the effect of the bioresorbable collagen membrane on the ...

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Merete Aaboe, Soren Schou, Erik Hjorting-Hansen,. Mogens Helbo. Osseointegration of subperiosteal implants using bovine bone substitute and various.
J Korean Acad Prosthodont : Volume 41, Number 3, 2003

THE EFFECT OF THE BIORESORBABLE COLLAGEN MEMBRANE ON THE REGENERATION OF BONE DEFECT BY USING THE MIXTURE OF AUTOGRAFT AND XENOGRAFT BONE Jung-Min Lee, D.D.S., M.S.D., Yung-Soo Kim, D.D.S., M.S.D., Ph.D., M.Sc.(O.S.U) Chang-Whe Kim, D.D.S., M.S.D., Ph.D., Jung-Suk Han, D.D.S., M.S.D., Ph.D. Department of Prosthodontics, Graduate School, Seoul National University Statement of problem : In cases where bony defects were present, guided bone regenerations have been performed to aid the placement of implants. Nowadays, the accepted concept is to isolate bone from soft tissue by using barrier membranes to allow room for generation of new bone. Nonresorbable membranes have been used extensively since the 1980's. However, this material has exhibited major shortcomings. To overcome these faults, efforts were made to develop resorbable membranes. Guided bone regenerations utilizing resorbable membranes were tried by a number of clinicians. Bio-Gide� is such a bioresorbable collagen that is easy to use and has shown fine clinical results. Purpose : The aim of this study was to evaluate the histological results of guided bone regenerations performed using resorbable collagen membrane(Bio-Gide�) with autogenous bone, bovine drived xenograft and combination of the two. Surface morphology and chemical composition was analyzed to understand the physical and chemical characteristics of bioresorbable collagen membrane and their effects on guided bone regeneration. Material and methods : Bioresorbable collagen membrane (Bio-Gide�), Xenograft Bone(BioOss),Two healthy, adult mongrel dogs were used. Results : 1. Bioresorbable collagen membrane is pure collagen containing large amounts of Glysine, Alanine, Proline and Hydroxyproline. 2. Bioresorbable collagen membrane is a membrane with collagen fibers arranged more loosely and porously compared to the inner surface of canine mucosa : This allows for easier attachment by bone-forming cells. Blood can seep into these spaces between fibers and form clots that help stabilize the membrane. The result is improved healing. 3. Bioresorbable collagen membrane has a bilayered structure : The side to come in contact with soft tissue is smooth and compact. This prevents soft tissue penetration into bony defects. As the side in contact with bone is rough and porous, it serves as a stabilizing structure for bone regeneration by allowing attachment of bone-forming cells. 4. Regardless of whether a membrane had been used or not, the group with autogenous bone and Bio-Oss� filling showed the greatest amount of bone fill inside a hole, followed by the group with autogenous bone filling, the group with blood and the group with Bio-Oss� Filling in order. 5. When a membrane was inserted, regardless of the type of bone substitute used, a lesser amount of resorption occurred compared to when a membrane was not inserted. 6. The border between bone substitute and surrounding bone was the most indistinct with the group with autogenous bone filling, followed by the group with autogenous bone and Bio-Oss� filling, the group with blood, and the group with Bio-Oss� filling. 7. Three months after surgery, Bio-Gide� and Bio-Oss� were distinguishable. Conclusion : The best results were obtained with the group with autogenous bone and Bio-Oss� filling used in conjunction with a membrane. Key Words Guided tissue regeneration, Bioresorbable Collagen Membrane, Bovine Drived Xenograft, Autogenous Bone

325

T

proper resorption rate enough to retain barrier

factors in the long-term success of implants. If the

Recently introduced bioresorbable collagen bar-

amount of the bone at the site is insufficient, the

rier (Bio-Gide�, Geistlich Biomaterials, Wolhusen,

implant cannot be completely submerged in the

Switzerland) has been used widely for guided bone

bone and will be exposed over soft tissue. The irritation

regeneration. It is very easy to use in guided bone

from surrounding soft tissue and the decrease of

regeneration and has shown fine clinical results.11,13

bone contact area could lead to increased probabili-

Bio-Gide� can be fused firmly to connective tissue

ty of implant failure. In cases where bony defects were

in contrast to nonresorbable membranes.14 In com-

present, guided bone regenerations have been per-

parison with nonresorbable membranes, collagen bar-

formed to aid the placement of implants.

