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Journal of Prosthodontic Research 57 (2013) 314

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Review
Current barrier membranes: Titanium mesh and other membranes for
guided bone regeneration in dental applications
Yunia Dwi Rakhmatia DDS, Yasunori Ayukawa DDS, PhD*, Akihiro Furuhashi DDS, PhD,
Kiyoshi Koyano DDS, PhD
Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation, Faculty of Dental Science, Kyushu University,
3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
Received 27 November 2012; accepted 18 December 2012
Available online 21 January 2013

Abstract
Research on guided bone regeneration (GBR) is still ongoing, with evidence mainly from preclinical studies. Various current barrier
membranes should fulfill the main design criteria for GBR, such as biocompatibility, occlusivity, spaciousness, clinical manageability and the
appropriate integration with the surrounding tissue. These GBR characteristics are required to provide the maximum membrane function and
mechanical support to the tissue during bone formation. In this review, various commercially available, resorbable and non-resorbable
membranes with different characteristics are discussed and summarized for their usefulness in preclinical studies. Membranes offer promising
solutions in animal models; however, an ideal membrane has not been established yet for clinical applications. Every membrane type presents
both advantages and disadvantages. Titanium mesh membranes offer superb mechanical properties for GBR treatment and its current efficacy in
trials will be a focus in this review. A thorough understanding of the benefits and limitations inherent to various materials in specific clinical
applications will be of great value and aid in the selection of an optimal membrane for GBR.
# 2013 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.

Keywords: Titanium mesh; Guided bone regeneration; Resorbable; Non resorbable; Membrane

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2. Principles of guided bone regeneration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3. Design criteria for GBR membrane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.1. Biocompatibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.2. Create a space for ingrowth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.3. Occlusivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3.4. Tissue integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3.5. Clinical manageability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
4. Barrier membranes for GBR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4.1. Resorbable membranes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4.2. Non-resorbable membranes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
4.2.1. e-PTFE membrane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
4.2.2. d-PTFE membrane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
4.2.3. Titanium mesh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Abbreviations: GBR, guided bone regeneration; GTR, guided tissue regeneration; Ti, titanium; e-PTFE, expanded polytetrafluoroethylene; d-PTFE, dense
1
polytetrafluoroethylene; Max, maxilla; Mand, mandibular; CTM, configured titanium mesh; M-TAM, micro titanium augmentation material; GT, Gore-Tex ;
1 1
GTRM, Gore-Tex regenerative membrane; GTAM, Gore-Tex augmentation material; RIF, rigid internal fixation; MI, microporous membrane; MIP,
microporous laser-perforated membrane; BG, bone grafts; MAR, mineral apposition rate; PRP, protein rich plasma; DBM, demineralized bone matrix; w, weeks;
m, months; y, years; Ant, anterior; Post, posterior; ND, no data.
* Corresponding author at: Tel.: +81 92 642 6441; fax: +81 92 642 6380.
E-mail address: ayukawa@dent.kyushu-u.ac.jp (Y. Ayukawa).

