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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 4  |  Page : 91-96

An update on the utilization of high-density polytetrafluoroethylene (d-PTFE) membranes for guided bone regeneration


Department of Periodontics and Community Dentistry, College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia

Date of Submission03-Dec-2020
Date of Acceptance04-Dec-2020
Date of Web Publication29-Dec-2020

Correspondence Address:
Dr. Reem Al-Kattan
Department of Periodontics and Community Dentistry, College of Dentistry, King Saud University, P.O. Box 60169, Riyadh 11545.
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INJO.INJO_51_20

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  Abstract 

Guided bone regeneration (GBR) procedure has produced acceptable results while utilizing various barrier membranes. Among the membranes used, expanded PTFE (e-PTFE) was the first material to demonstrate successful outcomes and it became the gold standard for GBR. However, early bacterial infection with membrane exposure affecting bone regeneration was the main drawback of e-PTFE. On the contrary, high density polytetrafluoroethylene (d-PFTE) ensures a good bone regeneration process in spite of membrane exposure in the oral cavity, and it also presents with a lower risk of early infection after surgical procedures. The purpose of this review is to provide an amendment to the existing knowledge about the GBR with special emphasis on the d-PTFE barrier membrane used for GBR. The relevant literature for this review was identified through a PubMed, MEDLINE, Scopus, and the Cochrane Library database search. Eleven articles that evaluated the use of d-PTFE as a barrier membrane for GBR were identified: two experimental studies and nine clinical studies. Considering the potential benefit they offer, d-PTFE is a favorable candidate for GBR. However, a careful surgical approach and thorough knowledge of the materials and management of complications significantly contribute to the success of GBR while utilizing d-PTFE.

Keywords: Barrier membranes, bone regeneration, dense PTFE, implant, resorbable membranes, ridge augmentation


How to cite this article:
Al-Kattan R. An update on the utilization of high-density polytetrafluoroethylene (d-PTFE) membranes for guided bone regeneration. Int J Oral Care Res 2020;8:91-6

How to cite this URL:
Al-Kattan R. An update on the utilization of high-density polytetrafluoroethylene (d-PTFE) membranes for guided bone regeneration. Int J Oral Care Res [serial online] 2020 [cited 2021 Jan 16];8:91-6. Available from: https://www.ijocr.org/text.asp?2020/8/4/91/305362




  Introduction Top


Implant dentistry has improved the quality of life of edentulous patients through implant-supported therapy. For an implant placement to be successful, the patient’s alveolar ridge must be adequate enough to retain the implant and to provide acceptable aesthetic and functional outcomes. However, such criteria are not met by many patients in routine clinical practice.[1],[2],[3] Bone loss or inadequacy could be attributed to many reasons, including tooth extraction, severe systemic diseases, periodontal diseases, trauma, failed endodontic therapies, and tumors; hence, the osseointegration of implants is crucial.[4] Several techniques and materials have been employed for vertical or horizontal augmentation of the alveolar ridge; they include osteodistraction, inferior alveolar nerve transposition, inlay and onlay bone grafting, and GBR procedures. Nonetheless, GBR utilizing various the barrier membrane is a standard technique producing acceptable results.[1],[3],[5],[6]

Definition and concept of GBR

According to the American Academy of Periodontology, GBR is defined as “a surgical procedure that augments alveolar bone volume in areas designated for future implant placement or around previously placed implants.”[7] GBR is based on principles of guided tissue regeneration (GTR)[8],[9]; however, GTR requires the regeneration of bone, periodontal ligament (PDL), and cementum to form a new periodontal apparatus whereas in GBR, bone formation around the implant needs to be enhanced and is complicated compared with GBR.[9] According to this concept, regeneration of osseous defects is likely to occur via the application of occlusive barrier membranes, which mechanically protect the blood clot, create space, and exclude soft tissue or non-osteogenic cell populations from the surrounding soft tissues. This enhances selective cell (pluripotential and osteogenic) populations originating from the parent bone to populate the osseous defects.

