BioXclude™ Technology Presentation

Amnion-Chorion

• Avascular tissue comprising the inner most layer of placenta separating the mother and fetus

Adapted from Boyd (1970)

Adapted from: Niknejad, H et, al.European Cells and Materials 2008; 15:88-99

Amniotic fluid

Maternal decidua

Layer Extracellular Matrix Composition

Amnion

Epithelium

Basement Membrane Collagen types III, IV, V; laminin, fibronectin, nidogen

Compact layer Collagen types I, III, V, VI; fibronectin

Fibroblast layer Collagen types I, III, VI; nidogen, laminin, fibronectin

Intermediate (spongy) layer

Collagen type I, III, IV; proteoglycans

Chorion

Reticular layer Collagen types I, III, IV, V, VI; proteoglycans

Basement Membrane Collagen types VI; fibronectin, laminin

Trophoblasts

Amniotic Tissue

Procurement - Placenta obtained from consenting

donor during elective caesarian section.

- Compliance with AATB and FDA allograft tissue standards.

Purion™ Processing Technology - First used in ophthalmology (2006)- Today used to treat chronic wounds, plastics, sports medicine, and many others- Cleanses and maintains delicate tissue structure - Dehydrates and embosses graft- Terminally sterilized (10-6 SAL)- Retains active growth factors, cytokines, and extracellular matrix architecture

Tissue Processing and Procurement

Benefits of Combined Amnion-Chorion Allograft

•BioXclude is the only product in thedental market with combined Amnion-Chorion

•BioXclude contains 4 to 5x more growthfactors than amnion only allografts

•Chorion layer accounts for over 80% ofthe growth factors found in BioXclude

•BioXclude is 4 to 5x thicker than amnion onlyallografts

IHC Analysis of Amnion Chorion and Porcine Membranes 1

* Significant difference vs. porcine** No significant difference vs. porcine

FGF = Fibroblast Growth FactorTGFβ = Transforming Growth Factor BetaPDGFα = Platelet-Derived Growth Factor AlphaPDGFβ = Platelet-Derived Growth Factor Beta

Laminin Laminin-5 TGFβ FGF PDGFα PDGFβ

Amnion Chorion(BioXclude, n=5)

4.4 ± 0.55 (p<0.001)*

4.2 ± 0.45(p<0.001)*

1.4 ± 0.9(p<0.05)*

0.7 ± 0.45(p<0.05)*

2.4 ± 0.55(p<0.005)*

3.2 ± 1.1(NS)**

Porcine Collagen(BioGide®, n=5)

0.0 0.0 0.0 0.0 0.0 3.0 ± 0.0

0.0

The picture can't be displayed.

4.2 ± 0.45

BioXclude Porcine

Laminin-5

Xenoudi P and Lucas M. IADR Meeting, Abstract #146797. San Diego, CA. March 16-19 2011University of Colorado School of Dental Medicine, Advanced Periodontal Therapies

PR061312v01

Purion® Processing Retains Biological Properties

Scientific Attributes of Amniotic Tissue

Literature Review - 2009― Reviewed over 150 papers (27 met inclusion criteria)― Findings: Possesses four unique attributes

(1) Immunoprivileged ― No foreign body inflammatory response― No reported adverse events ever reported

(2) Anti-Inflammatory ― Modulates inflammation: decreased patient pain― Downregulates inflammatory cell recruitment

(3) Anti-Bacterial ― Reduces risk of infection ― Tight seal formed after placement precludes bacteria

(4) Accelerates Healing― Cytokines / Growth Factors (PDGF, VEGF, FGF…) ― Cell adhesion proteins (fibronectin, laminin, laminin-5…)

Chen E, Tofe A. J Implant Adv Dent 2009; 2(3):67-75.

Courtesy of MiMedx Group

Presented at ER

42 Days postop

PR081301v01

Chronic Wound (use not in dental, GF potential) 2

10 Days postop debridement

Case Overview• Preop wound size was 18.75cm2; amputation

scheduled; Epifix® was last resort.• 30% wound area reduction at 7 days• Additional 15% area reduction at 14 days• Additional application at 14 days• Wound closed at 28 days.• At 3 months, patient is walking with custom

molded show.