1883-1958/$ see front matter # 2013 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
http://dx.doi.org/10.1016/j.jpor.2012.12.001
4 Y.D. Rakhmatia et al. / Journal of Prosthodontic Research 57 (2013) 314
5. Focus on titanium mesh and its role in GBR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1. Introduction
Adequate bone volume is an important prerequisite for a
predictable, long-term prognosis in implant dentistry.
However, some patients present with insufficient horizontal or
vertical bone, which frequently precludes the successful
outcome of an ideal implant placement (Fig. 1). Various
methods have been developed to increase bone volume and
augment new tissue growth: (1) Distraction osteogenesis,
which describes the surgical induction of a fracture and the
subsequent gradual separation of the two bone ends to create
spontaneous bone regeneration between the two fragments [1];
(2) Osteoinduction, which employs appropriate growth factors
and/or stem/ osteoprogenitor cells to encourage new bone
formation [24]; (3) Osteoconduction, in which a grafting
material serves as a scaffold for new bone formation [5]; and
(4) Guided bone regeneration (GBR), which provides spaces
using barrier membranes that are to be subsequently filled with
new bone [6,7].
Most biochemical osteoinductive approaches still have an
extremely limited clinical application, such as the use of bone
morphogenetic proteins (BMPs) [8]. In addition, in certain
locations, such as in the jaw, distraction osteogenesis is still in
its development phase and often leaves undesirable tissue
scarring [9]. This leaves GBR and the use of bone grafting
materials or combinations of these methods as the only ones
commonly applied in clinical practice. GBR is reported as
providing the best and the most predictable results when
employed to fill peri-implant bone defects with new bone
[6,7,10]. Furthermore, GBR improves the predictability of
bone augmentation and provides long-term stability to the
newly augmented site [11,12].
2. Principles of guided bone regeneration
The underlying concept of GBR was first introduced more
than 50 years ago, when cellulose acetate filters were
experimentally used for the regeneration of nerves and tendons
TM
[13]. Subsequently, cellulose acetate (Millipore membrane
filter) enhanced osseous healing of rib, radial bone and
femoral bone defects [14]. Later, a series of animal studies
provided evidence to show that GBR can predictably facilitate
bone regeneration in critical-sized osseous defects [1520], as
well as the healing of bone defects around dental implants by
augmenting the height and the width of atrophic alveolar
ridges prior to implant insertion [2126].
The basic principle of GBR (Fig. 2) involves the placement
of mechanical barriers to protect blood clots and to isolate the
bone defect from the surrounding connective tissue, thus
providing bone-forming cells with access to a secluded space
intended for bone regeneration [27]. According to this
principle, the use of a barrier membrane is advantageous to
facilitate augmentation of alveolar ridge defects, induce bone
regeneration, improve bone-grafting results, and treat failing
implants [28].
3. Design criteria for GBR membrane
In addition to the surgical technique used, there are many
factors that contribute to a successful GBR outcome, including
barrier occlusion and stability, the size of the barrier
perforations, peripheral sealing between the barrier and the
host bone, an adequate blood supply, and access to bone-
forming cells [2935]. Moreover, in the last few years, several
membrane designs have been studied that not only enhance
new bone formation, but also stabilize the bone graft below
the membrane and minimize the risk of collapse and/or soft
tissue ingrowth (Table 1) [19,25,31,32,3648].
For use as a medical device, barrier membranes must fulfill
five main design criteria, as described by Scantlebury [49]:
biocompatibility, space-making, cell-occlusiveness, tissue
integration and clinical manageability.
3.1. Biocompatibility
The membrane must provide an acceptable level of
biocompatibility. The interaction between the material and
tissue should not adversely affect the surrounding tissue, the
intended healing result, or the overall safety of the patient.
3.2. Create a space for ingrowth
The membrane should have an adequate stiffness to create
and maintain a suitable space for the intended osseous
regeneration. This quality is predominantly related to the
membrane thickness. In addition, a membrane should provide
an optimal space that can be maintained for tissue ingrowth but
also still provide adequate support to the tissue, even in large
defects. The material should also be appropriately malleable to
provide the specific geometry required for functional recon-
struction, but be sufficiently stiff to withstand the pressures
exerted by external forces, such as mastication in jaw
reconstructions [50]. If the membrane were to collapse into
the defect space, the volume for regeneration is reduced and an
optimal clinical outcome would not be achieved.
3.3. Occlusivity
An optimal barrier should be sufficiently occlusive to avoid
fibrous tissue formation, which may prevent or delay bone
formation. Occlusivity is therefore closely linked to membrane
porosity; this factor has a major influence on the potential for
cell invasion [46]. Indeed, barrier occlusivity of a membrane
 Y.D. Rakhmatia et al. / Journal of Prosthodontic Research 57 (2013) 3 5
14

Fig. 1. (a) An adequate bone volume (height and width) is a prerequisite for successful implant treatment. (b) Barrier membrane and bone graft as bone substitute
materials are placed to accelerate bone formation. (c) After new bone is formed final prosthesis is fabricated.

collagen deposition, the formation of avascular tissue, and

an absence of capillary growth and infiltration [55]. Pore
size will also affect the capacity of the material to support
the tissue. A large pore size will inevitably decrease the
resulting surface area of the material, which could limit
the important initial steps of cell adhesion onto the
membrane [56] and subsequent decrease of blood vessel
ingrowth [53].