riers showed greater decrease in probing depth,

function for five to six months.12

he quantity of the bone is one of the important

1,46

Guided bone regenerations have been used suc-

increase in attached gingiva and bone fill.15 Bio-

cessfully in restoring bony defects around im-

Gide� was readily resorbed without any inflammation

plants.2 Bone substitutes with osteoconductive

when dehiscence occurred. So it permitted dehiscence

properties and growth factors have been used

to be covered with granulation tissue.16 Resorbable

in the past to promote bone growth. Nowadays, how-

collagen membranes applied to wounds are readi-

ever, the accepted concept is to isolate bone from soft

ly stabilized through gel formation by collagen

tissue by using barrier membranes to allow room for

fibers and the actions of blood in the surgical area.

generation of new bone. The functions of barrier

Bio-Oss� is a hydroxyapatite bone substitute

membranes are inhibiting soft tissue growth into bony

made from bovine extremities. Among currently used

defects, protecting and immobilizing blood clots, and

bone substitutes, Bio-Oss� shows the greatest sim-

providing time needed for osteoblasts to proliferate

ilarity to human bone and exhibits a very high de-

and regenerate bone.7,8

gree of osteoconductivity during bone regenera-

3

4,5

6

Nonresorbable expanded polytetrafluoroethyl-

tion.56,57 Bio-Oss� shows slow resorption during re-

ene membranes (e-PTFE; Gore-Tex, W.L. Gore and

modeling. It has been well documented that Bio-Oss�

Associates, Flagstaff, AZ, USA) have been used

participates in bone remodeling and is resorbed

extensively since the 1980's. However, this mater-

slowly by osteoclasts.62 Most studies reported the de-

ial has exhibited three major shortcomings : fre-

creased resorption of regenerated bone when a

quent exposure of the membranes after surgery

combination of autogenous bone and Bio-Oss �

resulting in failure of guided bone regeneration, the

was used comparing to autogenous bone alone.

need for an additional surgery to remove the mem-

But, the results varied according to studies.36

9

brane, and the exposure of the newly regenerated

Guided bone regeneration utilizing Bio-Oss� and

bone to resorptive conditions after removal of mem-

Bio-Gide� in combination showed great success clin-

brane.10 To overcome these shortcomings, resorbable

ically.36 Most of the studies on bone regeneration conducted

membranes were introduced recently.

so far demonstrated individual differences among

Guided bone regenerations with resorbable mem11

branes were attempted by a number of clinicians.

subjects. To prove efficacy of procedures, a number

The required characteristics of resorbable mem-

of animals were utilized. In this study, to elimi-

11

brane for successful guided bone regeneration are

nate those variations of individual subject, com-

: the absence of foreign body reaction, bioresorba-

binations of bone substitute and membrane were in-

bility, the absence of residues after resorption and

vestigated in the same animals at three different heal-

326

ing period on bone regeneration properties.

was examined using SEM (×2000). Rough and

The aim of this study was to evaluate the histo-

smooth surfaces of the collagen membrane were ex-

logical results of guided bone regenerations using

amined in high power resolution (×500, ×2000).

resorbable collagen membrane (Bio-Gide� ) with autogenous bone, Bovine drived xenograft (Bio-Oss�)

b. Cross-sectional evaluation of Bio-Gide� (SEM)

and combination of the two. Surface morphology and

An overall survey of the membrane's cross-section

chemical composition was analyzed to understand

was carried out (×150). Each layer of the mem-

the physical and chemical characteristics of Bio-

brane was examined in high power resolution

Gide� and their effects on guided bone regeneration.

(x1000).

MATERIALS AND METHODS

3. Histological Evaluation

A. Materials.

Two healthy, adult mongrel dogs weighing approximately 15Kg were selected. All bicuspids were

Two adult healthy mongrel dogs with weighing

extracted beforehand and allowed to heal for three

approximately 15Kg were used. Bovine drived

months. Three months after tooth extractions, first



xenograft (Bio-Oss , Geistlich Biomaterials,

procedure for regeneration was performed. Ketamine

Wolhusen, Switzerland : particle size : 0.25-1.00

HCl (0.2cc/kg) (Ketalar ; Yuhan-Kimberly, Seoul,

mm) and Bioresorbable collagen membrane (Bio-Gide

Korea) and xylazine (0.3cc/kg) (Rompun ; Bayer-



Korea, Seoul, Korea) were used to induce general

, Geistlich Biomaterials, Wolhusen, Switzerland :

25 mm×25 mm) were used in this study.