Retains Biological Factors- Growth factors - Cell adhesion proteins- Interleukins - Tissue inhibitors of metalloproteinases

Cellular Activity - Migration of human

mesenchymal stem cells in-vitro - Recruitment of mesenchymal

progenitor stem cells in-vivo

Koob T et al. Int Wound J 2013; Online:1-8AmnioFix Scientific and Clinical Compendium, March 2013. MiMedx Group

Purion Processing Technology 3

Non-Dental Trade Names - EpiFix™ (wound care) - AmnioFix™ (sports medicine)- Many others

Cytokine FreshPurion

ProcessedPDGF-AA    PDGF-BB    TGF-a    TGF-b    bFGF    EGF    VEGF    IL-10    IL-4    PIGF    TIMP-1    TIMP-2    TIMP-4    

Cytokines Present in Amnion/Chorion Tissue

PR081306v02

#30 Pre-Op 1 week

2 week 4 week 18 week

Post-Op

Courtesy of Barton Foutz, DDS, Henderson, CO

Site Preservation without Flap Elevation or Primary Closure

Post-Op

Post-Op

Tooth #3 BX in Place* Site Closure

96 Hours 10 Days 3 Months

Holtzclaw D, Toscano N. J Implant Adv Clin Dent 2011; 2(6):49-55

* Grafted FDBA

Site Preservation 4

PR061316v01

Osseous Defect BioXclude Folded Over Itself* Site Closure

3 Months Implant Placement Pre-Op / 3 Month Post-Op

Courtesy of Dan Holtzclaw, DDS, MS, Austin TX

PR071302v02

Site Preservation (Moderate Buccal Defect) 5

* Site grafted with FDBA

Defect on #19 Site Closure* 10 Days

8 Weeks 3 Months

* Second piece of BioXclude was placed over the top covering crest and lingual aspect

PR061323v02

Site Preservation (Moderate Buccal Defect) 6

Courtesy of Dan Holtzclaw, DDS, MS, Austin TX

Excellent Tissue Profile

Buccal Dehiscence Defect Extraction Socket BioXclude Over FDBA

Non-Primary Closure 3 Months Pre-Op / 3 Mo Post-Op

Courtesy of Dan Holtzclaw, DDS, MS, Austin TX

Site Preservation (Small Buccal Defect)

Haroon Ashraf DDS, Kerri Font DDS,MS, Michael Schurr PhD, Mark Lucas DDS,MS, Charles Powell DDS,MS

University of Colorado School of Dental Medicine Postgraduate PeriodonticsABSTRACT Materials

Conclusion

Purpose: In surgical procedures, the selection of adjunctive biomaterials may amplify the innate regenerative potential within a wound and enhance the clinical outcome. The purpose of this study is to evaluate wound biomodification by assessing antimicrobial properties present within a human derived composite amnion-chorionmembrane (ACM).

Material & Methods: Membranes analyzed in the study were the human ACM BioXclude™ (SnoasisMedical) and the porcine derived collagen membrane BioGide® (Geistlich). Paper discs were used as a positive control along with paper discs containing tetracycline (TCN) at a minimum bactericidal concentration (MBC) of 62 µg/mL as a negative control. Three bacterial species were used in the study: Aggregatibacteractinomycetemcomitans (A.a.), Streptococcus mutans (S.m.), and Streptococcus oralis (S.o.).

The same number of colony forming units per milliliter (CFU/mL) for each bacterial species was inoculated on each membrane and control discs. Samples were grown over brain heart infusion (BHI) agar medium under optimal conditions. Discs from each group were removed at 12 and 24 hours and sonicated to remove the bacteria off the membranes. A serial dilution was performed to quantify bacterial growth in triplicate by counting the CFU/mL present. A Wilcoxon signed-rank test was performed to compare any differences between growths.

Results: Three in vitro trials were conducted. TheACM inhibited growth at all time points, with allbacterial strains, identical to the negative controlTCN discs. The collagen membrane and positivepaper controls did not inhibit growth of any of thebacterial species throughout the 24-hour studyperiod.

Bacterial Growth

It was determined that the ACM was as bactericidal as paper discs inoculated with TCN at its MBC. The collagen membrane does not appear to have anti-microbial properties due to its support of the bacterial growth similar to the positive control discs.

IN VITRO ANALYSIS OF ANTIMICROBIAL ACTIVITY BETWEEN AN AMNION-CHORION MEMBRANE AS COMPARED TO A COLLAGEN

MEMBRANE

Abstract # 2523349

0.7BioXclude - FGF (40x)

2.4BioXclude - PDGFα (40x)

Median Microbial Count

4.2 ± 0.45 0 ± 0

3.0 ± 03.2 ±1.1

Allograft Amnion Chorion Porcine Collagen0 ± 04.4 ± 0.55

Figure 1. Bacterial growth following removal of attempted A.a. culture from ACM (left half of plate) and collagen membrane (right half of plate) at 24 hours following serial dilution. P < 0.05 for microbial growth on ACM and negative control vs. either

collagen membrane or positive control.

Figure 2: Median microbial count for each membrane and bacteria at 12 hours.

Figure 3: Median microbial count for each membrane and bacteria at 24 hours.