Fig. 2. The principle of guided
bone regeneration using
mechanical barriers (membranes)
to seal off the bone defect from the
surrounding soft connective tissue
into a secluded space by which
cells only from the surrounding
bone can migrate.
may be at least as important
as its space-maintaining
properties when
regenerating bone defects
[51].
The architecture of the
porous structures in general,
and not the type of material
used, has been suggested to
confer the biological
activity of a material [52].
Membrane pores facilitate
the diffusion of fluids,
oxygen, nutrients and
bioactive substances for
cell growth, which is
vital for bone and soft
tissue regeneration.
However, these pores
must also be impermeable
to epithelial cells or
gingival fibroblasts (in the
case of dental implants);
a larger pore size will
allow these faster-growing
cells to overpopulate the
defect space and inhibit
the infiltration and activity
of bone-forming cells
[50]. A larger pore size
also acts an easy pathway
for bacterial
contamination, and
surgical removal of these
contaminated membranes
becomes complicated
because of the excess soft
tissue ingrowth [53,54]. If
pores are too small, on the
other hand, cell migration
of all cells is limited,
which leads to enhanced
Y.D.Tissue
3.4. Rakhmatia et al. / Journal
integration of Prosthodontic Research 57 (2013) 3 5
14
Tissue integration is the
key aspect of all tissue
regeneration techniques as it
is essential that the host
tissue integrates with the
membrane. It is well
established that the
structural integrity of the
barrier membrane and the
sufficient adaptability of its
borders to the adjacent
original bone constitute
prerequisites for predictable
new bone formation [29].
Tissue integration stabilizes
the healing wound process,
and helps to create a seal
between the bone and the
material to prevent fibrous
connective tissue integration
into the defect site. Tissue
integration between the
membrane and the contours
of the adjacent bone is
reliant on the membrane
space-making capacity of
the material; a material that
is too stiff would not be able
to mold to the shape of the
defect site.
3.5. Clinical manageability
A membrane should be
practical for clinical use,
particularly for dental
work. A membrane that is
difficult to use, such as one
that is too malleable, can be
frustrating and will often
lead to complications if it
cannot be reproducibly
used in a clinical setting,
particularly the usually
small setting inherent with
dental implants [50]. On
 6
Table 1
Summary of studies using GBR membranes with different membrane structures and designs.
Year [Ref] Animal model Type of membrane Study design Assessment Outcome
Author
2012 [36] Dog maxilla Remotis (multilayered with Histological evaluation Biodegradation and bone Remotis: an interconnective pore system, Bio-Gide: more
Rothamel interconnected system of at 4, 8, 12 and 24 weeks formation fibrous structure. Both membranes integrated into the
pores); BioGide (bilayer surrounding tissue without any inflammatory infection,
structure, smooth upper surface allowed early vascularization and supported underlying
and coarser bottom surface) bone formation. Biodegradation: Remotis (812 weeks);
Bio-Gide: 48 weeks.
2010 [37] Mouse calvaria Synthetic polylactide SEM; histological and morphometric Topographic (porosity of Interconnecting pores and channels (F: 660 mm), with
de Santana evaluation at 14 and 28 days membrane); bone formation smooth internal walls. Different sides of the barrier promote
differential soft tissue responses; however, similar amounts

