Beruflich Dokumente
Kultur Dokumente
67:1218-1225, 2009
struction procedures, to determine if cortical perforations have any effect on bone regeneration, and to
reiterate that bone graft containment is an important parameter for successful regeneration.
Materials and Methods: This was a prospective, randomized, controlled study performed on hound
dogs. Corticocancellous tibial bone grafting was performed to the lateral border of the mandible and
protected with barrier membranes (meshes). The experiment analyzed three different pore sized meshes,
compared with controls without the mesh. Two meshes (macroporous and microporous) were made of
titanium, and one was a resorbable mesh. Meshes were preformed into the shape of a cube with one face
open. Each side of the cube measured approximately 10 mm. Cubes were open-faced on one side, to
facilitate packing of the graft material. The dogs received bilateral ramus grafts. Cortical perforations
were created on the left ramus of all the dogs and compared with the right side, which did not have
perforations. The dogs were randomly divided into 3 groups and sacrificed at intervals of 1, 2, and 4
months. Before sacrifice, all dogs received 2 doses of tetracycline as a marker for new bone formation.
Histomorphometry was performed by using Bioquant image-analysis software. Areas of new bone and
soft tissue were measured. The rate of mineral apposition was also calculated. All values obtained via
histomorphometry were statistically analyzed with a t test.
Results: Thirty-one experimental sites were evaluated. The amount of new bone growth into the
macroporous mesh was significantly higher than in the other groups. The mean area of new bone
formation in large and small meshes was 66.26 13.78 mm2 and 52.82 24.75 mm2, respectively. In
the resorbable mesh group, the mean area of new bone formed was 46.76 21.22 mm2. The amount
of new bone formed in the control group was 29.80 9.35 mm2. There was no significant difference in
amount of bone formation between left and right sides (P .3172). Resorbable meshes had significant
soft tissue ingrowth (23.47 mm2) compared with macroporous mesh (16.96 mm2) and microporous
mesh (22.29 mm2). Controls had the least amount of soft tissue ingrowth (9.41 mm2). Mineral apposition
rate was found to be higher in the resorbable group (2.41 m/day), and the rate was lowest (1.09
m/day) in the large pore mesh group.
Conclusion: Macroporous membranes facilitated greater bone regeneration compared with micro-
porous and resorbable membranes. Macroporous mesh also prevented significant soft tissue ingrowth compared with other meshes. Containment of a bone graft is the most critical parameter in
successful bone regeneration. Cortical perforations did not have any effect on the quantity of
regenerated bone. Further research should be directed toward identifying a critical pore size and
manufacturing a reliable mesh that would prevent excessive soft tissue ingrowth in ridge augmentation procedures.
2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 67:1218-1225, 2009
*Assistant Professor, Department of Oral and Maxillofacial Surgery, University of Texas Health Science Center at San Antonio, San
Antonio, TX.
Senior Veterinarian, Animal Resources Program, University of
Alabama at Birmingham, Birmingham, AL.
Professor, Department of Biostatistics, University of Alabama at
Birmingham, Birmingham, AL.
Professor and Director, Department of Oral and Maxillofacial
Surgery, University of Alabama at Birmingham, Birmingham, AL.
0278-2391/09/6706-0011$36.00/0
doi:10.1016/j.joms.2008.11.022
1218
1219
GUTTA ET AL
Surgical Technique
BONE-HARVESTING TECHNIQUE
FIGURE 1. Preformed macroporous, microporous, and resorbable
meshes.
Gutta et al. Barrier Membranes for Ridge Augmentation. J Oral
Maxillofac Surg 2009.
Two surgical teams prepared simultaneously to harvest the tibia and perform the bone graft procedure to
the mandible. A tibial strut measuring 7 1 cm was
harvested (Fig 2). A small bone graft curette was then
1220
An extraoral approach with a submandibular incision was used bilaterally in all the animals. A subperiosteal dissection was then performed to expose the
lateral aspect of the body and ramus of the mandible
(Fig 3). Similar exposure was performed on the contralateral site. Four sites of regeneration were prepared on each side along the lateral body and ramus
of the mandible. On the left side, the cortex along the
proposed site of graft placement was perforated with
a 0.8-mm round carbide bur under copious irrigation
with normal saline (Fig 4).