BioXclude left exposed at site closure

1 week postop 1 month postop Final Abutment connection at 6 weeks

Absence of keratinized tissue

Courtesy of Nicola De Angelis, DDS, MS, University of Genoa, Italy

Keratinized Tissue Augmentation

BioXclude adapted around implants

Tooth #14 BioXclude Exposed* 2 Weeks

10 Weeks Restored (15 Months) Restored (15 Months)

* Grafted with FDBA

Courtesy of Muyeenul Hassan, BDSIndiana University School of Dentistry, Graduate Periodontics

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Site Preservation (heavy smoker) 7

Courtesy of Paul Rosen, DMD, MSYardley, PA

Extraction Socket with Bone Loss 15

Pre-Op 2 Weeks (BX Dehiscence) 5 Weeks

5 Months5 Months 5 Months

• Full maxilla flap reflection followed by scaling and root planning and osseous contouring.

• BioXclude placed over only one side the exposed bone.

• Reattachment measured by force needed to pull suture separating the gingiva.

Holtzclaw D et al. J Imp Adv Clin Dent 2102; 4(5); 19-25

Tensile Strength (in grams) Required to Separate Gingival Flap

72 hours 1 week 2 weeks 3 weeks

Control (nothing) 200 350 1,600 2,100*

BioXclude side 325 1,700 2000* 2,200** Sutures pulled through without flap displacement

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Aids in Formation of Clinical Attachment 37

Pre-Op BioXclude Placement Site Closure

Implants @ 4 months* 6 Months** 10 Months

Childers G. Retrieved from http://www.snoasismedical.com. May 2012

* 7.5 mm increase in ridge width (5.5 mm → 13 mm)** Increase zone of attached gingiva and partial root coverage on tooth #21

Ridge Split 25

PR061333v01

Overview - Single site (private practice) - 12 months results - 64 consecutive patients, 78 sites- Average age = 57 years (range 34-92)- 14 smokers, 2 oral bisphosphonates,

1 rheumatoid arthritis

Results - No adverse effects - Excellent early healing- PD: Pre = 8.5 mm, Post = 3.4 mm- CAL: Pre = 9.0 mm, Post = 4.4 mm- PD Improvement: 5.1 mm - CAL Improvement: 4.6 mm

Holtzclaw D, Toscano N, Clinical Advances in Periodontics. 2013; 3 (3): 131-137

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Clinical Study - Guided Tissue Regeneration 12

Pre-Op #30 Grafted with FDBADefect

BioXclude Placed Dry BioXclude Hydrated

Probing Depth Pre-Op = 12 mm 3 Months = 3 mm

16 Month Post-Op

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Guided Tissue Regeneration 35

Courtesy of Dan Holtzclaw, DDS, MS, Austin TX

Grade III Furcation Buccal BioXclude Over Bone Graft* Grade III Furcation Lingual

Site Closure Buccal 6 Month Post-Op

* Grafted with Osteocel and rhPDGF

Pre-Op / 6 Mo Post-Op

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Rosen, P . Clinical Advances in Periodontics. 2013; 3 (2): 64-69

Guided Tissue Regeneration 29

Pre-op radiograph BioXclude over FDBA

Site closure 1 week post-op 4 month radiograph

Missing buccal wall

PR031402v01

Courtesy of Muyeenul Hassan, BDS, MS, Univ of Detroit Mercy School of Dentistry

Sinus Lift Membrane Perforation Repair 23

Sinus membrane perforation

BioXclude™ Placement BioXclude™ adheres to the sinus membrane and seals perforation

Lateral sinus window covered with BioXclude™

Bone allograft placement into sinus cavity

Courtesy of Dan Holtzclaw, DDS, MSAustin, TX

Pre-Op CBCT Perforated Sinus Placed BioXclude

Sinus Packed w/ Bone Placed Sinus 4 Month CBCT

PR061338v01

Courtesy of Dan Holtzclaw, DDS, MS, Austin TX

Sinus Perforation and Elevation 24

Failed implant removal Bone graft placement

BioXclude placement Post-op view Reentry

Implant placement

PR101301v01

Courtesy of Robert Miller, DDS, MS, Austin TX

Immediate Implant 13

Immediate Implant

Placement Around Implants Intentionally Left Exposed

Placed Over Implant Treads 1 Year Post-Restoration

Courtesy of Dan Cullum, DDS (Coeur D Alene, ID)

#18 Extracted, #19 Edentulous

Pre-Op Implant #20 Defect

BioXclude in Place* 12 Month Post-Op 12 Month Radiograph

Pre-Op Radiograph

* Grafted with Accell Bone Putty

Implant Repair 29

Courtesy of Dan Holtzclaw, DDS, MS, Austin TX

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Buccal defect Bone graft placement

BioXclude placement Post-op view Reentry

Implant placement

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Courtesy of Robert Miller, DMD, Plantation, FL