Y.D. Rakhmatia et al. / Journal of Prosthodontic Research 57 (2013) 314

of enhanced bone formation.
2009 [38] Dog mandible Ti meshes (macro: 1.2 mm; Histological and morphometric Bone growth and soft tissue Macroporous membrane: greater bone regeneration,
Gutta micro: 6 mm porous); evaluation at 1, 2, and 4 months ingrowth area; MAR prevented significant soft tissue ingrowth, the lowest MAR
polylactic acid (1 mm porous) compared with microporous and Polylactic acid.
2008 [39] Dog mandible RIF, BG, MI, MI + BG, Histological and morphometric Bone area MI + BG: larger amounts of bone compared with other
Sverzut MIP, MIP + BG evaluation at 6 months groups. MIP alone and BG alone: no difference. MI: the least
bone area and reduced the amount of grafted bone.
2004 [40] Dog mandible e-PTFE (1525 mm pore size Histological and morphometric Bone regeneration (height); Occlusive and porous GTR; both space-provision and device
Polimeni and reinforced with evaluation at 8 weeks wound area; bone width occlusivity; occlusive and space-provision compared to sites
polyprophylene mesh) and the with porous GTR device or more limited space-provision:
300 mm porous devices significant bone regeneration.
2004 [41] Dog mandible e-PTFE membranes (1525 mm Histological and morphometric Bone regeneration (height); Space-provision: significant effect on bone regeneration
Polimeni pore size); calcium carbonate evaluation at 4 weeks wound area following GTR. Coral biomaterial: enhances space-provision
CI (resorbable, porous) and supports bone regeneration.
2003 [42] Rabbit skull Titanium barriers dome shaped Microradiograph; histological Area of tissue; area of The bone grew systematically along the titanium surface.
Van Steenberghe (w: 12 mm; height: 6 mm; evaluation at 3, 6 and 12 months trabeculae; mean trabeculae in After removal of the barrier, on average 75.3% and 59.4% of
thickness: 0.2 mm) dome the newly created tissue volume was maintained after 3 and
9 months, respectively.
2003 [43] Rat mand. ramus Hemisperical teflon packed Histological evaluation; The space in the capsule; newly In cell-permeable and cell-occlusive capsules grafted with
Mardas with DBM. Test capsules: planimetric measurement formed bone; DBM particles; DBM: similar amounts of bone formed. Invasion of
9 perforations; w: 0.3 mm. at 30, 60 and 120 days loose connective tissue undifferentiated mesenchymal cells from the surrounding
Contralateral side: non soft tissues into the barrier-protected area is unnecessary for
perforated (cell occlusive) bone formation with GTR.
2003 [44] Rabbit calvaria Hemispherical cap of titanium. Histological evaluation Areas of newly generated tissue Statistically significant difference: the amount of tissue
Yamada One cap had small holes (13 at 1 and 3 months (%) and mineralized bone in the generated between 1 and 3 months; the amount of
holes, w holes: 1.5 mm) and the newly generated tissue under mineralized bone generated at 3 months under the cap
other had no holes the Ti cap without holes. Total occlusiveness, sufficient stiffness and
passage of time allow predictable mineralized bone
augmentation.
2000 [19] Rabbit calvaria High density PTFE (TefGen-FD); Histological and morphologic Pattern of bone healing by TefGen: easier to detach from the underlying bone than GT.
Marouf semipermeable e-PTFE (Gore- evaluation at 4, 8 and 16 weeks morphological classification GBR: GT is more effective than TefGen-FD. GT membrane
Tex) lamellae were infiltrated by fibro-osseous tissue.
Table 1 (Continued )
Year [Ref] Animal model Type of membrane
Author
1999 [45] Dog mandible Ti reinforced e-PTFE: GTRM
Simion 1; GTRM 2; GTRM 3
1998 [32] Rat calvaria Prefabricated silicone frames +
Lundgren 7 barriers with different
occlusiveness (a stiff plastic
plate and 6 polyester meshes,
perforation: 10, 25, 50,
75, 100 and 300 mm)
1998 [31] Rabbit; edent. Gore-Tex augmentation
Lundgren area of the maxilla material (GTAM); non
perforated titanium foil;
perforated titanium foil
1997 [46] Rat subcut. tissue e-PTFE of 30, 60, 100 mm
Salzmann and epididymal structural differences
fat pads
1996 [47] Rat calvaria Dome-shaped e-PTFE
Zellin membranes with different
membrane porosity: <8, 2025
and 100 mm
1995 [25] Rat mand. ramus Resorbable: Guidor, Periogen,
Zellin Resolut LT, Resolut ST,
Vicryl C, Vicryl PM; non
resorbable: GTAM, Millipore
(pore size:0.22 mm), NYT, Ti-
foil
(50 mm gauge)
1994 [48] Rabbit calvaria Titanium cast gold device (2
Schmid tubes). 1 tube: closed by the
cast metal, 1 tube: covered
by an e-PTFE with 4 different
structures (GT Periodontal;
GTAM center part; GTAM
outer part; GT RC-10
Study design
Histological and morphometric
evaluation
Histological and morphometric
evaluation at 4, 8 and 12 weeks
Histological and morphometric
evaluation at 4 weeks
Histological and
immunohistochemical
examination at 5 weeks
Histological and morphometric
evaluation at 6, 12, 18 weeks
and 6 months
Histological evaluation
Histological evaluation at 8
months
Assessment Outcome
Regenerated tissue, membrane An extremely open porous microstructure + a totally
contact with regenerated bone occlusive barrier: significant regenerative outcomes.
or with bone However, these design may be applied only to resorbable
devices. Do not require removal.
Total area of tissue and total Totally occlusive barriers: the slowest rate of bone tissue
area of mineralized bone augmentation. Barriers with perforations >10 mm: faster
rate of bone augmentation. The amount of augmented
mineralized bone related to perforation sizes >10 mm: no
differences.
Y.D. Rakhmatia et al. / Journal of Prosthodontic Research 57 (2013) 314
Total of original bone area; The highest degree of regeneration: in defects underneath
remaining bone area; the titanium foils, particularly if perforated (covered/not by
mineralized bone; cortical GTAM-barriers). The space maintaining properties of a
and trabeculae bone; barrier may be at least as important as barrier occlusiveness
bone marrow when regenerating bone defects.
Fibrous capsule formation, 30 mm subcutaneous implants: dense fibrous capsule
endothelialization and activated formation. 60 mm: the greatest endothelialization. 100 mm:
monocytes and macrophages the largest values for the Monocyte/Macrophage Index.
Material structure and implant site influence the healing of
ePTFE. Activated monocytes/macrophages may inhibit
endothelialization of e-PTFE.
Percentage bone fill of domes The amount of new bone: at 6 weeks essentially obtained
with the two most porous membranes compared to the least
porous; at 12 weeks: no difference. The smallest internodal
distance: lack of membrane stabilization and more soft
tissue ingrowth from the side.
Numerical score of blood clot, GTAM, Millipore and Resolut long term: good
bone union, compact bone, bone osteopromotive effect compared to others membranes.
marrow, inflammatory response Inflammatory reaction was displayed in the surrounding
soft tissue. Different membranes differ strongly in
osteopromotive efficacy. Membranes developed primarily
for periodontal regeneration purposes may not be adequate
to promote bone healing.
Bone formation area in the After 8 months of healing, new bone had formed in all
cylinders irrespective of cylinders in all animals irrespective of whether the chamber
whether the chamber was for bone formation was sealed off by cast titanium or the
sealed off by cast titanium or ePTFE membrane. It is concluded that permeability of the
the e-PTFE membrane membrane is not necessary in the guided generation of new
bone.
7
8 Y.D. Rakhmatia et al. / Journal of Prosthodontic Research 57 (2013) 314

