PASS Principles For Predictable Bone.8
PASS Principles For Predictable Bone.8
PASS Principles For Predictable Bone.8
Bone Regeneration
Hom-Lay Wang, DDS, MSD,* and Lakshmi Boyapati, BDS†
uided bone regeneration (GBR) Guided bone regeneration is a supply and undifferentiated mesen-
veolar bone volume in areas designated ridges. Predictable regeneration re- for bone ingrowth, and stability of
for future implant placement, or around quires both a high level of technical wound and implant to induce blood
previously placed implants. The princi-
skill and a thorough understanding clot formation and uneventful heal-
ple of GBR is based on the principles of
guided tissue regeneration.1-4 The prin- of underlying principles of wound ing events. In addition, a novel flap
ciples delineated by Melcher5 described healing. This article describes the 4 design and clinical cases using this
the need for cell exclusion to enable the major biologic principles (i.e., principle are presented. (Implant
healing wound to be populated by cells PASS) necessary for predictable Dent 2006;15:8 –17)
thought to be more favorable for regen- bone regeneration: primary wound Key Words: guided bone regenera-
eration. In GBR, the cells that are re- closure to ensure undisturbed and tion, bone grafts, horizontal bone
quired to repopulate the wound are uninterrupted wound healing, angio- augmentation, implants
primarily osteoblasts. Osteoblasts are genesis to provide necessary blood
responsible for laying down new alveo-
lar bone and for future bone remodeling.
By selectively excluding epithelium and creation/maintenance, and stability of and overall tissue remodeling. In ad-
connective tissue with the use of bone both the initial blood clot and implant dition, postoperative discomfort may
grafting and barrier materials, bone is fixture (PASS). be reduced as a result of less exposure
“guided” into the desired position. of underlying connective tissue. Most
Dahlin et al6 were the first to show that investigators have advocated the ne-
bony defects created in rat mandibles PRIMARY CLOSURE
cessity of primary closure following
could be successfully closed using The 2 basic methods of wound implant placement to ensure predict-
guided tissue regeneration procedures. healing are termed healing by primary able GBR outcomes,7,12-15 while others
The success and predictability of intention and secondary intention, re-
have disputed its importance. 16,17
GBR have since vastly broadened the spectively. In healing by primary in-
Nonetheless, there is a consensus that
applicability of implant therapy. Im- tension, the edges of a wound are
primary wound coverage should be ac-
plants can now be placed in areas of placed together in virtually the same
position they held before the injury. complished whenever possible.
previously deficient bone volume,
Secondary intention describes healing Examining the effect of mem-
with success rates reported higher than
95%.7-11 However, to ensure predict- that occurs when wound edges cannot brane exposure on bone volume gains
ability of this technique, clinical pro- be closely approximated, resulting in a highlights the importance of primary
cedures should be based on sound wound that is slower to heal, requires wound closure. Machtei18 performed a
biologic principles. This article out- more collagen remodeling, and is metaanalysis to evaluate the effects of
lines the 4 major principles underlying more likely to result in scar formation. membrane exposure on treatment out-
successful GBR (Fig. 1): primary Realistically, true healing by primary comes in guided tissue regeneration
wound closure, angiogenesis, space intention is often difficult to achieve. and GBR. When looking at guided
However, primary wound closure is a tissue regeneration cases alone, ex-
fundamental surgical principle for posed membranes showed only 0.47
*Professor and Director of Graduate Periodontics, Department GBR because it creates an environ- mm less attachment gain compared to
of Periodontics and Oral Medicine, School of Dentistry,
University of Michigan, Ann Arbor, MI. ment that is undisturbed/unaltered by membranes that remained submerged.
†Resident, Department of Periodontics and Oral Medicine,
School of Dentistry, University of Michigan, Ann Arbor, MI. outside bacterial or mechanical insult. In comparison, membrane exposure
Passive closure of wound edges seemed to have a significant deleteri-
ISSN 1056-6163/06/01501-008
Implant Dentistry enables the wound to heal with less ous effect on bone formation. In cases
Volume 15 • Number 1
Copyright © 2006 by Lippincott Williams & Wilkins reepithelialization, collagen formation in which the membrane remained sub-
DOI: 10.1097/01.id.0000204762.39826.0f and remodeling, wound contraction, merged, a mean 3.01 mm of new bone
Implant drills were performed ac- defects associated with existing the margins of the defect in all
cording to manufacturer’s recom- implants, epithelium should be re- directions. Usually, the collagen
mended protocol. In addition, moved from the inner surface of membrane is hydrated in sterile
drilling was based upon the prefab- the flap using a sharp curette or saline or sterile water for 5-10
ricated surgical guides that consider diamond bur. The implant surface minutes before use, to improve
proper esthetic profile (Fig. 2F). should then be detoxified with ap- handling (malleability), however,
Fig. 2G shows implant placement propriate agents (e.g., 50 mg/mL this is not mandatory.
in a proper position with an obvious tetracycline for 3 minutes). • Fitting the flap: The flap is
horizontal ridge deficiency. • Fitting the membrane: Collagen checked and trimmed if necessary
• Removal of epithelium: Where membrane is trimmed and fitted to ensure that primary tension-
appropriate, as in treatment of so that it extends 2-3 mm beyond free closure is possible.