Historical overview of GBR

Early research on GBR dates back to 1957 when Murray et al.[10] used a barrier to physically seal off an anatomical site for bone healing. This was followed by a study by Dahlin et al.[11] who used a plastic cage to protect a blood clot and found that the interior of the cage became filled with bone. It was then that the authors reported in their publication about three main factors that were deemed necessary for the regeneration of bone: presence of blood clot, preserved osteoblasts, and contact with living tissues. This concept was later experimented on and confirmed by using Teflon leafs/barriers on mandibular two and three wall defects of rabbit models by Kahnberg.[12]

Ten years later, Dahlin et al.[11] initiated early research on GBR to identify solutions for confounding problems associated with reconstruction of large, osseous defects in the jaws and for the treatment of the atrophic mandible or maxilla. The authors surgically created a through-and-through defect in the ramus of 30 Sprague–Dawley rats. The defect on one side of the jaw was covered with a porous polytetrafluoroethylene (PTFE) membrane (Gore-Tex®) whereas the other side served as a control and was devoid of membrane covering. After healing at three, six, and nine weeks, the specimen evaluation demonstrated a highly significant increase in bone regeneration on the membrane site as compared with the control site. This was followed by experimentation in animal models, which demonstrated the generation of bone around titanium implants.[9] Further, the studies by Dahlin et al.[13] stood as a foundation for the principle of GBR in the regeneration of bone for clinical use. From thereon, GBR techniques and barrier membranes have undergone tremendous transformation.

Barrier membranes

Several types of barrier membrane materials, including PTFE, e-PTFE, d-PTFE, collagen, freeze-dried dura mater, dura mater, allografts, polyglactin 910, polylactid acid, polyglycolic acid, polyortoester, polyurethane, polyhydroxybutyrate, calcium sulfate, and titanium meshes, have been used in clinical studies to achieve GBR. Currently, these barrier membranes are classified into nonresorbable and resorbable types [Table 1].[14],[15],[16],[17] These materials provide additional benefits to the use of a membrane, such as protection of the wound from salivary contamination and mechanical disruption from external sources.[16]
Table 1: Classification of barrier membrane

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The e-PTFE was the first material to demonstrate successful outcomes, and it became the gold standard for GBR and GTR in the early 1990s.[15] e-PTFE is a highly stable polymer in biological or chemical environments, and it resists breakdown due to microbiological and enzymatic attack.[18] However, early bacterial infection with membrane exposure affecting bone regeneration is the main drawback of e-PTFE. On the contrary, d-PFTE has been specifically designed for use in bone-augmentation procedures, which seems to assure a good bone regeneration process even when the membrane is exposed to the oral cavity.[19],[20] Further, d-PTFE barriers can be used to regenerate a defective socket wall without flap elevation, repair an oral antral perforation, and restore a large amount of lost vertical keratinized tissue.[21] A previous literature review on the use of n-PTFE membranes for GBR reported that the membrane was promising as a barrier, however, the evidence was limited.[18]

Therefore, the purpose of this narrative review is to provide an amendment to the existing knowledge about the d-PTFE barrier membrane used in GBR procedures.


  Literature Search Top


The electronic database, PubMed, MEDLINE, Scopus, and the Cochrane Library were searched to identify relevant papers published between 2012 and October 2020 on titanium-reinforced PTFE membranes used in GBR procedures. The search strategy was limited to papers published in the English language. The literature was thoroughly searched for publications involving animal studies and human randomized clinical trials (RCTs), controlled clinical trials, prospective and retrospective studies, case series, and case reports.


  Results Top


The literature search revealed a total of 11 published articles involving d-PTFE relevant to the aim of this review. The articles included two animal studies[22],[23] and nine human studies[24],[25],[26],[27],[28],[29],[30],[31],[32] that were read to entirety to provide an update regarding the use of d-PTFE for GBR applications.

Animal studies

Mardas et al.[22] used d-PTFE and microporous membranes to evaluate GBR in calvarial critical size defects of healthy, osteoporotic and osteoporotic zoledronic acid (ZA) treated six-month-old Wistar rats. New bone generation was assessed by qualitative and quantitative histological analysis. The study outcome showed that ZA treatment and the adjunct use of membrane significantly enhanced new bone formation. It was concluded that application of the d-PTFE membranes in GBR promotes bone healing in healthy and osteoporotic rats. Further, ZA treatment may improve new bone formation in osteoporotic rats.

Altiparmak et al.[23] assessed the effect of induced membrane on GBR and compared its effect with d-PTFE membrane and collagen membrane. For the same purpose, one defect was created on the parietal bone of 16 white Vienna rabbits and cement was deposited inside the defects. After eight weeks, the bone cements were carefully removed from the defect without damaging the induced membrane. This was followed by creation of another two defects, which were filled with xenogenic graft materials and were covered with either d-PTFE, newly formed induced membrane, or collagen membrane. Histological evaluation was performed at the fourth and eighth week after the animals were sacrificed. The induced membrane and d-PTFE membrane group showed significantly higher new bone formation and mature bone ratios compared with the collagen membrane group. The study confirmed the induced membrane as a strong barrier that stimulated bone regeneration similar to d-PTFE.