Table 2
Typical commercially available membranes.
Commercial name Properties (pores; thick) Comments
Non resorbable expanded polytetrafluoroethylene (e-PTFE)
Gore-Tex1 0.530 mm. Discontinued Longest studies [5963]
Non resorbable high dense polytetrafluoroethylene (d-PTFE)
CytoplastTM (GBR; TXT) Less than 0.3 mm Primary closure unnecessary [64,65]
Cytoplast1Non Resorb Less than 1.36 mm Favorable bone regeneration [61]
TefGen FDTM 0.20.3 mm Easy to detach [19,54]
Nonresorbable ACE <0.2 mm; 0.2 mm Limited cell proliferation [66]
Non resorbable titanium mesh
Frios1BoneShields 0.03 mm; 0.1 mm Sufficient bone and graft maturity [67,68]
Tocksystem MeshTM 0.16.5 mm; 0.1 mm No sign of inflammation/resorption [68]
TM
M-TAM 1700 mm; 0.10.3 mm Excellent tissue compatibility [69]
Ti-Micromesh ACE 1700 mm; 0.1 mm Long term survival and success rate [70]
Resorbable collagen (origin type of collagen; resorption time)
1
BioGide Porcine (I and III); 24 weeks Useful alternative to e-PTFE [71]
1
BioMend Bovine (I); 8 weeks Bone growth, modulate cell behaviors [72,73]
1
Biosorb Membrane Bovine (I); 2638 weeks Provided stable fixation [74]
TM
Neomem Bovine (I); 2638 weeks Two layers, used in severe case [75]
OsseoGuard1 Bovine (I); 2432 weeks Improves aesthetic outcome [76]
Ossix Porcine (I); 1624 weeks Increased the woven bone [77]
Resorbable synthetic (origin; resorption time)
Atrisorb1 Poly-DL-lactide; 3648 weeks Custom fabricated membrane [78]
1
Biofix Polyglycolic acid; 2448 weeks Act as barrier to gingival cells and bacteria [79]
1
Epiguide Poly-DL-lactic acid; 2448 weeks Support developed blood clot [73]
Resolut XT Poly-DL-lactide/Co-glycolide; 8 weeks Porous structure influence the cells attached [73]
1
OsseoQuest Hydrolyzable Polyester; 1624 weeks Good tissue integration [80]
Vicryl Polyglactin 910 mesh; 8 weeks Most reliable results compared with non-resorbable [72]

