Tandartspraktijk | Volume 35, 1, Januari 2014 | Bohn Stafleu van Loghum Melle Vroom & Lodewijk Gründemann

NEW GENERATION PTFE-MEMBRANES

Non-resorbable
membranes
In the eighties and nineties various regenerative materials have been introduced
in the fields of periodontics and implantology. Many of these materials make use
of the principle of guided tissue regeneration (GTR), which also includes guided
bone regeneration (GBR). The then used non-resorbable membranes could lead
to good results. A considerable disadvantage, however, was that during exposure
of a non-resorbable membrane infections often arose and so this led to a (partial)
failure. The introduction of a “new” non-resorbable membrane will eliminate this
disadvantage. Melle Vroom and Lodewijk Gründemann give a report below of
their experiences regarding the use of these membranes.

T he principle of the GTR/GBR roughly means that due to

sealing off a cavity with the help of a regenerative material
the epithelial cells and connective tissue cells can be shut
out and bone regeneration is made possible from the inside out.
M.G. Vroom MSc qualified as a dentist (ACTA =Academic Centre for
Dentistry Amsterdam) in 1994 and as a periodontist (ACTA) in 1998.
L.J.M.M. Gründemann MSc qualified as a dentist (State University
Utrecht) in 1988 and as a periodontist (ACTA) in 1998. Both authors
This gives more time to the process of bone regeneration. One of are working as periodontists (NVvP = Dutch Union of Periodontists)
these regenerative materials is the material which has as its base and implantologists (NVOI = Dutch Union for Oral Implantology) in
polytetrafluoroethylene (PTFE), which has various applications in private practice the Periodontal Practice Friesland.
medical disciplines such as in cardiovascular surgery where it has
been used for over thirty years. Within the fields of periodontics
and implantology a form of PTFE which was treated by means of
heating and applying pressures, was introduced in the eighties. tured by the Gore company and has gained a lot of renown within
This resulted in an expanded form (e-PFTE). the field of dentistry. Various studies have shown that the use of
this material can lead to good (sometimes even spectacular)
This form, with or without titanium reinforcement, was manufac- results.1

Fig. 1 EM-image of the d-PTFE-membrane. The left figure shows an enlargement of the surface at point A. The right figure shows the
fibroblasts that attach to the d-PTFE membrane. (Photographs are used by courtesy of Osteogenics Biomedical, Inc.)

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Fig. 2 Schematic image of the modification of the membrane surface Fig. 2 A non-closed d-PTFE membrane four weeks in the mouth. The
(Regentex). Small indentations allow ingrowth of tissue. (Photographs are used membrane was placed directly after extraction of tooth #10.
by courtesy of Osteogenics Biomedical, Inc.)

An important proviso to achieve these results is that after applying d-PTFE membrane was marketed by the Osteogenics company
an e-PFTE membrane the tissues in the regenerative area remain under the brand name Cytoplast™ (with or without titanium
primarily closed off. This is awkward in larger size bone augmenta- reinforcement) in 1998.
tions because there is not sufficient tissue to cover the extension of
the bone. By applying relaxing incisions in many cases the tissues The company also added another modification in the surface of the
can be stretched more in order to obtain primary closure. The d-PTFE membrane (figure 2). In the surface situated against the
applied suturing techniques are of essential importance in keeping inside of the flap tiny indentations have been made. These
the edges of the wound firmly in position and in maintaining indentations allow partial ingrowth of tissue. This causes a
primary closure. reinforced connection between flap and membrane which, in case
of exposure, limits the epithelial ingrowth and prevents the
Exposure of e-PFTE membrane migration of bacteria alongside the membrane. It is remarkable that
In case exposure does occur (in approx. 30-40% of the cases) then this d-PTFE membrane was virtually ignored in the Netherlands as
this will nearly always have a very unfavourable impact on the far as we can tell, although very good results have been achieved
obtained regeneration rate. This can result in a regeneration rate as by its use. A possible explanation for this is the negative association
low as 0-60%.2,3 The cause for this is the open structure of an e-PFTE many clinicians have had in the past due to experiences with
membrane: in case of an exposure, bacteria from the oral cavity will non-resorbable (e-PTFE) membranes with re-entries, infections and
penetrate the e-PTFE membrane and migrate into the regeneration failures.
area. This results in the emergence of bacterial infections often
accompanied by suppuration. Studies have shown that the d-PTFE membrane achieves compara-
ble results to the e-PTFE membrane and is easier to remove.4 The
The association of non-resorbable membranes with exposures that latter is the case because the connection of the d-PTFE membrane
often led to failure has given the e-PTFE membrane a bad reputa- to the inside of the flap and the regenerative tissue can be more
tion among many clinicians. This has resulted into much more easily cut by the use of dental instruments. In the application of
attention being paid to the development and applications of d-PTFE membranes, it is of course most desirable to have no
resorbable membranes which do not directly lead to failure in case exposure of the membrane and/or the tissues in the augmentation
of exposure. Another factor is that in the use of non-resorbable area. That this is not so easy is shown in various studies that
materials an additional raising of the mucoperiostal flap is required. demonstrate an occurrence rate of exposure of 20% to 30% during
GTR treatments. So the treatment of soft tissues is of essential
Logically, this has led to the widespread application of resorbable importance. That is why a review indicates that GTR/GBR proce-
materials and the non-resorbable membranes have been pushed dures are not simple and require a high level of expertise and skill
into the background and some versions are even no longer available. on the part of the practitioner.1

