OJ Oral Max illo lac Surg

42 :150-160,1984

Soft Tissue Responses to Hydroxylapatite

Particles of Different Shapes
DALE J. MISIEK, DMD,* JOHN N. KENT, DDS,t and RONALD F. CARR, DDS:f:

Fifteen beagle dogs seven to 15 months of age had 0.5 g of hydroxylapatite

in the form of sharp-edged particles (HA-1) or rounded particles (HA-2)
implanted in buccal soft tissue pouches. Tissue specimens from each
site were obtained at two weeks, six weeks, three months, and six months.
A mild inflammatory response was seen at the implant sites with both
particle shapes; however, inflammation resolved at a faster rate in the sites
implanted with round hydroxylapatite particles.

Prosthetic rehabilitation of the denture patient by
use of bone grafts and alloplastic materials has long
been a controversial area. Long-term survival of
dental implants may be unacceptable, bone grafts
often show significant early postoperative resorp-
tion, and synthetic alveolar ridge augmentation fre-
quently fails because of extrusion of the material,
infection, or soft and hard tissue intolerance under
denture function.
Recent investigations have shown calcium phos-
phate ceramics to be attractive implant materials
because of a high degree of biocornpatibility.l -?
Dense hydroxylapatite (HA), in particular, has
shown great promise in both animal models and
human clinical trials for the purpose of preventing
postextraction alveolar ridge resorption.l-' filling of
osseous defects adjacent to teeth,5.6 and augmen-
tation of atrophic edentulous alveolar ridges.l"?
Long-term animal studies have shown actual
bonding of HA particles to bone by means of nat-
urally occurring cementing substances. 10-14
Recently, two different types of particulate HA
have been introduced for use in alveolar ridge aug-
mentation and filling of periodontal lesions. These
materials are essentially identical in composition
and in particle size, but the particles are quite dif-
ferently shaped (Figs . 1,2).
Periograf®§ and Alveograf®§ (HA-I) are supplied
in the form of irregularly-shaped, sharp-edged par-
Received from the Louisian a State University School of Den-
tistry, New Orleans, Louisiana .
• Clinical Assistant Professor, Department of Oral and Max-
illofacial Surgery.
t Professor and Head , Department of Oral and Maxillofacial
Surgery.
* Associate Professor, Department of Pathology.
Address correspondence a nd reprint requests to Dr. Kent :
Louisian a State Universit y School of Dentistry, 1100Florida Av-
enue. New Orleans. LA 70119.
§ Cook-Waite Laboratories . Inc.
ticles and Calcititevf (HA-2), in the form of
rounded particles. Because bone metabolism and
growth is naturally slow and can be affected by
subtle differences in the immediate environment,
particularly inflammation, it was considered of clin-
ical interest to compare the relative inflammatory
response of these two types of HA particles. The
buccal soft tissues of dogs were chosen as the im-
plant site because it was expected that any differ-
ence in inflammation would be more readily ap-
parent in soft rather than hard tissues . This site was
also chosen because the materials would be placed
in contact with the alveolar and movable vestibular
soft tissues, which could yield clinically important
data.
Materials and Methods
Fifteen beagle dogs were selected for this study,
each identified by tattoo. They ranged in age from
seven to 15 months at the beginning of the study
and weighed between 8-13 kg. The animals were
individually housed and maintained on identical
diets.
The animals were chosen at random to have 0.5
g of HA-I or HA-2 impl anted in each of their buccal
soft tis sue pouches . A s urgical plane of anesthesia
was obtained by use of 13 mg/lb of pentabarbital ,
and the buccal mucosa was prepared with a 1% so-
lution of providone iodine. Lidocaine, 2%, with 1/
100,000 epinephrine, was infiltrated into the sur-
gical sites for hemostasis . A l-crn horizontal inci-
sion was made in the buccal mucosa, and a sub -
mucosal pouch was created using blunt dissection.
The HA particles were then mixed with normal sa"
line, I: I volumetrically, in an open-ended, needle-
~ Calcitek, Inc.

