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