However, comparative studies have shown that the use of e-PFTE However, if an exposure occurs with the use of a d-PTFE membrane,
membranes show better results than the use of resorbable this will not automatically lead to infections and failure if a
membranes.1 That is why the e-PFTE is hailed in many regenerative well-considered protocol is followed.
studies as the “golden standard”.
The d-PTFE membrane in practice.
Various approaches are possible in practice for the use of d-PTFE
The d-PTFE membrane membranes. The use directly after an extraction is an indication
Some time ago, an adapted e-PTFE membrane has already been which we will further discuss in another paper in this magazine. In
developed. In this process the PFTE is treated without an applica- this application we can easily experience how undisturbed the
tion of pressures which caused a dense-PTFE (d-PTFE) to emerge. clinical picture is if a d-PTFE membrane does have an open
The great advantage of this is that the surface of this membrane connection to the oral cavity (figure 3).
has a less open structure which will not allow bacteria and bacterial
products to penetrate it (figure 1). In the right half of figure 1 we In our practice we have been using the d-PTFE membranes for a
can see how fibroblasts attach to the d-PTFE membrane. The considerable period with so far very satisfactory results. We will
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6 7

Fig. 4 The area of #23, 24 before the bone augmentation. The top of the Fig. 5 Clinical picture before the removal of the d-PFTE membrane five
alveolar process shows a width of 1-2 mm. months after placement.

Fig. 6 After removal of the d-PTFE membrane the increase of bone Fig. 7 Placement of an implant on position #23 as a base of the future
width is clearly visible. Compare to figure 4. replacement of #23 and 24.

discuss some of these cases in combination with clinical pictures. d-PTFE membrane with the object of placing implants later. The
membrane was fixed with a membrane fixation screw and
Case 1 (figures 4-7) underneath the membrane we applied allogenic bone material.
The first case concerns a 23-year old woman who was referred to us Healing proceeded without any complications and the tissues
for an implant in the area of #23 and 24. Periodontically there are remained closed. After six months we removed the d-PTFE
no specific problems. The clinical situation (figure 4) of the lower membrane and the fixation screw. A bone augmentation of approx.
front teeth shows that the bone width is much too limited at the 7 mm was the result of regeneration (figures 9-10). The implants
top of the alveolar process, i.e. 1-2 mm. We decided to perform a could then be placed (figure 11). In this case hard regeneration
bone augmentation in the area of #23, 24 with the use of a d-PTFE tissue was also shown to be present during drilling out. Figure 11
membrane with titanium reinforcement. As filler underneath the shows that bone augmentation in the area of #21 is possible even
membrane, we made use of an allogenic bone material to gain beyond the physiological limits of the alveolar process. This was
more stability and to support the regeneration process. 5,6,7 The also proven in an experimental study. 8,9
healing proceeded without any problems and the tissues remained
primarily closed. After five months we removed the d-PTFE Fixing the membrane with the (Pro-fix™) membrane fixation screw
membrane. A bone augmentation of 6-7 mm was the result (figures enabled us to make slight shape adaptions to the membrane even
5-6). Placing an implant was now relatively easy (figure 7). During after placement without moving the membrane. The fixation screw
the drilling out, a very good hardness was observable in the prevents/limits micro movements of the membrane from having a
regenerative tissue. In comparing clinical pictures 5 and 6 it is negative impact on the bone regeneration. Because GTR
clearly visible that the regenerative tissue exactly follows the treatments as described above are a sort of oral orthopedics in our
outline as dictated by the d-PTFE membrane. That shows the opinion, they require proper surgical treatment/techniques.
importance of deliberately pre-shaping the membrane. Especially in the light of sterile/hygienic surgical procedures.