the other hand, a membrane that is too stiff cannot be
contoured easily, and the sharp edges could perforate the
gingival tissue and subsequent exposure of the membrane
[57]. One study showed that non-resorbable barriers
provided a suitable stiffness over resorbable membranes
for optimal bone width and height in GBR [58].
4. Barrier membranes for GBR
Numerous barrier membranes have been developed to serve
a variety of functions in clinical applications, which can be
grouped as resorbable or non-resorbable membranes. The
biomaterial and physical properties of membranes ultimately
influence their function, and selection of a specific material is
based on the biological properties of the membrane as well as
the treatment requirements [59], with each material bearing
inherent advantages and disadvantages. Several of the
commercially available membranes are summarized in Table
2 [19,54,5980].
4.1. Resorbable membranes
Resorbable materials that are used as membranes all belong
to the groups of natural or synthetic polymers. Of these,
collagen and aliphatic polyesters, such as polyglycolide or
polylactide, are best known for their medical applicability
[81]. Collagen is derived from a number of sources and is
treated in various ways for membrane fabrication.
Polyglycolide or
polylactide can be made in large quantities, and the wide range
of available materials allows for the creation of a wide
spectrum of membranes with different physical, chemical, and
mechan- ical properties [82].
As the name suggests, resorbable materials offer the
advantage of being resorbed by the body, thus eliminating
the need for second-stage removal surgery. For this reason,
resorbable membranes appeal to both clinician and patients, in
reducing the risk of morbidity, the risk of tissue damage, and
from a cost-benefit point of view. In principle, stiff resorbable
membranes promote a similar degree of bone regeneration and
bone formation as non-resorbable membranes [83,84]. More-
over, in situations where the bone defect margins are
appropriately maintained by the membrane, favorable results
have been reported [85,86].
The disadvantages of resorbable materials, however, are
their unpredictable degree of resorption, which can
significantly alter the amount of bone formation [72]. If they
are resorbed too fast, the consequential lack of rigidity means
that additional support is required [38,87]. They also have
shortcomings when trying to protect large particulate grafts
[60]. When the membranes are exposed and/or associated with
inflammatory reactions in the adjacent tissue, the enzymatic
activity of macrophages and neutrophils causes the membrane
to rapidly degree, thereby affecting the structural integrity of
the membrane and causing decreased barrier function and less
bone regeneration or bone fill; this is particularly problematic
when grafting in conjunction with implant placement, as the
implant becomes unstable [88]. When
Y.D. Rakhmatia et al. / Journal of Prosthodontic Research 57 (2013) 3 9
14
the bone defect is not Y.D. Rakhmatia
maintain the etspace
al. / Journal
beneathof Prosthodontic
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14
supported by a physical the membrane for a digestive, cerebral and .
barrier, bone regeneration sufficient period, they are cardio-vascular surgeries, 2
fails. Even if the more predictable in their and basic research has .
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to keep the space, they reduced risk of long-term tissue-guided repair [61]. .
generally lose strength, complica- tions, and they Indeed, in a recent
collapse into the space and are simple to manage controlled study [63], it was d
lead to a failed clinically [90]. Non- shown that a combination of -
reconstruction [25]; for resorbable membranes also an e-PTFE membrane and P
example, when treating offer a unique characteristic. autogenous bone graft at T
periodontal defects, Their structure can be varied edentulous sites may limit F
resorbable membrane may with changes in porosity if a graft resorption, thus E
have a tendency to collapse more adaptable and tissue- enhancing bone repair.
[89]. compatible alternative, and e-PTFE membrane has m
multiple designs are two different e
4 commercially available and microstructures: a coronal m
. can be further developed on border and an occlusive b
2 demand [59]. We will portion. The coronal border, r
. discuss three predominant with internodal distance of a
non-resorbable membranes: 25 mm, has an open n
N the expanded and dense microstructure collar that e
o forms of PTFE (e- and d- facilitates early clot High density PTFE (d-
n PTFE) and titanium mesh. formation and collagen PTFE) membrane (ex.