anesthesia. Bio-Gide� was used on the right side . To serve as control, Bio-Gide� was not used on the left side. After performing local anesthesia with 2 %

B. Methods.

lidocaine (1:100000 epi. Kwangmyung, Seoul, Korea), crestal incision and vertical incision extending from

1. Composition Analysis of Bio-Gide � ;

the ridge crest to the lower border of the mandible

Fluorometric Analysis System.

was carried out on the buccal side and elevated a full

(KOREA BASIC SCIENCE INSTITUTE : KBSI)

thickness flap to expose bone surface. Special care was taken to avoid the damage of inferior alveolar

Hydrolysis and PITC labeling was performed

nerve. After complete deflection of the flap, a

on 0.61mg of Bio-Gide � via PICO-tag (Waters)

trephine bur, 5mm in diameter (3i Implant

method. Chromatogram was obtained by loading 10

Innovations Inc., USA), was used to create four ar-

μl of specimen, taken from the 4000μl of PITC-labelled

tificial bony defects 1.5mm in depth. A round bur was

test material, onto a HPLC apparatus.

used to remove the column of bone created by the

(http://comp.kbsi.re.kr/home/biomol/instru-

trephine bur and smooth the floor of the cavity to

ment/FAS/HPLC.html)

form a cylindrical bony hole 5 mm in diameter and 1.5mm in depth. These holes were set 1-2 mm

a. Surface evaluation (SEM : JSM-840A, JOEL,

apart. Starting from the most anterior cavity and mov-

Japan)

ing posteriorly, the bony holes were filled with

The inner surface of canine mucosa (Schneiderian

blood (without bone substitute), autogenous bone



(bone particles formed during drilling), autoge-

membrane) and the rough surface of Bio-Gide

327

was elevated only to a level just above the area of the

nous bone+Bio-Oss� (1:1 ratio by volume) and BioOss (Fig. 1). Each bone substitute filled its holes flush

first procedure. The rest were carried out identically.

with the original ridge level. On the right side, a piece

Antibiotics and analgesics were prescribed.



Two months after the first procedure, the third pro-



of Bio-Gide large enough to cover all the holes

cedure was carried out with the same method.

were placed over the bone before closing the mucoperiosteal flap (Fig. 2). On the left side, to serve as

Three months after the first procedure, the fourth

controls, the flap was closed without placing mem-

procedure was performed. After the crestal incision,

branes. Antibiotics and analgesics were prescribed

vertical incision descending from the ridge crest was

(Kanamycin, Anaprox).

placed on the lingual side to elevate a full thickness flap. The rest was done in the same manner as

One month after the first procedure, the second pro-

with the first procedure.

cedure was done. Anesthesia and incisions were per-

The dogs were sacrificed immediately after the

formed the same as before. Mucoperiosteal flap

Fig. 1. From Left (anterior) Blood, autogenous bone, autogenous bone+Bio-Oss�, Bio-Oss�.

Fig. 2. A piece of Bio-Gide� was placed over the bone before closing the flap.

Fig. 3. Time schedule of experiment.

328

Glu (Glutamate + Glutamine), and Asp (Aspartate + Asparagine). 2. Electron Microscope Examination a. Surface evaluation (SEM) The inner surface of canine mucosa (Schneiderian membrane) and the rough surface of Bio-Gide� were examined using SEM (×2000) (Fig. 6. (a), (b)). The smooth surface shows densely compacted collagen fibers running in one direction. On the rough

Fig. 4. Diagram of experiment.

surface, however, the fibers were loose and porous without any direction in their arrangement (×500, ×2000) (Fig. 7, 8).

fourth surgery. Tissue fixation with formalin was done and histological specimens were prepared.

b. Cross-sectional evaluation of Bio-Gide� (SEM)

RESULTS

Bilayered structure of Bio-Gide� was observed (× 150) (Fig. 9). This bilayered structure was compact

1. Composition Analysis of Bio-Gide



on one side and porous on the other. The smooth side of the membrane was compacted with collagen

As can be seen in Fig. 5, the collagen in Bio-Gide� is

fiber with dense structure, but in the rough side of

composed of various amino acids. The major amino

the membrane, collagen fiber was made of loose and

acids are Glysine, Alanine, Proline, Hydroxyproline,

porous structure (Fig. 10, 11).

Fig. 5. Chromatogram of Bio-Gide� .