The harvested particulate graft was then packed
into the preformed mesh cubes. Meshes were overlaid along the lateral border of the mandible. This was
done such that the open end of the mesh cube faced
the lateral cortex of the mandible. Each mesh was
then secured with approximately 1.1-mm-diameter
titanium screws of a depth sufficient to pierce the
buccal cortex, but not pierce the lingual cortex. For
the control site, an equivalent amount of bone graft
material was used as in the mesh cubes. Control sites
were not covered by a barrier membrane. Once grafts
were secured, the wound was closed and the opposite side was addressed. The site preparation was the
same, except that no holes were drilled through the
cortex of the ramus. The mesh cubes with bone graft
Eight specimens were harvested from each mandible for a total of 31 specimens. In group I, the resorbable mesh on the left side was excluded from the
study due to improper surgical technique. All specimens were trimmed and fixed in 10% neutral buffered
formalin for 1 month. All specimens were subjected
to tissue processing, dehydration, and infiltration
with methyl methacrylate (MMA) solution, according
to the standard operating procedure of the UAB Orthopaedic Research Laboratory, and subsequently embedded in methylmethacrylate. All specimens with
embedding mixture were placed under ultraviolet
light for 48 hours to allow for polymerization. A
buccal-lingual midline section was obtained from
each specimen using an Exakt macrosaw. Each midline section was then ground to 80 to 100 m, using
an Exakt grinder (Exakt Technologies Inc, Oklahoma
City, OK). Then sections were stained with Sandersons bone stain (Surgipath Inc, Richmond, IL).
1221
GUTTA ET AL
HISTOMORPHOMETRY
Results
All values obtained with histomorphometry were
statistically analyzed with a t test.
BONE GROWTH
1222
Macroporous Mesh
Macroporous mesh
No mesh
Resorbable mesh
Microporous mesh
No Mesh
Resorbable Mesh
Microporous Mesh
.0004
.0480
.0828
.1512
.0175
.5250
.0004
.0480
.1512
.0828
.0175
.5250
Gutta et al. Barrier Membranes for Ridge Augmentation. J Oral Maxillofac Surg 2009.
The rate of mineral apposition (MAR) was calculated by dividing the distance between the 2 tetracycline markers by the time interval between their administrations. The MAR was observed to be higher in
the resorbable mesh group, with a mean value of 2.41
/day, followed by the group with microporous
mesh, which corresponded to 2.25 /day. In the
group without mesh, the MAR was 2.2 /day. The
lowest value was noted in the group with macroporous mesh, at 1.09 /day (Figs 9-12).
Discussion
The resorbable mesh had significant soft tissue ingrowth (23.47 22.22 mm2) compared with macroporous mesh (16.96 8.02 mm2) and microporous
mesh (22.29 16.50 mm2). The statistical difference
in soft tissue formation between each group is represented in Table 2. Controls had the least amount of
soft tissue ingrowth (9.41 4.82 mm2). The amount
of soft tissue ingrowth into the mesh was not statistically different between the right and the left sides (P
.2301). The amount of bone growth compared
with soft tissue ingrowth was statistically higher in all
groups combined (P .0043).
GUTTA ET AL
Taylor and Smith tested 2 types of porous methylmethacrylate implants with average pore sizes of 42
m and 361 m.13 They found that the smaller pore
size was inadequate for penetrations of capillaries.
Based on our search, there is no information in the
maxillofacial literature on the optimal pore size of
barrier membranes for prevention of excessive soft
tissue ingrowth.
In this study, there was an increased quantity of
bone formation in the large pore mesh compared
with the small pore mesh. This finding was consistent with Bobyn et al, who reported that implants
with a large pore size initially had greater ingrowth.14 At the end of the 52 weeks of their study,
they concluded that the difference in pore size has
no influence on the healing response and on clinical consequences. In the present study, the amount
of bone growth between smaller pore size meshes
was not significant statistically (P .5250). Similarly, there was no statistical difference in the
amount of bone growth between small and large
pore sized meshes (P .1512).
