BONE AND SOFT TISSUE REGENERATIVE RESPONSE FOLLOWING ALVEOLAR RIDGE AUGMENTATION USING MACROPOROUS POLYSULFONE IMPLANTS WITH AND WITHOUT DEMINERALIZED BONE POWDER IN MACACA FASCICULARIS By Fouad Se Salama, B~DoSo Submitted to the Faculty of t~e School of Graduate Studies of the Medical College of Georgia in Partial Fulfillment of the Requirements for the Degree of Master of Science in Oral Biology June 1987 Bone and Soft.Tissue Regenerative Response Following Alveolar Ridge Augmentation Using Macroporous Polysulfone Imp_lants With and Without Demineralized Bone Powder In Macaca Fascicularis This thesis submitted by Fouad So Salama has been examined and approved by an appointed committee of the faculty of the School of Graduate Studies of the Medical College of ~eorgiae The signatures which appear below verify the fact that all required changes hav~ been incorporated and that the thesis has received final approval with reference to content, form and accuracy of presentationo This thesis is therefore accepted in partial fulfillment of the requirements for the degree of Master of Science in Oral Bi6logyo i ABSTRACT Successful augmentation of bone surfaces has great clinical application, particularly to the face and oral cavity regionso More than 24 mi 11 ion Americans are edentulous and must depend upon dentures to eat and to restore their norma 1 speech and appearance o Porous po lysul fane (PPSF) is frequently used to fill osseous voidso The purpose of this study was to· test tooth soft, ti.ssue and bone response to porous po lysul fane (PPSF), with and without demineralized bone powder (DBP) in Macaca fascicularise Six adult female monkeys, 12-15 year~ of ~ge, were used in this study. One animal was sacrificed and used as a bone donor and the other five were recipientso All mandibular molar teeth were extracted and masstve alveolectomies were performedo The wounds were left to heal for 5 to 8 1/2 months postoperativelyo At the time of implantation~ PPSF with DBP was inserted subperiosteally into the left mandibular edentulous areas while PPSF alone was inserted into the right sideso The. animals were sacrificed at 42, .60, or 90 days following implantationo Each mandible was cut- into 3mm thick coronal sections which were then examined and photographed with a dissecting microscopeo Some specimens were then decalcified, embedded in paraffin and sect i aned and stained With. H & Eo Other specimens were processed undecalcified in glycol and methylmethacrylate for histomorphometric measurements and tetracycline labe1ling·., Also, some specimens were processed for scanning electron microscopyo No inflammation or untoward reaction of the 'implantation sites were noted at the time of sacrifice. Histologically, the 42 day specimens of the' DBP-PPSF side· (experimental side) revealed penetration of fibrous tissue rich in ' i i fibroblasts and vessels into the pores of PPSF comparirig to the PPSF side (control side)., The fibrous tissue also surrounded the implant., Some multinucleated giant cells and macrophages were present., At 60 days, the PPSF side showed more organized fibrous tissue and bone grew only for a. short distance into the polysulfone. In contrast, the PPSF-DBP side showed large amounts of .bone formation within the pores of the polysulfone and almost covered the implant., The newly formed bone contained osteocytes and was -surrounded by osteob 1asts. At 90 days, the PPSF side showed more bone tormation on the lower half of the. implant" These res~lts suggested that PPSF is a suitable non-resorbable material that accommodates bone and soft tissue formation. A1 so :p the use of DBP enhanced both rate and amount of the new bone., In· conclusion; PPSF with and without DBP is a suitable material that can be used successfully for alveolar ridge augmentation. ' I iii ACKNOWLEDGEMENTS First I would 1 ike to express my deep appreciation to my major advisor, Dr ... Mohamed Sharawy•. He is ,not only my mentor~ but also a friend. I extend my most sincere thanks for his close guidance and support.through some difficult times. His inspirational guidance and truly knowledgeable approaches have created an environment conducive to a student's success .. His talent and advice have given me an insight and enthusiasm for the future.. I w~uld like to thank Dr .. Norris O'Dell for his expert advises and Dr .. Frank Lake for his help and guidanceo I would als~·1ike to thank Dr. David Pashley for his cooperation and in making his research fac·ilities available to me. To the other members ~f my Committee, Dro Louis Gangarosa, Dr. Baldev Singh and Dr .. 