329

b) Group of 1 month after filling

3. Histochemical Evaluation

: A few Bio-Oss� particles were observed over the granulation tissue that filled the defect. Surface of bone

A. Without membrane

showed the continuity of periosteum and over the 1) Group with blood only

periosteum, intact oral mucosa was observed.

a) Group on the day of filling

c) Group of 2 months after filling

: A few blood clots were observed. The outline of

: The surface of bony defect showed almost no ac-

bone was clearly observed. Bony defect maintained

cumulation of regenerated bone. Among the parti-

the cut shape and covered with mucosa.

cles, fibrous tissue was packed. The findings were similar to that of 1 month after filling.

b) Group of 1 month after filling : Resorption started from the edge of hole and

d) Group of 3 months after filling

wider depression was observed than original hole.

: The findings were same with that of 2 months af-

Thin layer of bone, densely stained with hematox-

ter filling (Fig. 13).

ilin than original bone, was observed outer sur3) Group with Bio-Oss� and autogenous bone

face of bone. The surface of bone was covered with

filling

collagenous tissue. No osteoblast was observed (Fig. 12).

a) Group on the day of filling : Bony defect maintained the cut shape. Inside the

c) Group of 2 months after filling : The surface of bone showed wider depression than

hole, autogenous bone particles and Bio-Oss� par-

surrounding. Regenerated bone layer which was

ticles were accumulated and original bone particles

wider than that of 1 month after filling was ob-

also were observed. The filled hole was covered with

served, and it was more densely stained with hema-

gingival mucosa.

toxilin than original bone. Regenerated bone had many marrow space. Outer surface of bone was

b) Group of 1 month after filling

covered with periosteum that was composed with

: The formation and accumulation of new bone were partly observed between the surface of bone

tough collagen. Osteoblasts were observed.

defect and autogenous bone. Osteoblasts were obd) Group of 3 months after filling

served. But, Bio-Oss� particles were separated from

: The surface of bone showed wider depression than

regenerated bone with fibrous tissue. There were no

surrounding. More matured regenerated bone was

evidence of new bone formation on the surround-

observed and the quantity of filled bone was incresed,

ings of Bio-Oss� particles.

comparing with that of 2 months after filling. c) Group of 2 months after filling 2) Group with Bio-Oss� filling

: Autogenous bone fused to regenerated bony trabecula, and a lot of regenerated bony trabeculae filled

a) Group on the day of filling

the defect. Between bony trabeculae, Bio-Oss� par-

: The outline of bone was clearly observed. Inside

ticles fused to regenerated trabeculae and showed



the hole, Bio-Oss particles were densely packed with

appearance of integration with trabeculae. Osteoblasts

blood clots.

were observed. A portion of Bio-Oss� particles

330

were separated from the out surface of bone and re-

was clearly observed. Bony defect maintained the cut

mained freely outside the defect (Fig. 14).

shape and covered with membrane. Over the membrane, gingival mucosa was observed.

d) Group of 3 months after filling : More matured regenerated bone was observed.

b) Group of 1 month after filling

Osteoblasts were observed. The findings were same

: From the bottom of the hole, regenerated bony

with that of 2 months after filling (Fig. 15).

trabeculae formed and grew toward the membrane. The proliferation of regenerated bony trabeculae was

4) Group with autogenous bone filling

observed. Osteoblasts were observed.

a) Group on the day of filling

c) Group of 2 months after filling

: The hole was filled with autogenous bone par-

: The proliferation of regenerated bony trabeculae

ticles and blood clot. The outline of bone was

was observed. Many parts of the hole was filled with

clearly observed.

regenerated bone. Membrane covered the regenerated bone. Osteoblasts were observed (Fig. 18).

b) Group of 1 month after filling : Regenerated bone had many marrow space.

d) Group of 3 months after filling

Autogenous bone particles fused to newly generated

: Under the membrane, matured regenerated

bone. There were active formation of osteoid tissue

bone filled the hole. The findings were same with that

and under that, original hard bone also observed with-

of 2 months after filling.

out changing. Osteoblasts were observed (Fig. 16). 2) Group with Bio-Oss� filling c) Group of 2 months after filling a) Group on the day of filling

: Autogenous bone particles fused to generated bony trabecula and abundant connective tissue

: The outline of bone was clearly observed. Inside

filled the space between newly generated bony

the hole, Bio-Oss� particles were packed with blood

trabeculae. Under the periosteum, accumulated

clots. Bony defect was covered with membrane.

new bone was observed. Sound and intact mucosa b) Group of 1 month after filling

covered the regenerated bone (Fig. 17).