Several other investigators studied bone ingrowth
into systems with different pore sizes.15-17 They
showed that a pore size of 100 m allows bone
ingrowth, but a pore size greater than 150 m is
required for osteon formation. Studies on the rate of
bone ingrowth mentioned that bone ingrowth would
occur if a pore size was greater than 50 m.18 These
studies indicated that the optimum pore size required
for bone ingrowth remains undefined. But for osteon
formation, the pore size should be greater than 150
m. An interesting finding in our study involves the
mineral apposition rate in the mesh with large pore
size. Although this group had a greater amount of
bone formation compared with other groups, the
1223
MAR was only 1.09 m. Based on this observation,
this finding is consistent with the study of Bobyn et
al.14 There might have been faster ingrowth of boneforming cells into the mesh with large pore size. The
mineral apposition might have been slower due to
increased surface area through the large pores.
Micromovement between bone and implanted material was also shown to prevent bony ingrowth and
result in the development of fibrous tissue membrane,
particularly if this occurs during the healing process
after implantation.18-21 During the initial 3-week healing period there should be minimal stress on the
implanted barrier membrane, to prevent any fibrous
ingrowth. With sufficient initial stability, the early
tissue infiltrate through the pores will differentiate to
bone by either direct bone formation or appositional
bone growth from adjacent bone. This was described
by Spector, based on observations of tissue ingrowth
into porous polymer systems.22 Pilliar et al demonstrated that bone can form within porous implants
even with limited initial movement, provided the site
is sufficiently vascular and that no local inflammatory
reactions occur. The extent of this movement is less
than 150 m.23 In contrast to the above studies, with
excellent blood supply to the maxillofacial region and
despite using rigid fixation for the titanium mesh or
other membranes, there are reports associated with
thick fibrous tissue beneath the membrane.7,24,25
In this study, meshes had been secured well with a
titanium screw. Also, the extraoral approach helps
with stability during masticatory function. Another
distinct advantage with this approach is the absence
of mesh exposure. As reported in the literature, a
significant amount of soft tissue ingrowth into the
mesh was also noted. The amount of soft tissue ingrowth was greater in the resorbable mesh group.
1224
Macroporous Mesh
Macroporous mesh
No mesh
Resorbable mesh
Microporous mesh
No Mesh
Resorbable Mesh
Microporous Mesh
.2985
.3853
.0673
.4613
.0818
.8737
.2985
.3853
.4613
.0673
.0818
.8737
Gutta et al. Barrier Membranes for Ridge Augmentation. J Oral Maxillofac Surg 2009.
References
1. Hurley L, Stinchfield F, Bassett A, Lyon W: The role of soft
tissues in osteogenesis. An experimental study of canine spine
fusions. J Bone Joint Surg [Am] 41A:1243, 1959
2. Boyne PJ: Regeneration of alveolar bone beneath cellulose
acetate filter implants. J Dent Res 43:827, 1964
3. Boyne P, Mikels T: Restoration of alveolar ridges by intramandibular transposition osseous grafting. J Oral Surg 26:569, 1968
4. Boyne P: Restoration of osseous defects in maxillofacial casualties. J Am Dent Assoc 78:767, 1969
5. Buser D, Dula K, Belser U, et al: Localized ridge augmentation
using guided bone regeneration. II. Surgical procedure in the
mandible. Int J Periodont Restor Dent 15:10, 1995
GUTTA ET AL
6. Mattout P, Mattout C: Conditions for success in guided bone
regeneration: Retrospective study on 376 implant sites. J Periodontol 71:1904, 2000
7. Simion M, Trisi P, Piattelli A: Vertical ridge augmentation using
