Rethinking the Gold Standard: James Melville, DDS, FACS, on Tissue Engineering

At a 12-year-old boy’s final preoperative appointment, he told his doctor how eager he was to return to showing cattle at the rodeo. Diagnosed with ameloblastoma and scheduled for a free fibula procedure, he would typically have faced a recovery period that made competing unlikely for at least a year.

However, his physician, James Melville, DDS, FACS, has dedicated his career to advancing the emerging field of tissue engineering. Recognizing that the boy was a strong candidate, Dr. Melville recommended tissue engineering as an alternative approach. The surgery was successful — and the boy was back at the rodeo just one month later.

Dr. Melville still performs traditional free vascular transfers in approximately 80% of cases. However, when a patient has an eligible defect — particularly when adequate soft tissue closure can be achieved — he offers tissue engineering as an option. For patients like the young cowboy, this approach can mean a much faster return to normal life compared to a lengthy procedure requiring the harvest of fibula, hip, or shoulder bone.

Dr. Melville first became interested in tissue engineering during his residency at the University of Miami under Robert Marx, DDS, an early pioneer in the field. At a time when many believed true regeneration was not possible, he was struck by the number of patients improving with this approach. 

When he later established his practice in Houston, he began implementing tissue engineering and adapting it based on his own clinical experience. “We put different aspects into what we do. I think that’s best for the patient,” he says.

At its core, Dr. Melville explains, tissue engineering is the ability to regenerate bone — and, to a lesser extent, nerves and dermis — using the patient’s own biology. In oral and maxillofacial surgery, its primary role is rebuilding bone in the alveolus, mandible, and maxilla. While autogenous bone grafting remains the gold standard, tissue engineering offers a way to avoid a second surgical site. Instead of harvesting bone, clinicians can aspirate and concentrate progenitor cells through a minimally invasive approach and use them to direct new bone formation.

The approach relies on three essential components: cells, a scaffold or matrix, and a signaling molecule such as bone morphogenetic protein (BMP). When combined in a stable, protected environment, these elements allow the body to regenerate targeted tissue. “Tissue engineering is decreasing morbidity of the donor harvest and regenerating the patient’s own bone by maximizing the biological capabilities of their own body,” Dr. Melville says.

Rather than relying on a laboratory, Dr. Melville views the body itself as the bioreactor. By creating the right conditions in vivo — and maintaining a reliable soft tissue barrier — bone can form predictably within the patient.

Patient selection remains critical. Dr. Melville evaluates both the size of the defect and the availability of soft tissue coverage. Cases where a stable mucosal closure can be achieved are the best candidates, while defects with direct communication to the oral cavity present greater challenges. “If I determine we have enough tissue to close, achieve a tight seal, and maintain a barrier between the graft and the oral cavity, then the patient would be a candidate,” he says.

When patients are eligible, Dr. Melville presents all options — free fibula, traditional grafting, and tissue engineering. In the majority of cases, patients choose tissue engineering to avoid a second surgical site, a preference that is especially common among pediatric patients. His work has drawn patients from across the country and internationally, including as far as the Netherlands.

While he believes strongly in the approach, Dr. Melville acknowledges that widespread adoption will take time. Longstanding dogma and the continued status of autogenous bone as the gold standard present barriers to change. Still, he has seen firsthand how tissue engineering can improve patient outcomes.

“The exciting part is we are in an era of exponential advancement,” he says. “Eventually, maybe we will even create something in a lab and place it into a patient.”

He values hearing from other surgeons who have adopted his techniques and achieved similar results. “That’s the best validation,” he says.

Ultimately, Dr. Melville encourages fellow oral and maxillofacial surgeons to explore the approach. 

“It gives you another tool, and gives patients options,” he says. “Oral surgeons have really led advancements in bone regeneration and tissue engineering. We’ve already shown that tissue engineering is equivalent to the gold standard in certain cases. So we should embrace it and push it forward.”