: Bony defect was covered with membrane which d) Group of 3 months after filling

had fine fibrous structure. Between membrane and

: regenerated bone and autogenous bone were fused

surface of bone, collagenous fiber was observed. Some

to original bone. More Calcified regenerated bone was ob-

of Bio-Oss � particles were separated from bone and

served than before. Regenerated bone did not filled the

embedded in membrane (Fig. 19).

hole completely. Wide depression was still observed. c) Group of 2 months after filling : Bony defect was filled with Bio-Oss� covered with

B. With membrane

membrane. But, formation of new bone was not observed surrounding the Bio- Oss� particles.

1) Group with blood only

Some of Bio-Oss� particles were separated from a) Group on the day of filling

defect and they were found between membrane

: Blood clots were observed. The outline of bone

and the mucosa over the membrane. Bio-Oss� act-

331

ed like a foreign body. At the bottom of the hole, a

b) Group of 1 month after filling

little formation of regenerated bone was observed

: The formation and accumulation of new bone



but Bio-Oss was covered with fibrous tissue and did

were partly observed between the surface of bone

not fused to regenerated bone (Fig. 20).

defect and autogenous bone. Osteoblasts were observed. Formation of new bone was not observed

d) Group of 3 months after filling

around the Bio-Oss�. Bio-Oss� particles were not ob-

: The findings were same with that of 2 months af-

served outside the membrane. Very little resorption of the surrounding bone was also observed.

ter filling (Fig. 21). 3) Group with Bio-Oss� and autogenous bone filling

c) Group of 2 months after filling : Autogenous bone fused to regenerated bony tra-

a) Group of on the day of filling

becula, and a lot of regenerated bony trabeculae filled the defect. Between bony trabeculae, Bio-Oss� par-

: Bony defect maintained the cut shape. Inside the �

hole, autogenous bone particles and Bio-Oss par-

ticles fused to regenerated trabeculae and showed

ticles were accumulated and original bone particles

appearance of integration with trabeculae. Osteoblasts

were also observed. The filled hole was covered with

were observed. Matured regenerated bone was ob-

membrane.

served under the membrane. There were no re-

Table I. Summary of histological evaluation

Without membrane Group

Osteoblasts

with Blood only

Thin layer of regenerated bone

With membrane Osteoblasts and osteoid tissue Active bone formation

Group

At th bottom of the

with Bio-Oss� filling

Fibrous encapsulation of �

hole -Osteoblasts

Bio-Oss particles

Fibrous encapsulation of

Separation of Bio-Oss�

Bio-Oss� particles

particles from the hole

Separation of Bio-Oss� particles from the hole

Osteoblasts

Group �

with Bio-Oss

and autogenous bone filling



Bio-Oss particles fused to regenerated trabeculae Fibrous encapsulation of Bio-Oss� particles Outside the hole-a portions of

Osteoblasts and osteoid tissue No resorption of bone A lot of regenerated bony trabeculae filled the hole as the original bone level

Bio-Oss� particles Group with autogenous bone filling

Osteoblasts

Osteoblasts

Active bone formation

and osteoid tissue

Slight resorption of bone

Active bone formation No resorption of bone

332

sorption of autogenous bone and regenerated bone

lagen membrane is more effective in encouraging cell

under membrane.

attachment. This also makes exceptional biocompatibility of the membrane and allows excellent

d) Group of 3 months after filling

cell adhesion to the material's surface. Because

: Regenerated bone filled the hole as the original

membranes have more loosely and porously arranged

bone level. The other findings were same with

collagen fibers than Schneiderian membrane, those

that of 2 months after filling (Fig. 22).

have better adherence to bone-forming cells. Blood can seep into the spaces between fibers to form

4) Group with autogenous bone filling

clots that help to stabilize the membranes.

a) Group of on the day of filling

brane, Bio-Gide�, was very easy to manipulate.

: The hole was filled with autogenous bone par-

The slight elasticity of the membrane allowed Bio-

ticles and blood clot was covered with membrane.

Gide� to completely cover the bony defect which was

The outline of bone was intact.

filled with autogenous bone or bone substitutes.

During procedures, the resorbable collagen mem-

Another characteristics of Bio-Gide� is the high b) Group of 1 month after filling

toughness. From the results using membrane, Bio-

: Regenerated bone had many marrow space.