Case 2 (figures 8-11) d-PTFE regeneration limits (vertical/horizontal)

The second case concerns a 58-year old woman, who wished for a In studies horizontal extensions of 3.1 mm to 7.1 mm have been
fixed prosthesis in the third quadrant. After periodontal treatment reported.2, 10, 11 The great challenge is to realize the vertical bone
she was in the follow-up care stage and showed a stable, healthy augmentation. In a vertical sense increases of 4-7 mm supracrestal
periodontium. The 3-D image generated by a CB-CT scan (figure 8) bone augmentation are feasible according to some studies.12, 13 In
of the third quadrant, however, showed an alveolar process whose this case the challenge is even greater in dealing with the soft
width was too limited at the top. We decided to perform a bone tissues in such a way that primary closure is feasible and stable.
augmentation in the area of #18-21 using a titanium reinforced
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8 9 10 11

Fig. 8 The 3D-image (CB-CT scan) shows a limited bone width. Fig. 10 Picture of the regenerative tissue directly after removal of the
d-PFTE membrane. The indentation where the fixation screw was located is
Fig. 9 Clinical picture before the removal six months after placing the visible in the coronal area of #20.
d-PTFE membrane with titanium reinforcement and a membrane fixation
screw. Fig. 11 Placing implants #19 and 21. The increased bone width is clearly
visible. Compare to figure 8.

Clinical treatment exposures mistakenly treats it accordingly. The exact time the exposure occurs
We have also observed the occurrence of exposures in some cases is of clinical importance. Histological studies have shown that the
of bone augmentation in our practice. Experience teaches us that foundation for bone generation is laid after four weeks.14, 15 We
an exposure can already be observed during the removal of the speak of an osteoid matrix then. It is crucial, therefore, to prevent
sutures, but sometimes only after a couple of months. That is why any inflammatory reactions during the first four weeks even in case
the patient receives instructions to check the augmentation area of an exposure. This is perfectly possible while using a d-PTFE
carefully at least twice a week and in case of a visible membrane (‘a membrane. But if, in case of an exposure, the edge of the
spot with the colour of white paper’) to get in touch with the membrane is also exposed, there is a definite point of entry. Early
practice immediately. It is also good to let the patient know that an removal of the membrane is then indicated. If the underlying
exposure not by any means (directly) means that the procedure has regenerative tissue has not become involved in the inflammation
failed. In addition, it might be sensible to make sure that the process, it is still possible to obtain regeneration even in such a
referring dentist doesn’t assume the exposure is exposed bone and situation.

12 13

14 15

Fig. 12 The #29 area before the bone augmentation. Fig. 14 Picture of regenerative tissue four months after placement and
two months after removal of the d-PTFE membrane.
Fig. 13 A d-PFTE membrane has been placed and fixed with a
membrane fixation screw. Fig. 15 Placing an implant in the area of #29 is perfectly possible now.
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16 17

Fig. 16 The regenerative tissue immediately after removal of the d-PTFE Fig. 17 Second-stage treatment three months after removal of the
membrane. The membrane was removed earlier than planned on membrane. The implant becomes visible after first removing hard
account of the presence of a fistula. The implant in position #9, that had regenerated tissue by means of rotary instruments.
been placed together with the d-PTFE membrane, has been overgrown
with hard regenerative tissue.

Case 3 (figures 12-15) of hard regenerative tissue that had even grown over the implant
In the third case, more than two months after placing a d-PTFE (figure 16). After three months the second-stage treatment was
membrane a local exposure emerged in the area of #29 (figures performed, in which the implant was sought out by removing bone
12-13) For the 57-year old patient, the plan was to place two (figure 17).
implants in the fourth quadrant. The area to be augmented showed
a defect in the beginning in which the vestibular wall was lacking. d-PTFE without titanium reinforcement
(figure 12). Here we removed the d-PTFE membrane after diagnos- The application of a d-PTFE membrane without titanium reinforce-
ing the exposure. After a two-month healing period we placed the ment is perfectly possible in case of smaller bone augmentations.
implants. Figure 14 shows that the surface of the regenerative For example in combination with placing an implant. The
tissue does not appear as smooth as in the previously shown case, membrane in such a case has mainly a protective function and can
where the membrane remained in place for a longer period easily be removed during second-stage treatment. Currently, many
without exposure. The bone situation still enabled us to place the clinicians use a resorbable membrane in such cases. But the use of a
implants (figure 15). d-PFFE membrane is much more convenient because these
membranes are considerably less expensive than resorbable
Complications membranes.
One complication we have occasionally observed is the emergence
of a swelling in the tissues 2-3 months after placing the Conclusion
membranes. Sometimes accompanied by fistula formation. If in The d-PTFE membrane is a perfectly useful membrane whose use
such a case the membrane is removed, the swelling will quickly can lead to very good results. Considering its broad applicability,
fade. It is remarkable that we have observed that the augmentation we think the d-PTFE membrane can become the new standard
process in such a case will still provide a good result. One example product and it is often preferable to a resorbable membrane.
of this is case 4, the treatment of a 44-year old patient who was
provided with an implant in the area of #9 directly after removing The authors declare they gain no financial benefits from mentioning the
#9 and 10. We combined this with bone augmentation (d-PTFE products named in this article.
membrane and allogenic bone material). After 2 months a fistula
was formed and we removed the membrane. The clinical picture
immediately after the removal of the membrane still showed a lot
Tandartspraktijk | Volume 35, 1, Januari 2014 | Bohn Stafleu van Loghum Melle Vroom & Lodewijk Gründemann

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