150
MISIEK ET AL 151

FIGURE I. Sc anning
electron microscopy of
HA-I particles, magnifica-
tion 65 x.

FIGURE 2. Scanning
electron microscopy of
HA-2 particles, magnifica-
tion 65x.
152
less, plastic syringe and injected into the pouch.
Resorbable polyglycolic acid sutures were used to
provide a watertight closure of the wound edges.
Several soft tissue/HA specimens were excised
at two-week, six-week, three-month, and six-month
intervals from each site. The specimens were im-
SOFf-TISSUE RESPONSES TO HA PARTICLES
FIGURE 3. HA-I im-
plant site at two weeks .
Histiocytes and foreign
body giant cells border
spaces previously occu-
pied by particles. There is
moderately cellular, focally
vascular fibrous tissue with
•aggregates of inflammatory
cells between the particles.
Hematoxylin and eosin,
magnification 100x.
FIGURE 4. HA-2 im-
plant site at two weeks. A
sheet of histiocytes can be
seen bordering the particle
space. Hematoxylin and
eosin, magnification 500 x .
mediately placed in 10% formalin and allowed to fix
for 24 hours. A method of rapid decalcification was
then that used to remove the HA mineral' and the
I RDO . Dupage Kinetic Laboratories, Inc., 29 W 550 N. Au-
rora Rd., Naderville, IL 60540.
MISIEK ET AL 153

FIGURE 5. HA-2 im-

plant site at two weeks. In-
terparticle tissue consists
of proliferative fibroblasts
and blood vessels (granu-
lation tissue) with scat-
tered inflammatory cells.
Histiocytes are present at
tissue-particle interfaces.
Hematoxylin and eosin,
magnification 100x .

FIGURE 6. HA-2 im-

plant site at two weeks. Fi-
brovascular tissue with a
border of histiocytes can
be seen at the interface of
particle and tissue. Hema-
toxylin and eosin, magni-
fication 500 x .

specimens were embedded in paraffin, sectioned,
mounted, and stained with hematoxylin and eosin.
Results
The two-week specimens (Figs. 3-6) showed
mild inflammation adjacent to both the HA-I and
HA·2 particles. Some artifactual distortion of the
interparticle fibrous network was noted, and gran-
ulation tissue with foreign body giant cells could be
seen in both specimens to about the same degree.
The particles themselves were rimmed with histio-
cytes, which is typical of a foreign-body reaction.
154 SOFf-TISSUE RESPONSES TO HA PARTICLES

FIGURE 7. HA-I im-

plant site at six weeks.
Sheets of histiocytes bor-
dering particle spaces have
an epithelioid appearance.
Interparticle tissue is
focally hyalinized and
contains some scattered
inflammatory cells. He-
matoxylin and eosin, mag-
nification 100 x .

FIGURE 8. HA-I im-

plant site at six weeks.
Histiocytes at tissue-par-
ticle interface have a epi-
thelioid (squamous) ap-
pearance. Hematoxylin
and eosin, magnification
500x.
MISIEK ET AL 155

FIGURE 9. HA-2 im-

plant site at six weeks .
Histiocytes bordering par-
ticle spaces appear some-
what flattened. Inter-
particle fibrous tissue is
collagenous, relatively acel-
lular, and contains oc-
casional inflammatory cells.
Irregularity of particle
space s is interpreted as
artifactual folding of tis-
sue. Hematoxylin and eo-
sin, magnification 100x .

FIGURE 10. HA-2 im-

plant site at s ix weeks.
Two particle spaces are
shown , the upper bordered
by ovoid histiocytes, the
lower by flattened histio-
cytes and fibroblasts. He-
matoxylin and eosin, mag-
nification 500 x .
156 SOFT-TISSUE RESPONSES TO HA PARTICLES

FIGURE I I. HA-I im-

plant site at three months.
Interparticle connective
tissue is collagenous but
moderately cellular. Some
histiocytes can be seen
bordering the particle
spaces; inflammatory cells
are less numerous than
seen in earlier specimens.
Hematoxylin and eosin,
magnification 100x .

