone Autografts and Tooth Autografts

Bone autografts have historically been considered the gold standard for bone regeneration procedures, principally because they embody all the ideal traits of a graft: osteoconductivity, osteoinductivity, osteogenesis, and effective bone binding [23,24]. Autogenous bone, harvested from intraoral sites like the mandibular ramus or symphysis or extraoral sites such as the iliac crest, provided not only a structural scaffold but also living cells and a rich matrix of growth factors, including type I collagen and non-collagenous proteins, critical for new bone formation and integration [25]. These characteristics, coupled with excellent biocompatibility and non-toxicity, which contribute to fast and effective bone regeneration, especially valuable in critical defects (>5 mm) where vascularization of the graft is paramount [11]. Studies by Nkenke and Neukam have shown low graft failure rates and high patient acceptance for intraoral donor sites like the ramus and symphysis, with the ramus being preferred for horizontal or vertical ridge augmentation and sinus elevations [26]. A comprehensive retrospective review (2009–2011) conducted in a German military hospital documented a graft survival rate of 95.6% and an early implant survival rate of 99.7% at reconstructed sites using autologous bone [25].

Nonetheless, critical drawbacks persist. Bone harvesting necessitates additional surgery, resulting in donor site morbidity characterized by postoperative pain, infection, scarring, and neural disturbances, most notably hypoesthesia of the mandibular and lingual nerves, observed in up to 10.4% and 2.8% of cases, respectively, though these complications were temporary and recovered within the medium term [11,25,27]. The quantity and quality of available donor bone can be restricted by age, osteoporosis, diabetes, and other systemic diseases, often limiting these procedures [11]. Furthermore, resorption rates for bone blocks can range widely, from 25% to 60%, as shown by Widmark et al., affecting the long-term stability and necessitating careful monitoring [25,28]. Strategies like limiting the post-grafting period to 3–6 months have proven effective for minimizing resorption and facilitating earlier implant restoration [25]. Moreover, there are additional concerns such as need for hospitalization and a multidisciplinary team for extraoral harvesting, alongside the risk of soft tissue dehiscence and infection (with rates 2.6–5.6%) [25].

Tooth autografts have emerged as a trending and scientifically validated alternative, drawing particular interest due to their similar embryologic origin and biochemical composition with bone [24]. Teeth, especially dentin, consist of 70–75% inorganic content, 20% organic (predominantly type I collagen), and about 10% water, which is similar to the composition of alveolar bone [24,29]. Numerous studies have demonstrated that dentin contains a range of growth factors and non-collagenous proteins (e.g., BMPs, Insulin-like Growth Factor (IGF), TGF-β, Dentin Matrix Protein 1 (DMP-1), Dentin Sialophosphoprotein (DSPP), Osteocalcin (OC), Osteopontin (OPN), and Alkaline Phosphotase (ALP) that play fundamental roles in promoting osteogenesis and angiogenesis [24,30]. Early experimental work by Yeomans et al. revealed that decalcified dentin transplanted into rabbit muscle induced osteoinduction and stable new bone formation within four weeks, establishing the premise for further research into human applications [31]. Kim et al.’s pioneering animal studies validated the osteoinductive potential of autogenous dentin, culminating in the development of granular bone substitute material (AutoBT, Korea Tooth Bank) [24,29,32]. Additional research by Xu et al. and Schwarz et al. correlated the replacement of the tooth graft-bone interface with new bone and satisfactory support for the alveolar crest and successful staged implantation [24,33,34].