Gide� had no evidence of tearing in spite of irrita-

Autogenous bone particles fused to newly generated

tional condition, even 3 months after insertion. The

bone and made bony trabeculae. There were active

fiber of collagen makes a triple helix structure con-

formation of osteoid tissue. No absorption of au-

taining large amounts of hydroxyproline. This hy-

togenous bone was observed.

droxyproline, found in abundance in Bio-Gide�, serves to stabilize the triple helix structure. The

c) Group of 2 months after filling

helical structure possesses great tensile strength

: The activity of osteoblast was high and many part

and is resistant to tear. Also, collagen fibers permit structural elasticity during the crystalline phase of

of hole was filled with regenerated bone.

bone regeneration, allowing the membrane to serve d) Group of 3 months after filling

as a barrier by maintaining its position in the face of

: Bone defect was filled as the original level with

epithelial migration from the soft tissue side.30

regenerated bone and autogenous bone particles fused

The continuity of the mandible was observed

with regenerated bone. In the marrow space and sur-

the membrane used groups comparing with non-

roundings of regenerated bone, there were many os-

used groups (Fig. 12, 23). The groups used the

teoblasts. In the new trabeculae, there were many la-

membrane exhibited significantly lesser depres-

cunae. There were many mature trabeculae which

sion of the cortical bone. During soft tissue invasion

had progress of calcification (Fig. 23).

and the resorption of bone substitutes, the membrane functioned as a protector for maintaining the room.

DISCUSSION

Regardless of the type of bone substitute used, membrane-used groups demonstrated lesser re-

From the results, the bone side of detached

sorption of bone substitutes and greater degree of

Schneiderian membrane contains non-collagen

bone replacement. In the membrane used group with

components together with collagen. But, Bio-Gide

autogenous bone filling, the transplanted bone



is composed of highly purified collagen. Because

showed slight resorption at the both edges of the de-

it is mainly composed of collagen, resorbable col-

fect. Instead, in the membrane non-used groups

333

filled with autogenous bone, a broad depression of

rier in guided bone regeneration. The function of

the defect could be observed.

porous structure gives the space for osteoblasts at-

Using membrane, improved healing was achieved.

tachment. These functions of bilayer structure were

From the results, when a membrane was used, re-

examined with an in vitro study, fibroblasts were ob-

gardless of the type of bone substitute, a lesser

served after cultured on the smooth and rough

amount of resorption occurred than when a mem-

surfaces of Bio-Gide� . On the smooth surface, al-

brane was inserted. Bone fill was evaluated after the

though there were penetrations by individual cells,

completion of the guided bone regenerations to

There were no destruction of the structure of mem-

estimate regenerability. From this study, bone fill

brane or formation of tissue structure. On the rough

could not be calculated, but, compared bone fill

surface, osteoblasts attached themselves to the col-

between each groups with gross observation.

lagen fibers of the membrane by penetrating and ad-

Membrane used groups had higher bone fill than

hering to the loose, porous structure.15

non-used groups. In the similar investigation by Nociti

Three months after the first procedure, by the

et al.15 resorbable membrane was used to manage ar-

naked eyes, Bio-Gide� was not distinguished from

tificially-induced peri-implantitis. When Bio-Oss�

covered soft tissue. But, in the histological evalua-

was used alone to fill the defect, without a membrane,

tion, the membrane was clear, with a little breakdown.

the degree of bone fill was significantly lesser (21.26

At three months, slight resorption had begun, but the

±6.87%) than when a resorbable membrane (Bio-Gide

shape was unaltered (Fig. 24). As it takes longer than



) was also used (27.77±14.07%). Regardless of

typical collagen to be resorbed, Bio-Gide� remains

using a membrane, group with autogenous bone and

in the site long enough to prevent epithelial pene-

Bio-Oss� filling retained the greatest amount of its

tration. Therefore, second surgery for membrane re-

volume inside a hole and showed the highest bone

moval is unnecessary. Resorbable collagen mem-

fill among the groups, followed by autogenous

branes must not release any toxic byproducts dur-



bone, Bio-Oss and blood in order. One, two and

ing resorption. The evidences of inflammatory reaction

three months after filling, group with Bio-Oss�

to membrane or necrosis of cells were not observed

and autogenous bone filling showed excellent fusion

in histologic findings. In the study, Bio-Gide�

to surrounding bone. On the interface to the sur-

showed cellocclusive properties by being slowly

rounding bone, bone regeneration had started in au-

resorbed and preventing infiltration of epithelial cells.