Clinical studies

Cucchi et al.[24] used the d-PTFE membrane and corticocancellous porcine-derived bone for the GBR of a vertical bone defect with simultaneous placement of a dental implant in the posterior mandible. Histological analysis was performed to assess the bone formation from a biopsy sample of the grafted site collected nine months after the surgery. The peri-implant bone was successfully maintained for up to two years after prosthesis delivery. Also, the functional loading of the implant was successfully supported by the formed bone. The overall procedure recommended the use of a d-PTFE nonresorbable membrane to allow successful regeneration of the vertical bone defect without the inclusion of any autogenous bone.

In 2017, Cucchi et al.[25] in their RCT evaluated vertical bone gain and complications rate after GBR. One-stage GBR was performed on 40 partially edentulous patients with atrophic posterior mandible who received either titanium-reinforced d-PTFE membranes or titanium meshes covered by cross-linked collagen membranes. All complications related to “surgical” and “healing” and between “minor” and “major” were recorded along with the evaluation of vertical bone gain and primary implants stability. In the d-PTFE membrane group, surgical and healing complication rates were 5.0% and 15.0%, respectively; whereas in the titanium mesh group, the group B, surgical and healing complication rates were 15.8% and 21.1%, respectively. There was no significant difference observed between the groups in relation to vertical bone gain, complications rate, and implant stability.

In their case report, Ghensi et al.[26] described the procedure to overcome the exposure of a d-PTFE membrane after a maxillary GBR procedure and allowing implants insertion. The authors followed a careful protocol instead of removing the d-PTFE membrane after its exposure. The protocol consisted of repeated oral rinsing using 0.12% chlorhexidine mouthwashes, application of 1% chlorexidine gel, and weekly oral hygiene follow-up. This approach demonstrated successful augmentation of bone and enabled the insertion of dental implants. It was concluded that management of membrane exposure requires awareness of the materials used and decent oral hygiene.

In his case series, Herzberg[27] described 10 single span cases treated with vertical GBR by using d-PTFE membranes and followed up to 36 months. The author concluded that a reliable option for vertical GBR of a single tooth span is to use a d-PTFE membrane. However, careful flap design and management should follow to ensure uneventful healing.

Cucchi et al.[28] clinically and histologically assessed the connective tissue (pseudo-periosteum) layer formed above the newly formed bone after GBR with titanium-reinforced d-PTFE or titanium (Ti)-mesh with resorbable membranes. For the same purpose, 40 patients with partial edentulism in the posterior mandible were allocated into two treatment groups: Ti-reinforced d-PTFE membrane and Ti-mesh with resorbable membranes. The vertical bone gain was recorded during re-opening surgery at nine months and found no significant difference between the groups. However, the nonresorbable d-PTFE membrane showed higher bone density and a thinner pseudo-periosteum layer above the newly formed bone. This is crucial, because the dense pseudo-membrane usually presents with low cellularity and no mineralization.

De Carvalho et al.[29] evaluated the GBR performed by using d-PTFE membranes, with and without xenograft material by computerized tomography-based body composition (CTBC). In the test group, the sockets were filled with graft materials and covered with d-PTFE. In the control group, the sockets were filled with the blood clots and covered with d-PTFE. The bone width and height were assessed at buccal plate, alveolar height, cervical third, middle third, and apical third. The study showed that xenograft in conjunction with d-PTFE membranes proved to be superior compared with the same membrane and blood clot only in regions of the crest, middle third, and alveolar height.

In their case series on GBR of post-extraction sockets, Koidou et al.[30] demonstrated that d-PTFE membrane used over a resorbable collagen membrane prevents the early degradation of the collagen membrane and preserves its integrity in post-extraction sockets. The d-PTFE membrane can, thus, serve as a practicable choice to healing by primary intention. Further, the d-PTFE membrane is found to prevent the translocation of the mucogingival junction and the distortion of the local anatomy while creating a wide area of keratinized gingiva.