Structural and chemical analyses, including Scanning Electron Microscope (SEM) and X-ray Diffraction (XRD) studies, reinforce the similarity between tooth grafts and autogenous cortical bone, with the root segment of tooth grafts manifesting low crystallinity that enhances osteoinduction and osteoconduction while the crown’s high crystallinity makes it less susceptible to breakdown but suitable for structural roles [24]. The presence of dentin-specific non-collagenous proteins, unique to tooth but with homologous roles in bone tissues (e.g., DPP, DSP, DMP-1), further cements the biological equivalence and potential clinical utility of tooth autografts [24]. Key osteogenic and angiogenic factors such as TGF-β, Platelet-Derived Growth Factor (PDGF), Fibroblast Growth Factor (FGF), Vascular Endothelial Growth Factor (VEGF), and IGF-I/II are abundantly present in dentin and have been shown to regulate cell proliferation, differentiation, and bone matrix synthesis, collectively enhancing wound healing and supporting new bone formation in both in vivo and in vitro settings [24]. Koga et al. and Bono et al. have highlighted the crucial role of partial demineralization and sterilization in exposing BMPs and collagen fibers, optimizing osteoinductive potential and minimizing the risk of infection [24,35,36].

The clinical relevance of tooth autograft has been confirmed through multiple comparative and prospective studies. Minetti et al. analyzed 101 histological specimens of sites treated with demineralized autologous tooth-derived biomaterial for alveolus preservation, showing reliable formation of vital new bone suitable for dental implant rehabilitation [12,37]. Similarly, Korsch and Peichl’s retrospective analysis compared the tooth-shell and bone-shell techniques for lateral ridge reconstruction and found no significant differences in outcome, complications, or osseointegration, underscoring the viability of autologous dentin as a less invasive alternative [12,38]. Sang-Ho Jun et al. compared tooth bone grafts with inorganic bovine bone (Bio-Oss) for sinus grafts, revealing equivalent bone density and height and superimposable implant stability and marginal bone resorption between groups [12,39]. Okubo et al. and Park et al. explored the use of deciduous teeth particles for site preservation and bone augmentation, noting strong osteoinductive capacity and an absence of adverse immune reactions—a crucial benefit in patients reluctant to accept animal-derived biomaterials [12,40,41].

Despite these impressive findings, tooth autografts face critical practical limitations. The volume available from extracted teeth is inherently limited, averaging between 0.38–0.96 cc per tooth (mean weight 0.68–1.88 g), rendering it insufficient for large defect repairs unless combined with other biomaterials such as autologous bone or xenografts, a solution supported by Umebayashi et al. [12,42]. Kadkhodazadeh et al. found that human tooth particulates can increase cell proliferation compared to bovine xenograft, synthetic graft, and demineralized freeze-dried bone allograft, though its overall osteopromotional capacity was slightly inferior to that of purer osteogenic materials [12,43]. Additionally, long-term studies have noted that some cases involving dentin grafts exhibited high bone resorption rates, though rapid bone replacement occurred without inflammatory response and overall performance was at least comparable to allogeneic and xenogeneic biomaterials [44].

Tooth autograft techniques avoid the need for a secondary donor site, which drastically reduce surgical morbidity, hospital costs, and patient recovery time—a compelling consideration in contemporary minimally invasive dentistry [11]. The methods for processing teeth into usable graft material, notably those employing chairside tooth transformers and automated shredding/decontamination machines, are rapidly improving, expanding the feasibility of autologous tooth-derived biomaterials in routine practice [12,24].

Bone autograft, as confirmed by systematic reviews and multicenter clinical data, remains the gold standard for regenerating critical-size bone defects, but its inherent requirement for additional surgery, morbidity, and resource restriction has driven the pursuit of alternative approaches [11,23,24,25]. Tooth autograft, supported by extensive biochemical, histological, and clinical research—citing works from Kim et al. [29,30], Yeomans et al. [31], Xu et al. [33], Bono et al. [36], Minetti et al. [37], Korsch and Peichl [38], Sang-Ho Jun [39], and others—offers a scientifically sound, biologically active, and patient-friendly alternative for small to moderate defects, alveolar preservation, and single-site augmentation [12]. The ideal choice between these materials must take into account defect size, patient risk, and clinician expertise. Autologous tooth grafting is likely to become standard practice for many indications given its favorable biology, reduced invasiveness, and comparable outcomes to the traditional gold standard.