FIGURE 12. HA-I im-

plant site at three months.
A band of tissue can be
seen between two particle
spaces, which are bordered
by oval or elongated histio-
cytes. Hematoxylin and
eosin, magnification 500 x .
MISIEK ET AL 157

FIGURE 13. HA-2 im-

plant site at three months.
Connective tissue is mini-
mally cellular and collage-
nous and contains sparse
inflammatory cells. The
particle spaces are lined by
flattened cells, presumably
histiocytes, but in reduced
number from earlier speci-
mens. Hematoxylin and
eosin, magnification 100 x .

FIGURE 14. HA-2 im-

plant site at three months.
A membrane-like band of
flattened cells, presumably
histiocytes, can be seen at
the tissue-particle inter-
face. Hematoxylin and
eosin, magnification 500 x .
158 SOFT-TISSUE RESPONSES TO HA PARTICLES

FIGURE 15. HA-I im-

plant site at six months.
The connective tissue is
moderately vascular and
cellular. Histiocytes can
-still be seen bordering
many of the particle
spaces. Hematoxylin and
eosin, magnification 100 x .

FIGURE 16. HA-I im-

plant site at six months,
showing a particle space
lined by histiocytes. He-
matoxylin and eosin, mag-
nification 500 x .
 MISIEK ET AL 159

FIGURE 17. HA-2 im-

plant site at six months.
Hypocellular fibrous tissue
can be seen lining the
tissue-particle interfaces.
Hematoxylin and eosin,
magnification 100 x .