Immediate Implant (Moderate Facial Defect) 14

Extraction #8 and #9 FDBA placed

Untrimmed BioXclude placed Bone has grown over seated implants at 5 month reentry,

Placement of healing abutments

Deep V shaped defects present after implant placement

PR021501v01

Courtesy of Robert J Miller, DMD, Plantation, FL

Immediate Implant 22

Pre-Op Placement of BioXclude

10 Days Post-OP Implants at 3 Months Final Restoration

Grafted w/FDBA

* 4.2 mm increase in ridge width at site #28 (2.3 mm → 6.5 mm) 4 mm increase in ridge width at site #29 (4.5 mm → 8.5 mm)

Holtzclaw D, Toscano N. J Implant Adv Clin Dent 2012; 4(2):25-37

Ridge Split 32

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Extraction #23-26, Tenting Screws Placed

Collagen Membrane PlacedGrafted with FDBA

BioXclude Placement Site Closure*

PR061346v02

* Vestibular dissection into the chin was performed to close the site.

Double Membrane - GBR 26

Courtesy of Dan Holtzclaw, DDS, MS, Austin TX

Healing at 21 Days

Defect at #10 Block Graft* BX over Grafted Area

10 Days Post-Op Re-Entry at 7.5 Months Pre-Op and 11 Months

* Grafted with Cancellous Allograft Block and FDBA

Block Graft 19

PR061334v01

Wang V. Retrieved from http://www.snoasismedical.com. January 2013

Missing Palatal Bone BioXclude Placement* Site Closure (note gingival cleft)

48 Hours Post-Op 10 Days Post-Op Pre-Op 6 Months* Placed over rhBMP-2 + Collagen Sponge and Titanium Mesh

PR061335v01

Courtesy of Dan Holtzclaw, DDS, MS, Austin TX

rhBMP-2 and Titanium 17

Atrophic anterior maxilla

BioXclude placed over Ti; site closure

8 month healing Mesh removed at 10 months, implants placed*

CBCT scans at preop and 10 months

rh-BMP2 is placed underneath Ti mesh

PR021502v02

Courtesy of Dan Holtzclaw, DDS, MS, Austin, TX

Ridge Augmentation with rhBMP-2 and Ti 20

Healing abutments placed after 4 months

At 10 days incision line epithelialized over

* All exposed threads are grafted with Maxxeus 70/30 allograft blend and BioXclude

Allograft Block and Particulate* BioXclude Placed Over ePTFE

Site Closure 2 Week Post-Op Pre-op CBCT

* Both block graft and cortical/cancellous particulate are contain allogenic stem cells

PR091303v01

Courtesy of Paul Petrungaro, DDS, Chicago, IL

GBR with ePTFE and Block Graft 21

Edentulous Site with Ext #24, 25

4 Month Post-op

82 year old female with OAF, post extraction #3

CBCT view Defect exposed

Defect covered with buccal fat pad and then BioXclude

Buccal flap advanced with primary closure

6 week postop

PR051501v01

Courtesy of Erica Shook, DDS, University of the Pacific, Dugoni School of Dentistry, Dept of Oral & Maxillofacial Surgery, San Francisco, CA

Oroantral Fistula (OAF) Closure 18

Extracted #18 and #19

Non-primary closure 14 week re-entry Implants placed

Allograft blend placed

PR051401v01

Courtesy of Dan Holtzclaw, DDS, MS, Austin, TX

Double Extraction Site Preservation 8

BioXclude placed

Parabiosis Model Stem Cell Recruitment In Vivo

• Tissue samples taken at 3, 7, 14 and 28 days.

Villeda S. et al 2014

Mann et al. J Surg Res, 2015

dhACM

Sham

Control ADM

GFP

• Implanted dHACMs recruited significantly more progenitor cells compared with controls (*P < 0.05) and displayed in vivo SDF-1 expression with incorporation of CD34, CD90 and CD31 + progenitor cells within the matrix.

Courtesy of MiMedx Group

EpiFix® placed

PR081302v01

Healing with Reduced Scar Tissue 36

Day 1 Week 2 Week 3 Week 4 10 Months

Overview - Randomized, controlled, split month study- 9 patients, 22 sites- Sites grafted with Maxxeus FDBA; covered

with either ACM (BioXclude) or d-PTFE- Membranes left intentionally exposed

Results at 3 Months Postoperative- Statistically significant greater bone volume

measured by micro CT (55.1% vs 39.7%) - Statistically significant less post-op pain on

days 1 and 2- Radiographic increase in ridge height (slight

loss in height for d-PTFE) - Less radiological ridge width resorption

Hassan, M, Blanchard S, Prakasam, S. AAP Poster Presentation. Sept 19-22, 2014, San Francisco, CA. University of Indiaana, Department of Periodontics

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Clinical Study – Site Preservation 38

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Thank You!