In their case report on a 72-year-old female requiring dental implants to replace teeth, Ibraheem and Blanchard (2020)[31] demonstrated that intentional implant thread exposure on their buccal surfaces and simultaneous d-PTFE membrane exposure did not produce any adverse healing outcomes for alveolar ridge augmentation.

Windisch et al.[32] showed that staged and simultaneous vertical reconstruction of deficient alveolar ridges by means of GBR with titanium-reinforced d-PTFE membranes combined with a bilaminar split-thickness flap design delivered predictable hard tissue formation as determined clinically and radiographically.


  Discussion Top


The first exclusive report on d-PTFE was reported by Carbonell et al.,[18] in which the author concluded that the d-PTFE membrane was a promising candidate as a barrier membrane. However, the studies considered to make such a conclusion were limited. Hence, in the current review, we sought to understand the existing knowledge about d-PTFE for GBR and therefore the articles published from 2012 to Oct 2020 were considered, although the first clinical use of this material dates back to 1995.[19],[20]

The d-PTFE is made of 100% pure biomedical-grade inert PTFE, which is dense, nonporous, nonexpanded, and nonpermeable.[19] The d-PTFE membranes currently available in the market are summarized in [Table 2]. These materials are available in different sizes, textures, and with or without reinforcement. The recently introduced d-PTFE membrane is permamem® (Botiss biomaterials, Berlin, Germany), which is claimed to be an exceptionally thin membrane (~0.08 mm). The material is found to be intact and maintains its surface characteristics both during the initial implantation and for the entire healing time. The manufacturer also states that this material can be utilized in certain cases that require open healing. This was confirmed in a study by Papi et al., who concluded that this novel d-PTFE membrane was effective in alveolar ridge preservation. The complete exposure of this barrier membrane did not cause any adverse outcomes on the regeneration.[33]
Table 2: Commercially available d-PTFE membranes

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The thickness of d-PTFE membranes varies from 0.13 to 0.25 mm, and the low porosity varies from 0.2 to 0.3 mm. On contrary, e-PTFE has a higher porosity (5–30 mm) but a similar thickness compared with d-PTFE. The reduced pore size and minor bacterial infiltration enables the d-PTFE membrane to be widely used.[33] Further, both d-PTFE and e-PTFE have the same indications, but the property of d-PTFE allows no primary closure without causing any adverse effect on the final results.[19],[20],[34] The d-PTFE is a phenomenal substitute to e-PTFE and it is also considered equivalent to newer generation of resorbable membranes.[19],[20],[25],[35],[36]

The animal studies included in this review demonstrated that the application of d-PTFE membranes in GBR promotes bone regeneration even in osteoporotic rats.[22] Another study comparing the induced membrane with that of d-PTFE found no significant difference in new bone formation and mature bone ratios between the two. However, the study confirmed that the induced membrane and the d-PTFE membrane were superior to the collagen membrane.[23]

The surfaces of d-PTFE membranes are uniformly flat, which helps in reducing the attachment of cells and fibers to its surface and extremely decreases any mechanical attachment of the membrane to the tissues.[37] Hence, it can be intentionally left exposed and be removed from the surgical site without a need for second surgery. The density of the d-PTFE membrane allows reduced bacterial penetration and also prevents cell adhesion.[37] Further, the nonresorbable d-PTFE has higher bone density and a thinner pseudo-periosteum layer formed on the newly formed bone.

Contrary to the advantages of the d-PTFE membrane over e-PTFE, a few studies have shown that the dense structure of the PTFE elicits more biofilm accumulation and increased biofilm thickness compared with e- PTFE.[38],[39] This was due to the multifibrillar structure of e-PTFE that does not favor the adhesion and growth of bacteria.


  Conclusion Top


Within the limits of the present review, the following conclusions are drawn:

  • Satisfactory results can be achieved even in cases of accidental exposure of the d-PTFE membrane.


  • However, a careful surgical approach and thorough knowledge of the materials and management of complications significantly contribute to the success of GBR utilizing d-PTFE.


  • The comparison of d-PTFE over other membranes did not demonstrate the dominance of other membranes, rather a similar outcome was observed.


  • D-PTFE used alone or with other graft material or with a titanium reinforcement has shown convincing outcomes.


  • Considering the potential benefit they offer, d-PTFE is a favorable candidate for GBR. However, the existing evidence regarding the use of d-PTFE for GBR is limited. This necessitates effecting more clinical studies and RCTs with histological and radiographic assessment.


  • Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
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        Tables

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