3.2. Autografts and Allografts for Bone Regeneration

Bone autografts, when compared with bone allografts, possess intrinsic living cells and a rich matrix of growth factors, providing both scaffolding and biological stimulus essential for new bone formation [5]. Various studies have illustrated that autografts yield successful outcomes, that expedites mineralization and osteointegration [11]. In a comparative bone regeneration study of mandibular defects, autografts produced a bone density of 65% at four weeks, which increased to 85% by eight weeks, while allografts achieved only 45% and 65% at the same intervals [45]. The histomorphometric and biochemical analyses further revealed higher osteocalcin and alkaline phosphatase levels in the autograft group, marking greater osteoblastic activity and higher bone turnover rates [45]. However, the disadvantages, coupled with the unpredictable resorption rates and the costs associated with surgical complexity, have driven practitioners to seek alternatives that reduce patient morbidity and streamline clinical workflows [5].

Bone allograft, in this regard, has gained widespread option in dental surgeries, especially for medium and small-sized defects. Allografts are obtained from human donors and processed in bone banks, and exist in various forms, such as fresh-frozen, freeze-dried, demineralized bone matrix (DBM), or decellularized extracellular matrix (dECM) [5,11,24,45]. Unlike autografts, bone allografts inherently lack living osteogenic cells due to processing, and most of their biological activity depends on their retained matrix and the presence of growth factors like BMPs and non-collagenous proteins [5]. The osteoinductive and osteoconductive properties of mineralized and demineralized allografts have been repeatedly evaluated, with the consensus that while allografts provide a competent scaffold for bone formation, their osteogenic capability is significantly less compared to autografts [3]. Urist’s research initially correlated BMP presence with the osteoinductive capability of cortical allograft but subsequent studies indicate that cancellous bone allografts may possess marginally superior osteoinductive properties, as their lower density accelerates vascularization and matrix integration [5]. Modern research has shown that allograft demineralization, particularly when performed under optimal acidic conditions, exposes further bioactive components and enhances osteoinductive performance [3,5]. The loss of viable cells and the weakening of mechanical properties through lyophilization (freeze-drying) and sterilization, especially when gamma irradiation or ethylene oxide is used, remain persistent drawbacks, causing up to 60% reduction in torsional strength, and extended healing periods as compared to fresh or unprocessed bone [5]. Piattelli et al., for instance, showed that demineralized freeze-dried bone allograft was largely replaced by connective tissue rather than new bone, highlighting the limitations in osteoinductive potential [46]. Meanwhile, Barry et al. reported that the clinical success rates for large-volume allograft osteochondral procedures ranged only between 60 and 90%—a respectable figure, but not consistently matching that seen in autograft procedures [47]. The risk, albeit extremely low with modern protocols, of disease transmission, immune sensitization (especially related to Human Leukocyte Antigen (HLA) antigens as indicated by Piaia et al.), and possible graft rejection create further complications [3,5]. While most studies have demonstrated that regulatory safeguards minimize this risk (transmission rates cited at 1 in 2–8 million), these still remain a point of consideration in the literature and clinical decision-making [24].

A key advantage of allograft lies in its immediate availability and avoidance of donor site morbidity, eliminating the need for a second surgical intervention and associated complications [5,11]. Its flexible forms—block, particulate, paste—allow clinicians to tailor grafting approaches to site-specific requirements [5]. Furthermore, the combination of cortical and cancellous allograft tissue confers a synergy of mechanical strength and faster revascularization; cortical segments support the defect at early stages, while cancellous portions foster incorporation and replacement by new bone [5]. For large defects or load-bearing regions, these structural attributes can be advantageous. Freeze-dried bone allografts remain the most prevalent, offering long storage life and low immunogenicity, though their osteoinductive performance is limited by the absence of vital bone cells and reduced concentration of growth factors [3,11]. Clinical and animal model studies consistently reveal that while allografts are satisfactory for defect filling, socket preservation, sinus floor elevation, and peri-implant bone regeneration, healing is slower, integration is less predictable, and the new bone formed is sparser and less mature at comparable time points when compared with autograft [11]. In an experimental rabbit mandibular defect model, Group B rabbits receiving allograft showed delayed bridging, lower density, and reduced serum markers of bone formation compared to Group A autograft recipients, reinforcing these intrinsic limitations [45].