FIGURE 18. HA-2 im-

plant site at six months. A
junction of three particle
space s with lining "mem-
branes" of flat to slightly
ovoid cells is shown . He-
matoxylin and eosin, mag-
nification 500 x .
160
Six-week specimens of both materials showed a
slightly milder inflammatory response. In the HA-
I specimens (Figs. 7,8), granulation tissue and his-
tiocytes were still present throughout. The inter-
particle matrix was looser and less collagenized
when compared with the HA-2 specimens, which
also had somewhat fewer histiocytes lining the par-
ticle spaces (Figs. 9,10).
At three months, the number of inflammatory
cells in the HA-I specimens had decreased and the
interparticle matrix was more collagenized (Figs.
11 ,12). The cellular component was still prominent,
however, and histiocytes could be seen lining the
spaces occupied by the hydroxylapatite particles.
The three-month, HA-2 specimens had fewer cells,
and the majority of the interstitial tissue consisted
of mature collagen (Figs . 13,14). The tissue lining
the particle spaces showed fewer histiocytes and
was taking on a "membranous" appearance; the
lack of inflammatory cells was notable.
The six-month specimens showed even greater
differences. The HA-I specimens were still rela-
tively cellular (Figs. 15,16). The linings of the par-
ticle sites still contained histiocytes throughout the
specimens except for some focal hypocellular areas .
By contrast, the six-month, HA-2 specimens were
hypocellular and predominantly collagenous (Figs.
17,18). The "membranes" previously noted at three
months had also taken on a hypo cellular character,
with almost no evidence of inflammation remaining.
Discussion
The results of this experiment are consistent with
previous reports on the effect of implant shape on
tissue inflammation. In one such study, which com-
pared triangular-, pentagonal-, and circular-shaped
rods of various polymeric materials using rat
muscle, the triangular-shaped implants showed the
greatest inflammatory reaction; pentagonal shapes
showed less , and circular rods showed the least ac-
tivity." This difference was attributed to the acute
angles (sharp points) of the triangular shape. The
HA-l particles show multiple sharp edges and
points when examined under scanning electron mi-
croscopy, taking on a "broken glass" appearance,
whereas the HA-2 particles are devoid of any jagged
or sharp edges that might serve as a continued
source of irritation and inflammation (Figs. 1,2).
In the sequence of specimens we examined, the
inflammation, although mild in both instances, did
not resolve at equal rates in the HA-I and HA-2
specimens. Particles of HA-l, because of their
irregular, sharp configuration, had a tendency
to irritate the surrounding soft tissues, which
showed clear evidence of low-grade inflammation
throughout the study period. Whether a similar sit-
SOFf-TISSUE RESPONSES TO HA PARTICLES
uation would occur if the particles were implanted
in bone or a subperiosteal site is not known. How-
ever, if an inflammatory response developed when
.this material was onlayed on an atrophic edentulous
alveolar ridge, it could have an adverse effect On
the consolidation of these particles and their incor-
poration into bone, thus enhancing the possibility
of mucosal irritation beneath the denture, or even
dehiscence.
Implantation of two shapes of hydroxylapatite
particles in Beagle dogs resulted in a mild inflam-
matory response in both instances. Resolution of
the inflammation, however, proceeded at a faster
rate in soft tissue sites containing smooth, rounded
hydroxylapatite particles than in those containing
irregular, sharp hydroxylapatite particles.
References
1. Jarcho M: Calcium phosphate ceramics as hard tissue pros-
thetics. Clin Orthoped 157:259, 1981
2. deGroot K: Bioceramics consisting of calcium phosphate
salts. Biornaterials 1:47,1980
3. Denissen HW, deGroot K: Immediate dental root implants
from synthetic dense calcium hydroxylapatite. J Prosthet
Dent 42:551, 1979
4. Denissen HW, deGroot K, Kakkes P, et al : Animal and
human studies of sintered hydroxyapatite as a material
for tooth root implants. First World Biomaterials Con-
gress, Baden, Austria, 1980,3 .8.1 (abstract)
5. Boyne PJ, Shapton BA: The response of surgical periodontal
defects to implantations with a hydroxyapatite ceramic.
Trans. 4th Ann. Meet. Soc. Biernat. 10th Int. Biernat.
Symp. 1978, p 115
6. Rabalais ML, Yukna RA, Mayer ET: Evaluation of Dur-
apatite ceramic as an alloplastic implant in periodontal
osseous defects. J Periodont 52:680, 1981
7. Kent IN, James RB, Finger 1M, et al: Augmentation of de-
ficient edentulous alveolar ridges with dense polycrystal-
line hydroxyapatite. First World Biomaterials Congres s,
Baden, Austria, 1980,3.8.2 (abstract)
8. Kent IN, Quinn JH, Zide MF, et al: Correction of alveolar
ridge deficiencies with nonresorbable hydroxylapatite.
JADA 105:993, 1982
9. Kent IN, Quinn JH, Zide MF, et aJ: Alveolar ridge augmen-
tation using nonresorbable hydroxylapatite with or
without autogenous cancellous bone . J Oral Maxillofac
Surg 41:629, 1983
10. Jarcho M, Jasty V, Gumaer KI, et al: Electron microscopic
study of a bone-hydroxyapatite implant interface. Trans.
4th Ann. Meet. Soc . Biornat. 10th Int. Biernat. Syrnp.
1978, p 112
II. Jarcho M, Kay JF, Gumaer KI, et al: Tissue, cellular and
subcellular events at a bone-ceramic hydroxyapatite in-
terface. J Bioengin 1:79, 1977
12. Jasty V, Jarcho M, Gumaer KI, et al: Bone tissue response
to dense hydroxyapatite disc implants in mongrel dogs: a
light and electron microscopic study. Ninth International
Congress of Electron Microscopy, 2:674, 1978
13. Kay JF, Doremus RH, Jarcho M: Ion micromilling of bone-
implant interfaces. Trans. 4th Ann. Meet. Soc. Biernat.
10th Int. Biomat. Symp. 1978, p 154
14. Ogiso M, Keneda H, Arasaki J; et al: Epithelial attachment
and bone tissue formation on the surface of hydroxyap a-
tite ceramics. First World Biomaterials Congress, Baden,
Austria , 1980,4.1.5 (abstract)
15. Matlaga BF, Yasenchak LP, SaIthouse TN: Tissue response
to implanted polymers: the significance of sample shape.
J Biomed Mater Res 10:391, 1976