'Greg Pa~r, a debt of gratitude is owed for their encouragements advices and reading· this thesis~ I would like to thank Dr. Emad Helmy for his help during the implantation procedures. A special acknowledgment goes to the staff of the Department of Oral Biology/Anatomy. To Mrs. Vera Larke for preparing the photographs, Mrs .. Linda Cullum for the l eng hours spent in typing this thesis, to .Mrs.. Cathy Pennington and Ms. Linda Shoemake for their skillful assistanceQ Acknowledgement is a 1so due to Dr.. Lowe 11 Greenbaum and Dr. Thomas Dirksen for their encouragement and support. I wou 1d 1 ike. to thank Dr. Gera 1d Loft, Dr. George Schuster and Dr o Ken Morris for their he 1p and advice. Also,· I would like to thank Dr. Robert Shimp, Mr. Raymo.nd Griffin I and Dr. Malcolm Kling for their valuable assistance during the surgical· procedures. iv Finally, I thank my wife,- Faika, and my son~ Ahmed~ for their patience during difficult times and their ·understanding has been an important factor for the completion of this work. I dedicate this work with lasting love and thanks to my dear parents, Saad El-Din and Nemat, whose dedication to my childhood instilled in me the desire to achieve high goals and whose tender- and loving ~upport has contributed immeasurably to this accomplishment. v Table of Contents Page Io INTRODUCTION 1 A.. Statement of the Problem and Aims ·1 Bo Review of Literature 2 1., Residual Ridge Overview 2 2., History and Background of Atrophic Ridge Management 7 3., Hard Tissue Augmentation 10 a., Background 10 b. Biological Materials 12 1)., Bone 12 2)., Cartilage 17 3)., Demineralized Bone 19 c., Alloplastic Materi~ls \34 1)., Metals, Ceramics and Polymers 34· 2)., Porous Polysulfone 40 C., Rationale. 43. D.. Specific Aims 46 lie MATERIALS AND METHODS 47 A., Animals 47 B. Food and Care of Animals 47 C. Materials . 47 1., Demineralized Bone Powder 47 2., Porous Polysulfone 48 D., Procedures 48 1. Preparation of the Alveolar Ridge 48 vi Page 2o Preparatjon of Porous Polysulfone 50 3m Implantation Procedures 50 4-.. Animal Sacrifice 51 5o Evaluating Techniques 53 6o Scanning Electron ~icroscopy 54 IIIo RESULTS 56 Ao Forty-two Days After Implantation (Group I) 56 lo Polysulfone Side 56 ao Gross Appearance 56 bo Stereoscopic Examination 57 Co Histologic Examination 57 2o Polysulfone-Demineralized Bone Powder Side 59 ao Gross Appearance 59 be Stereoscopic Examination 59· Co Histologic Examination 59 Bo Sixty Days Following Ridge Augmentation (Group II) 59 l., , Po ly.sul fane Side 59 ac Gross Appearance 59 bo, Stereoscopic Examination 60 c. Histologic Examination 60 2o ~ixty Days Following Polysulfone-Demineralized 62 Bone Powder I · a. Gross Appear~nce 62 bo Stereoscopic Examination 62 Ce Histologic Examination 63 vii Page d. -~J stomorphometri c Resu 1ts 65 e. Tetracycline Labeling 66 C. Ninety Days Following Implantation (Group III) 67 1. Polysulfone Side 67 a. Gross Appearance 67 b. Stereoscopic Examination 67 Cc Scanning Electron Microscopy Results 67 d. Histologic Examination 68 e. Histomorphometric Results 69 f., Tetracycline Labelling 69 ·IV. DISCUSSION 70 V. CONCLUSIONS 90 VI., REFERENCES 149 VI I G APPENDIX 175 viii LIST OF FIGURES Plate Figure Page 1 1 Photomicrograph showing a piece of long bone 95 and DBP 2 Photomicrograph showing a culture of DBP 95 3 Photomicrograph of PPSF bar 95 4 Photomicrograph of PPSF block with six holes 95 2 5 Photograph of the mandibular edentulous molar 97 area 6 Photograph of PPSF block on the surface of the 97 edentulous area 7 Photograph of the stone cast of the partially 97 edentulous mandible 8 Photograph of the acrylic splint on the stone 97. cast 3 9 Photograph showing the wound closure 99 10 .Photograph of the acrylic splint 99 . 11 Photograph-of the acrylic splint fixed with 99 _circumferential wiring 12 Photograph showing erosiori of the mucosa- 99 cove~ing the implant 4 13 P.hotograRh.of the partially edentulous mandible 101. (42 days) 14 Photomicrograph of coronal section of the 101 mandible ( PP SF , 42 days ) . ix Plate Figure Page 15 Photomicrograph of a histologic section {PPSF~~ 101 42 days) 16 Photomicrograph of a histologic section (PPSF, 101 42 days) 5 17 Photomicrograph of ~ histologic section (PPSFs 103 42 days) 18 Photomicrogrpah of a histologic section (PPSF, 103 42 days) 19 Photomicrogrpah of a histologic section (PPSF, . 103 42 days) 20 Photomicrograph of a histologic section (PPSF, 103 42 days) 6 21 Photomicrograph of a coronal section of the 105 edentulous mandible (PPSF + DBP, 42 days) 22 Photomicrograph of a histologic section (PPSF + 105 DBP, 42 days) 23 Photomicrograph of a histologic section (PPSF + 105 DBPs 42 days) 24 Photomicrograph of a histologic section (PPSF + 105 DBP, 42 days) 7 25 Photomicrograph of a histologic section (PPSF + 107 DBP, 42 days) 26 Photomicrograph of a histologic section (PPSF + 107 DBP, 42 days) x Plate. Fi"gure Page 27 Photomicrograph of a coronal section of the 107 · edentulous mandible (PPSF, 60 days) . 28 Photomicrograph of a histologic section (PPSF, 107 60 days) 8 29 Photomicrograph of a histologic section (PPSF, 109 60 days) 30 Photomicrograph of a histologic section (PPSF, .