As a conclusion, bone allograft remains a widely used solution in dentistry, particularly for patients with limitations for autologous bone harvesting and while the regeneration potential is minor than autografts.

3.3. Tooth Allografts

Tooth allografts are natural biocomposites that can be derived either from living donors (such as premolars extracted for orthodontic treatment, third molars, or any periodontally compromised teeth) or from cadavers, and they contain natural mineral content and collagen matrix. Although no published articles currently exist on tooth allograft, it is reasonable to anticipate that its future clinical properties would mirror those observed in bone autograft, bone allograft, and tooth autograft, combining both opportunities and challenges.

From bone allograft experiences, a tooth allograft would likely retain the key osteoconductive and potentially osteoinductive properties derived from dentin’s unique growth factor and collagen content, albeit without living osteogenic cells, which limits direct osteogenesis as seen with autografts. Like bone allografts, a tooth allograft might present advantages such as immediate availability, elimination of donor site morbidity, and scalable preparation for treating a wider range of defects. However, like the challenges found in bone allograft, there would be concerns about immunogenicity and disease transmission, given the transfer of graft material between genetically different individuals, and it remains uncertain how the immune system would respond specifically to allogeneic dentin or tooth tissue. Another likely drawback is that processing methods essential for making tooth allograft safe—such as sterilization and possible demineralization—could diminish its biological activity just as observed in freeze-dried or demineralized bone allografts, ultimately reducing the graft’s osteoinductive potential and mechanical integrity.

While tooth allografts might serve as versatile scaffolds for alveolar bone regeneration, their osteogenic capacity would probably remain inferior to that of tooth or bone autografts, and rigorous screening protocols would be vital to minimize infection risk, following protocols established for bone allograft transplantation. Hence, the future development of tooth allograft as a grafting material has potential to offer a valuable, biocompatible alternative, with clinical significance in expanding the pool of available graft tissue. Advantages include reduced surgical morbidity, and a non-invasive treatment option. However, its efficacy and safety will depend on overcoming challenges analogous to those faced by bone allografts, including the optimization of processing protocols to preserve biological activity without compromising mechanical strength or patient safety.

Since tooth allografts requires rigorous donor screening and processing to ensure safety, several challenges arise including regulatory restrictions on tooth sourcing, shorter usability span, difficulties in standardization and sterilization, risk of disease transmission and immunogenic reactions due to the presence of donor antigens, elevated processing costs, issues related to patient acceptance, ethical considerations, and technique sensitivity that require rigorous quality control and further investigation. As common knowledge obtained from scientific reports, after bone grafting, there may be a transient increase in immune markers, such as immunoglobulins and T-cell activation, particularly CD4+ cells, indicating a humoral and cellular response to the graft [48]. Although modern processing techniques used for bone allografts (e.g., deep freezing, decellularization) reduce antigenicity, complete elimination is challenging, and a significant proportion of recipients may develop immunological sensitization, as evidenced by HLA responses [3]. Despite these reactions, clinical complications are infrequent, and the immunogenicity is generally considered moderate and acceptable for clinical use. In near future, tooth allografts can serve as valuable alternatives, but further research is lacking to understand their risks and advantages over the other options.