TM
- fiber attachment to stabilize Cytoplast Regentex GBR-
r 4 the membrane until it 200 or TXT-200;
e . becomes fixed [59,61]. The Osteogenics Biomedical
s 2 occlusive portion has an Inc., Lubbock, Texas,
o . internodal distance of less USA) is one alternative to
r 1 than 8 mm to allow nutrient e-PTFE. This
b . inflow while preventing the membrane was originally
a infiltration of other tissue developed in 1993, and its
b e cell types [59]. e-PTFE success in bone and tissue
l - comprises numerous small regeneration is well
e P pores, which encourage documented [64,65]. This
T tissue cell attachment that membrane is made of a
m F stabilizes the host-tissue high-density PTFE, with a
e E interface. These smaller submicron (0.2 mm) pore
m pores also act to restrict the size. Because of this high
b m migration of epithelial cells density and small pore size,
r e [62]. However, this material bacterial infiltration into the
a m requires second-stage bone augmentation site is
n b surgical extrac- tion, which eliminated, which protects
e r may expose the membrane the underlying graft material
s a to bacteria [60]. and/or implant.
n Furthermore, e-PTFE must Furthermore, primary soft
Non-resorbable e be removed immediately in tissue closure is not required
membranes include According to its the case of inflammation. At [54,65]. Previous authors
polytetrafluoroethylene structure, PTFE can be present, e-PTFE membrane have reported that d-PTFE
(PTFE) and titanium mesh. divided into two types: has been discontinued and completely blocks the
One drawback in the use of expanded-PTFE (e-PTFE) is not available for dental penetration of food and
this type of membrane is the and high density-PTFE (d- use; however, possible bacteria, and thus, even if it
necessity for its removal PTFE). The Gore-Tex
1
alternatives are available. is exposed to the oral cavity,
with a second- stage membrane (W.L. Gore & it is still acts as an
surgical procedure. Associates, Flagstaff, AZ, appropriate membrane
However, this disadvantage USA), which is composed barrier [91,92].
may be overshadowed by of e-PTFE, has been widely Interestingly, one of the
the advantages offered. used in clinical treatment
TM
materials, Cytoplast , does
These membranes provide and had become a first not have porous structure
an effective barrier function choice material for and its attachment to tissues
in terms of biocompat- tissue/bone regeneration. It is weak. Thus, it can be
ibility [86], they can removed easily by pulling
on the membrane without Y.D. Rakhmatia et al. / Journal of Prosthodontic Research 57 (2013) 3 11
14
lifting the mucosal flap. In Research into GBR is
addition, even if it is still ongoing and evidence
exposed, the risk of for the use of titanium in
infection is less than that of dental applications is
e-PTFE [61]. expanding, particularly for
alveolar ridge reconstruction
4 prior to implant placement.
. We searched the PubMed
2 Medline databases from
. 1991 to 2011 and retrieved
3 all relevant articles (in
. English only) reporting the
use of titanium mesh for
T bone regeneration in the
i clinic, using various search
t terms (membrane/gbr/bone
a regeneration/tita- nium
n mesh/titanium membrane).
i The study summaries are
u shown in Table 3
m [35,60,6870,94,97107].
Titanium mesh (Ti-mesh)
m has excellent mechanical
e proper- ties for the
s stabilization of bone grafts
h beneath the membrane. Its
Besides PTFE rigidity provides extensive
membranes, titanium is space maintenance and
another non- resorbable prevents contour collapse;
material applicable for its elasticity prevents
dental bone repair. In mucosal compression; its
1969, Boyne et al. stability prevents graft
inaugurated a mesh from displacement; and its
titanium for the plasticity permits bending,
reconstruction of large contouring, and adaptation
discontinuity osseous to any unique bony defect
defects [96]. Titanium has [60,97]. Various studies
been used extensively in have shown that Ti-mesh
numerous surgical maintains space with a
applications because of its higher degree of
high strength and rigidity, predictably, even in cases
its low density and with a large bony cavity
corresponding low weight, [57,71,108,109]. In addition,
its ability to withstand high it is believed that the
temperatures and its smooth surface of Ti-mesh
resistance to corrosion makes it less susceptible to
[87,93,94]. This metal is bacterial contamination than
highly reactive, and can be resorbable materials
readily passivated to form a
protective oxide layer,
which accounts for its high
corrosion resistance [95].
The low density of titanium
provides both high-strength
and lightweight dental
materials [95].