a membrane technique associated with osseointegrated implants. Int J Periodont Restor Dent 14:496, 1994
8. Simion M, Jovanovic S, Trisi P, et al: Vertical ridge augmentation around dental implants using a membrane technique and
autogenous bone or allografts in humans. Int J Periodont Restor
Dent 18:8, 1998
9. Elkin SL, Vedi S, Bord S, Garrahan NJ, Hodson ME, Compston
JE: Histomorphometric analysis of bone biopsies from the iliac
crest of adults with cystic fibrosis. Am J Respir Crit Care Med
166:1470, 2002
10. Parfitt AM, Travers R, Rauch F, Glorieux FH: Structural and
cellular changes during bone growth in healthy children. Bone
27:487, 2000
11. Salvatore J, Gilmer WJ, Kashgarian M, Barbee W: An experimental study of the influence of pore size of implanted polyurethane sponges upon subsequent tissue formation. Surg Gynecol Obstet 112:463, 1961
12. Chvapil M, Holusa R, Kliment K, Stoll M: Some chemical and
biological characteristics of a new collagen-polymer compound material. J Biomed Mater Res 3:315, 1969
13. Taylor D, Smith F: Porous methyl methacrylate as an implant
material. J Biomed Mater Res 6:467, 1972
14. Bobyn J, Stackpool G, Hacking S, et al: Characteristics of bone
ingrowth and interface mechanics of a new porous tantalum
biomaterial. J Bone Joint Surg [Br] 81:907, 1999
15. Klawitter J, Bagwell J, Weinstein A, Sauer B: An evaluation of
bone growth into porous high density polyethylene. J Biomed
Mater Res 10:311, 1976
16. Spector M, Flemming W, Kreutner A: Bone growth into porous
high-density polyethylene. J Biomed Mater Res 10:595, 1976
17. Niles J, Coletti JJ, Wilson C: Biomechanical evaluation of boneporous material interfaces. J Biomed Mater Res 7:231, 1973
18. Welsh R, Pilliar R, Macnab I: Surgical implants. The role of
surface porosity in fixation to bone and acrylic. J Bone Joint
Surg [Am] 53:963, 1971
1225
19. Cameron H, Pilliar R, MacNab I: The effect of movement on the
bonding of porous metal to bone. J Biomed Mater Res 7:301,
1973
20. Ducheyne P, De Meester P, Aernoudt E: Influence of a functional dynamic loading on bone ingrowth into surface pores of
orthopedic implants. J Biomed Mater Res 11:811, 1977
21. Heck D, Nakajima I, Kelly P, Chao E: The effect of load alteration on the biological and biomechanical performance of a
titanium fiber-metal segmental prosthesis. J Bone Joint Surg
[Am] 68:118, 1986
22. Spector M: Bone ingrowth into porous polymers, in Williams
DF (ed): Biocompatibility of Orthopedic Implants (vol 2). Boca
Raton, FL, CRC Press, 1982, p 55
23. Pilliar R, Cameron H, Welsh R, Binnington A: Radiographic and
morphologic studies of load-bearing porous-surfaced structured implants. Clin Orthop Relat Res 156:249, 1981
24. Becker W, Becker B, McGuire M: Localized ridge augmentation
using absorbable pins and e-PTFE barrier membranes: A new
surgical technique. Case reports. Int J Periodont Restor Dent
14:48, 1994
25. Jovanovic S, Nevins M: Bone formation utilizing titanium-reinforced barrier membranes. Int J Periodont Restor Dent 15:56,
1995
26. Buser D, Brgger U, Lang N, Nyman S: Regeneration and enlargement of jaw bone using guided tissue regeneration. Clin
Oral Implants Res 1:22, 1990
27. Schliephake H, Kracht D: Vertical ridge augmentation using
polylactic membranes in conjunction with immediate implants
in periodontally compromised extraction sites: An experimental study in dogs. Int J Oral Maxillofac Implants 12:325, 1997
28. Kostopoulos L, Karring T: Augmentation of the rat mandible
using guided tissue regeneration. Clin Oral Implants Res 5:75,
1994
29. Simion M, Trisi P, Maglione M, Piattelli A: A preliminary report
on a method for studying the permeability of expanded polytetrafluoroethylene membrane to bacteria in vitro: A scanning
electron microscopic and histological study. J Periodontol 65:
755, 1994