4. Tooth Banking

Tooth banking involves the systematic collection, sterilization, processing, and storage of extracted teeth. This concept extends beyond dental pulp stem cell preservation used in tissue banking [49]. Tooth banking as described by Zeitlin, is a minimally invasive procedure that collects teeth from dental clinics or hospitals when patients undergo the extraction of third molars or periodontally compromised teeth, or extractions required during orthodontic treatment [49]. These teeth, sourced from living donors or cadavers, can offer a valuable alternative to autografts as they undergo specialized processing to be transformed into biocompatible bone graft substitutes [49]. The future protocol for banking teeth intended for tooth allograft use should emphasize stringent cleaning, sterilization, and quality control to ensure safety and efficacy. The protocols should align with international tissue banking standards, including sterility assurance levels (SAL) and validated sterilization methods, to guarantee the safety of tooth allografts for its future clinical use [50].

To date, tooth banking has primarily been used to preserve dental pulp stem cells (DPSCs), which are mesenchymal stem cells found within the dental pulp tissue of extracted or exfoliated teeth. These stem cells have significant regenerative potential for use in dental and systemic tissue regeneration due to their ability to differentiate into multiple cell types [49,50]. The first step after extraction of a tooth is to immediately place it in sterile transport media like balanced salt solutions such as phosphate-buffered saline (PBS) or hanks buffered saline solution (HBSS), to prevent microbial contamination while transporting it to the laboratory. The process starts with disinfection of the tooth and inspections to confirm its suitability for graft processing. Detailed documentation of the tooth’s origin should also be recorded. Processing should occur in controlled sterile rooms to minimize contamination risks and cross-sample microbial transfer [49].

Just like tooth autografts, after cleaning and inspection, the tooth can be milled into granules of controlled particle size, optimizing surface area for cell attachment and vascular infiltration. It is then demineralized, as the primary focus for graft material preparation is on mechanical and chemical processing to convert the tooth into a bone graft substitute. It selectively exposes the organic matrix, such as collagen, thereby enhancing osteoinductive and osteoconductive properties by increasing the availability of bioactive factors like BMPs. The graft material undergoes validated sterilization steps to eliminate pathogens while preserving biological activity [37].

Nowadays, demineralization can be performed using automated processing systems, such as the Tooth Transformer system (TT Tooth Transformer SRL, Milan, Italy), BonMaker (Korea Dental Solution Co., Ltd. (KDS), Busan, South Korea), Vacuasonic (CosmoBioMedicare Co., Ltd., Seoul, South Korea), and Smart Dentin Grinder (KometaBio Inc., Tenafly, NJ, USA) [24,37]. These devices automate the cleaning, grinding, demineralization, and sterilization of extracted teeth, turning them into particulate or block graft materials suitable for bone regeneration in just a few minutes. This process can also enable the tooth allograft to act as a natural biocomposite scaffold, closely resembling tooth autografts in both composition and regenerative potential.

Regulatory and Ethical Considerations: The use of tooth allografts as graft material will be subjected to rigorous regulatory oversight to ensure patient safety. This starts with donor screening protocols that include evaluation of the medical history, testing for any infectious disease, and consent procedures aligned with national and international tissue banking regulations, such as those outlined by the European Union or the U.S. Food and Drug Administration (FDA), depending on jurisdiction. This includes maintaining detailed records, ensuring sterility and quality control, and providing documentation of graft processing and storage conditions [50].

Ethical considerations also play a pivotal role in graft material selection and use. Full transparency and proper consent are essential when sourcing and utilizing extracted teeth to uphold ethical standards and maintain patient trust [49,50].