togenous bone. Regenerated bony trabeculae were

The resorption process of Bio-Gide� is initiated by



observed between particles of Bio-Oss . Similar

collagenase. The resulting fragments are denatured

study was done by Hocker. He compared the effect

and gelatined at 37。C.28,29 They are then further

of supporting bone materials in guided bone re-

broken down to oligopeptides and amino acids by



generations using Bio-Gide . Greater amounts of ver-

gelatinases and proteinases and resorbed.26

tical bone growth were observed when autoge-

In the membrane-used groups, no antigenic reaction

nous bone (78%) and Bio-Oss� (70%) were used in

was observed. Lack of antigenicity is one of the

conjunction as compared to when no supporting ma-

most important advantages of Bio-Gide�. In contrast

terial was used (44%).40

to larger proteins, generally, collagen exhibits a



Bio-Gide is a bilayer structure with a smooth and

much lower degree of antigenicity. As the anti-

compact layer which contact with soft tissue and a

genicity of collagen is due to the presence of telopep-

rough and porous surface that contacts with bone

tides, Bio-Gide� is undergone a refining process

(Fig. 10, 11). The function of compact structure of the

to remove telopeptides during manufacture to

membrane which contacts to soft tissue is the bar-

eliminate antigenicity.22,23,25,,35

334

Bio-Oss� is a hydroxyapatite bone substitute tak-

To identify the site of holes on mandible, radi-

en from bovine extremities. Its safety regarding use on

ographs were taken. At that time, Bio-Oss� had

human beings have been well documented.30-32,43

more radio-opacity and was readily identifiable

Chemical and thermal treatments during manu-

on radiographs. Holes with autogenous bone only

facture endows Bio-Oss a highly-purified mineral

was unclear. Holes with blood showed radiolu-

bone structure.

cency. 3 months after first filling procedure, the



During filling procedures, autogenous bone was

line of transition was observed between newly re-

most densely packed followed by combination of Bio-

generated tissue and surrounding original bone in

Oss� and autogenous bone and Bio-Oss� (Fig. 25).

all groups. In the group with Bio-Oss� and auto-

While group with Bio- Oss� filling without a mem-

genous bone filling, even Bio-Oss� well fused to hard

brane, even if the bone substitute had been well-

tissues, the line of transition was observed. Group

packed during filling procedure, it was not re-

with autogenous bone filling, healing was good

tained within the hole and observed outside the hole.

and it was distinguishable through a difference in

Group with Bio-Oss� filling, a fibrous capsule was

the degree of staining from original bone to regen-

observed. Two months after first filling procedure,

erated bone.

when Bio-Oss� alone was used with a membrane,

CONCLUSIONS

particles were separate and clearly distinguishable. A fibrous capsule was formed at the interface between the surrounding bone and Bio-Oss�.

1. Bioresorbable collagen membrane is pure colla-

Compared the regenerability of bone between the

gen containing large amounts of Glysine, Alanine,

group with Bio-Oss� filling and the group with

Proline and Hydroxyproline.

blood, The latter group showed more regenerated

2. Bioresorbable collagen membrane is a mem-

bone and better capacity of filling the hole than

brane with collagen fibers arranged more loose-

the former group. Bio-Oss alone acted like the for-

ly and porously compared to the inner surface of

eign body and encapsulated by fibrous tissue. In the

canine mucosa : This allows for easier attachment



result of the group with Bio-Oss and Autogenous

by bone-forming cells. Blood can seep into these

bone filling, such fibrous encapsulation was ob-

spaces between fibers and form clots that help sta-

served lesser than the group with Bio-Oss� filling

bilize the membrane. The result is improved



healing.

3 months after filling. Filled autogenous bone allowed Bio-Oss easily fused to newly generated bone tra-

3. Bioresorbable collagen membrane has a bilayered

beculae. Also, autogenous bone between Bio-Oss�

structure : The side to come in contact with soft

particles fused to the surrounding bone.

tissue is smooth and compact. This prevents



Another characteristic of Bio-Oss is slow re-

soft tissue penetration into bony defects. As the

sorption during remodeling. This enables the par-

side in contact with bone is rough and porous, it

ticles of Bio-Oss� to serve as supports during the for-

serves as a stabilizing structure for bone regen-

mation of new bone.

eration by allowing attachment of bone-forming



cells.



Bio-Oss participates in bone remodeling and is

4. Regardless of whether a membrane had been

resorbed slowly by osteoclasts. The histological results of this study support that Bio-Oss , due to its

used or not, the group with autogenous bone and

slow resorption, helps to reduce the resorption of new-

Bio-Oss� filling showed the greatest amount of

ly-formed bone by providing stability to augmented

bone fill inside a hole, followed by the group with

bone during guided bone regeneration.

autogenous bone filling, the group with blood and



335

the group with Bio-Oss� filling in order. 5. When a membrane was inserted, regardless of the type of bone substitute used, a lesser amount of 10.

resorption occurred compared to when a membrane was not inserted. 6. The border between bone substitute and sur-

11.

rounding bone was the most indistinct with the group with autogenous bone filling, followed by the group with autogenous bone and Bio-Oss� filling, the group with blood, and the group with Bio-

12.