AUTOR(EN): Hom-Lay Wang, DDS, MSD*, “PASS”-Prinzipien für eine vorhersagbar erfolgreiche Knochengewebsregeneration
Lakshmi Boyapati, BDS**. *Professor und
Leiter des Graduiertenkollegs für Orthodon- ABSTRACT: Die geleitete Knochengewebswiederherstellung stellt eine eingeführte
tie, Abteilung für Orthodontie und Oralmedi- Methode zur Anreicherung unzureichender Alveolarleisten dar. Eine vorhersagbare gute
zin, zahnmedizinische Fakultät, Universität Regeneration bedarf sowohl der groen technischen Fähigkeiten wie auch eines pro-
von Michigan, Ann Arbot, MI, USA. **Assis- funden Kenntnisstandes bezüglich der einer erfolgreichen Wundheilung zu Grunde lieg-
tenzarzt, Abteilung für Orthodontie und enden Prinzipien. Die vorliegende Arbeit beschreibt die vier wesentlichen biologischen
Oralmedizin, zahnmedizinische Fakultät, Uni- Prinzipien (d.h. PASS), die für eine vorhersagbar gute Knochenregeneration erforderlich
versität von Michigan, Ann Arbot, MI, USA. sind. Hierzu gehören: der primäre Wundverschluss zur Gewährleistung einer ungestörten
Schriftverkehr: Dr. Hom-Lay Wang, Professor und ununterbrochenen Wundheilung; Gefäbildung zur Bereitstellung eines aus-
und Leiter des Graduiertenkollegs für Orth- reichenden Blutzuflusses sowie unveränderte Mesenchymalzellen; Raumerhaltung oder
odontie (Professor and Director of Graduate -schaffung, um den entsprechenden Platz für Neuknochenbildung bereit zu stellen; und
Periodontics), Abteilung für Orthodontie und Wund- sowie Implantatstabilität zur Vermeidung von Blutgerinnselbildung und unerwün-
Oralmedizin (Department of Periodontics and schten Begleiterscheinungen bei der Heilung. Auerdem werden in der Abhandlung eine
Oral Medicine), zahnmedizinische Fakultät neuartige Lappenkonstruktion sowie klinische Fälle, die dieses Prinzip praktisch zur
der Universität von Michigan (University of Anwendung gebracht haben, vorgestellt.
Michigan School of Dentistry), 1011 North
University Avenue, Ann Arbor, Michigan SCHLÜSSELWÖRTER: Geleitete Knochengewebswiederherstellung, Knochentrans-
48109-1078, USA. Telefon: (734) 763-3383, plantat, horizontale Knochengewebsanreicherung, Implantate
Fax: (734) 936-0374. eMail: homlay@umich.
edu
AUTOR(ES): Hom-Lay Wang, DDS, MSD*, Los principios “PASS” para la regeneración pronosticable del hueso
Lakshmi Boyapati, BDS**. *Profesor y Direc-
tor de Periodóntica Graduada, Departamento ABSTRACTO: La regeneración guiada del hueso es una técnica bien establecida para
de Periodóntica y Medicina Oral, Facultad de aumentar crestas alveolares deficientes. La regeneración pronosticable requiere un alto
Odontologı́a, Universidad de Michigan, Ann Ar- nivel de aptitud técnica y un completo entendimiento de los principios de curación de una
bor, MI, EE.UU. **Residente, Departamento de herida. Esta manuscrito describe los cuatro principios biológicos principales (PASS)
Periodóntica y Medicina Oral, Facultad de Od- necesarios para la regeneración pronosticable del hueso; cierre de la herida principal para
ontologı́a, Universidad de Michigan, Ann Arbor, asegurar una curación de la herida sin problemas y sin interrupciones; angiogénesis para
MI, EE.UU. Correspondencia a: Dr. Hom-Lay proporcionar el suministro necesario de sangre y células mesenquimales indiferenciadas;
Wang, Professor and Director of Graduate Pe- mantenimiento/creación del espacio para facilitar un espacio adecuado para el crecimiento
riodontics, Departament of Periodontics and del hueso; y estabilidad para la herida y el implante para inducir la formación de un
Oral Medicine, University of Michigan School of coágulo sanguı́neo y una curación sin dificultades. Además, se presentan un diseño nuevo de
Dentistry, 1011 North University Avenue, Ann la aleta y casos clı́nicos que utilizan este principio.
Arbor, MI 48109-1078, U.S.A. Teléfono: (734)
763-3383 Fax: (734) 936-0374. Dirección PALABRAS CLAVES: GBR; regeneración guiada del hueso; injertos de hueso; aumento
electrónica: horizontal del hueso, implantes.