5. Future Directions and Perspectives

The integration of advanced material science, bioengineering, and personalized medicine in the field of bone regeneration is rapidly evolving with the advent of next-generation biocomposites [51]. Ongoing clinical trials and multicenter randomized controlled trials are critical to validate the safety, efficacy, and long-term benefits of these next-generation biocomposites. These innovations promise to revolutionize regenerative dentistry and maxillofacial surgery by providing grafts that are biologically active, mechanically robust, and precisely tailored to individual anatomical and clinical requirements. These innovations also have the potential to reduce surgical time and morbidity, enhance bone volume retention and implant success rates, and solve issues of donor scarcity and disease transmission [51,52]. Notably, bone allografts derived from human donors are currently popular in clinical practice, accounting for over 57% of the bone graft market [53]. Given this substantial market share and the ongoing growth driven by their osteoconductive and osteoinductive properties, it is reasonable to envision that tooth allografts—once fully accepted by regulatory authorities and legalized for widespread clinical use—can represent a significant portion of the market in the future. With their natural biocomposite characteristics and promising clinical outcomes, tooth allografts can become a major alternative bone graft material, complementing or even expanding the current allograft market.

Recent development of nanostructured scaffolds and growth factor delivery systems that enhance the osteoinductive and osteoconductive properties of graft materials has shown control over scaffold architecture at the molecular level by improving cell adhesion, proliferation, and differentiation. Furthermore, bone healing and remodeling can be improved by incorporating bioactive molecules such as BMPs and platelet-derived growth factors into these scaffolds. These engineered grafts aim to recapitulate the osteoconductive and osteoinductive properties of native bone while offering scalable production and reduced risk of disease transmission [54,55,56].

“Smart” grafts, fabricated using 3D printing, such as those produced with the maxgraft® bonebuilder technology (Botiss biomaterials GmbH, Zossen, Germany), have been a significant breakthrough [57]. With the help of patients’ imaging data and Computer-Aided Design (CAD), grafts that perfectly fit complex anatomical defects can be produced, particularly in craniomaxillofacial reconstruction. Personalized bio-ceramic grafts and hybrid composites with integration of mesenchymal stem cells can be engineered and 3D printed to match the mechanical and biological properties of native bone, optimizing integration, load-bearing capacity, and promoting rapid vascularization [58].

To treat complex bone defects with patient-specific, cell-seeded scaffolds, personalized grafting and tissue engineering techniques are becoming more viable for clinical use. Projects like MAXIBONE and technologies like Segmental Additive Tissue Engineering (SATE) are prime examples of the translation of laboratory innovations into clinical trials [59]. MAXIBONE was a European research project aimed at creating personalized maxillary bone regeneration by using autologous bone marrow stem cells from the iliac crest combined with 3D-printed biomaterial scaffolds to address maxillofacial bone deficits before dental implant placement. It was a multicenter randomized controlled trial of 101 patients across six countries; the project demonstrated the safety and efficacy of autologous cultured stem cells and calcium phosphate biomaterials as an alternative to traditional bone grafting. The outcomes of this project showed satisfactory bone regeneration in patients, enabling successful placement of dental implants in treated patients, and the project demonstrated the viability of Mesenchymal Stem Cell (MSC)-based therapies for jawbone augmentation prior to dental implant placement. These strategies emphasize the importance of tailoring graft composition, geometry, and cellular content to meet the specific needs of each patient, thereby enhancing functional and aesthetic outcomes [59].

Biocomposite graft materials are an advancing area within regenerative dentistry and maxillofacial surgery that increasingly emphasizes the use of customized materials tailored to meet specific clinical requirements. There is a growing need for systematic reviews and meta-analyses focusing on the latest scientific literature comparing various bone graft alternatives, including traditional methods and emerging technologies like custom-made 3D printing. Such comprehensive evaluations will help clarify outcomes reported in the literature, illustrate the impact of technological innovations on bone regeneration, and assess the practicality and effectiveness of novel graft materials.

6. Conclusions

Technological developments in tissue processing, customized graft manufacturing, and growth factor delivery systems have the potential to completely transform the use of next-generation biocomposites, providing grafts that are not only mechanically strong and biologically active but also specifically adapted to each patient’s anatomical and regenerative needs. Tooth autografts have already proven their advantages over other grafting options; however, there are no scientific papers on tooth allografts, and further research and clinical validation are lacking to evaluate tooth allografts’ function and outcomes as future alternatives for dental and craniofacial restorations.