5. Focus on
titanium mesh
and its role in
GBR
 10
Table 3
Summary of clinical studies with titanium mesh membranes prior to implant placement.
Study Titanium mesh No. of patients Defect type Bone Grafts Bone (%) Infection, Exposures, Implant placement No. of Implant survival
or Removal (months) implants (follow-up)
2012 [97] MTAM 0.1-mm-thick; 27 Alveolar ridge max Bone Graft Material 85.18 Exposure: 26% 5.7 69 100% (2 years)
Her w pores: 1.7 mm and mand
2010 [98] Ti-mesh 15: mesh only; Edentulous ridge Anorganic bovine bone 100 Exposure: 28.5% 6 97 Mesh only: 97.3%;
Torres 15: mesh + PRP max and mand (Ti mesh only) Mesh + PRP:
100% (2 years)
2009 [70] ACE 24 Alveolar ridge Mand ramus 85 Exposure and 89 56 100% (38 years)
Corinaldesi removal: 14.8%
2008 [99] Ridge Form Mesh 44 Alveolar ridge max Illiac crest/tibia/mand. + 97.72 Exposure: 52.7% 6.9 174 ND

Y.D. Rakhmatia et al. / Journal of Prosthodontic Research 57 (2013) 314

Louis and mand hydroxyapatite Removal: 7
Failed placement: 1
2007 [100] Micro Dynamic Mesh 23 Edentulous ridge max Mand ramus or mental 83.33 Exposure: 33.33% 46 24 ND
Roccuzzo and mand symphysis (4 from 12 sites)
Removal: 8.33%
2006 [101] Custom fit 11 Max Hip onlay grafts 54 Exposure: 5 (bone was 917 Ant: 30 Ant: 82.6% (9 years);
Molly formed enough) Post: 16 Post: 76.6% (6 years)
2006 [68] Frios 17 Alveolar ridge max Chin, ramus, extra socket, 73 Exposure: 35.3% 8.47 41 71% (6 months)
Proussaefs and mand Max tuber + Bio-Oss
2004 [35] Micro Dynamic and 18 Edentulous ridge max Mand ramus or mental 83.33 Exposure: 22.22% 46 37 100% (2 months)
Roccuzzo Modus 1, 5 and mand symphysis Temporary paresthesia:
27.77%
2003 [102] CTM 10 Alveolar ridge Bovine bone mineral 81.2 Exposure: 20% 9 10 ND
Artzi
2003 [94] Cortical Mesh 18 Alveolar ridge No 100 No 46 50 100% (7 years)
Degidi
2002 [103] Sofamor Danek 1 Edentulous ridge Iliac crest 100 No 7 Max (10), ND
Lozada Mand (6)
2001 [104] Bonesheet + e-PTFE 22 Alveolar ridge No 81.8 Exposure: 4 sites Max (6), 22 ND
Assenza Removal: 2 sites Mand (4)
2001 [105] 0.2-mm-thick Ti-mesh 14 Edentulous Illiac and anorganic 100 Exposure: 14.28% 45 59 98.3% (4 years)
Maiorana bovine bone
1999 [106] M-TAM 15 Alveolar ridge Cancellous bone 93.5 Exposure and 510 20 ND
von Arx removal: 1 sites
1998 [69] Tocksystem 80 25 Edentulous ridge max Retromolar mand 96 Dehiscence: 3 implants 8 120 ND
Malchiodi mm microhole (1 patient)
1998 [107] M-TAM 18 Alveolar ridges Retromolar area and chin 100 No 5.2 27 100% (13 years)
von Arx
1996 [60] M-TAM 20 Alveolar ridge Retromolar area, impacted 90 Exposure: 50% 68 28 ND
von Arx canine, chin Removal: 1 patient
Y.D. Rakhmatia et al. / Journal of Prosthodontic Research 57 (2013) 3 11
14
12 [67]. Studies indicate that,
14
because of their spongy
architecture, resorbable
membranes are a possible
nidus for infection, and
microbial colonization
within superficial and deep
portions of membrane is
favored [110,111].
However, the stiffness
of the Ti-mesh also
lends itself to
causing an increased
number of exposures, such
as mechanical irritation to
the mucosal flaps [112]. In
addition, the sharp edges,
caused by cutting, trimming,
and bending of titanium
mesh, might be responsible
for exposure of titanium
barriers [57]. Despite the
exposure, von Arx et al.
noticed no infection in any
of their patients [60]. This
offers an advantage as
compared with e-PTFE
barriers, which result in
infection when exposed
[113,114].
The superb properties of
Ti-mesh make it optimal for
successful GBR
[35,70,94,98,105,107].
However, many pro- blems
still remain and need to be
resolved to increase the
predictable nature of these
materials. Most problems
with Ti- mesh arise from
their exposure and from soft
tissue ingrowth. The
stiffness of Ti-mesh can
maintain space better than
other membrane, but may
result in mucosal irritation
that leads to exposure of the
membrane. This space
maintenance and resistance
to collapse is influenced by
the thickness of the Ti-
mesh, and as such, an
appropriate thickness must
be balanced with the
likelihood of irritation when
using Ti-mesh for GBR.
Another common feature
of commercially available
Ti- mesh membranes is its
macroporosity (in the
millimeter range). This is
Y.D. Rakhmatia
thought to etplay
al. / Journal of Prosthodontic
a critical Research 57 (2013)
disadvantages, 3
a membrane lateral and vertical bone
role in maintaining blood should be selected based augmentation. However,
supply and is believed to on a thorough under- necessary adjustments to the
enhance regeneration by standing of the benefits and pore size and frequency in
improving wound stability limitations inherent to the titanium mesh biomaterials
through tissue integration materials in relation to the should improve their
and allowing diffusion of functional requirements in efficacy in dental applica-
extracellular nutrients across the specific clinical tions.
the membrane [54,115,116]. application.
Another advantage of this Titanium mesh offers
an excellent solution for C
macroporosity is related to
GBR in dental applications o
the attachment of soft
n
tissues, which may stabilize over other membrane types.
f
and restrict the migration of Preliminary clinical studies
l
epithelial cells [61,117,118]. have also shown its
i
However, this makes the predictable nature in both
c
material difficult to remove t
at the second surgery. These
macro- and multi-porous
o
characteristics also create f
sharp spots when the
material is cut or bent, and
i
may provide an easy
n
pathway for microbial
t
contamination into the
e
healing site [94]. Thus, the
r
development of less porous e
and micropore-sized Ti- s
mesh membrane could t
alleviate some of the current
difficulties associated with
s
Ti-mesh in dental
t
applications. a
t
6 e
. m
e
C n
o t
n
c All authors state that
l they have no conflicts
u of interest.
s
i
o R
n e
f
The concept of GBR for e
the reconstruction of the r
alveolar ridge defect prior to e
implant placement has been n
developed in an effort to c
optimize treatment e
strategies. Research from s
animal and clinical studies
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