Oss filling. 7. Three months after surgery, Bio-Gide� and Bio-

13.



Oss were distinguishable, but, due to the beginning of resorption, the shape of Bio-Gide� 14.

was changed a little. 8. The best results were obtained with the group with autogenous bone and Bio-Oss� filling used in conjunction with a membrane.

15.

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Reprint request to: DR. YUNG-SOO KIM, D.D.S., M.S.D., Ph.D. DEPT. OF PROSTHODONTICS, COLLEGE OF DENTISITY, SEOUL NATIONAL UNIV. 28-1 YEONGUN-DONG, CHONGNO-GU, 110-749, SEOUL KOREA [email protected]

337

사진부도 ①

Fig. 4. Schneiderian membrane of dog. : Bone side detached (x2000).

Fig. 5. Rough surface of Bio-Gide�. : Collagen structure (x2000).

Fig. 6. Rough surface Bio-Gide� (x500) left, Smooth surface of Bio-Gide� (x500) right.

Fig 7. Rough surface of Bio-Gide� (x2000) left, Smooth surface of Bio-Gide� (x2000) right.

Fig. 8. Cross-sectional view of Bio-Gide� Fig. 9. Layer of soft tissue side of mem- Fig. 10. Layer of bony side of membrane : Dense, compact structure. brane : Porous, loose structure. (x150).

338

사진부도 ②

Fig. 11. The group with blood without using membrane 1 month after filling. Resorption started from the edge of hole and wider depression was observed than original hole.

Fig. 12. The group with Bio-Oss� filling without using memebrane 3 months after filling. A few Bio-Oss� particles were observed over the granulation tissue that filled the defect. Almost no accumulation of regenerated bone was observed.

Fig. 13. The Group with Bio-Oss� and autogenous bone filling without using membrane 2 months after filling. Autogenous bone fused to regenerated bony trabecula, Bio-Oss� particles fused to regenerated trabeculae and showed appearance of integration with trabeculae. A portion of Bio-Oss� particles remained freely outside the defect.

Fig. 14. The group with Bio-Oss� and autogenous bonefilling. Matured regenerated bone was observed. Between bony trabeculae, Bio-Oss� particles fused to regenerated trabeculae and showed appearance of integration with trabeculae. Osteoblasts were observed.

Fig. 15. The group with autogenous bone filling without using membrane 1 month after filling. Regenerated bone had many marrow space. Autogenous bone particles fused to newly generated bone.

Fig. 16. The group with autogenous bone filling without using membrane 2 months after filling. Regenerated bone and autogenous bone were fused to original bone. Regenerated bone did not filled the hole completely. Wide depression was still observed.

339

사진부도 ③

Fig. 17. The group with blood only using membrane 2 months after filling. The proliferation of regenerated bony trabeculae was observed. Many parts of the hole was filled with regenerated bone. Memebrane covered the regenerated bone. Osteoblasts were observed.

Fig. 18. The group with Bio-Oss� filling using membrane 1 month after filling. Bony defect was covered with fine fibrous membrane. Collagenous fiber was observed.

Fig. 19. The group with Bio-Oss� filling 2 months after filling using membrane. Fibrous encapsulation of was observed Bio-Oss� particles.

Fig. 20. The group with Bio-Oss� fillng using membrane 3 months after filling. At the bottom of the hole, a little formation of regenerated bone was observed but BioOss� was covered with fibrous tissue and did not fused to regenerated bone.

Fig. 21. The group with Bio-Oss� and autogenous bone filling using memebrane 3 months after filling. Regenerated bone filled the hole as the original bone level.

Fig. 22. The group with autogenous bone filling using membrane 3 months after filling. Regenerated bone filled the hole as the original bone level.

340

사진부도 ④

Fig. 23. Three months after surgery, Bio-Oss� and Bio-Gide� were clearly distinguishable.

Fig. 24. In terms retaining its space within a defect, autogenous bone showed the greatest effectiveness(upper left), followed by Bio-Oss� and autogenous bone composite(upper right) and Bio-Oss�(lower left) and blood(lower right).

341