Barrier membranes: More

than the barrier effect?

Journal of Clinical Periodontology
2019

Alka rose james

II MDS
content
▫ Introduction
▫ History
▫ classification
▫ Types of membrane
▫ Role of membrane
▫ conclusion

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Introduction

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Four methods have been used to increase the bone
formation and to augment the bone volume
▫ osteoinduction by use of appropriate growth factors
▫ osteoconduction, where a grafting material serves as a
scaffold for new bone growth
▫ distraction osteogenesis, by which a fracture is
surgically induced and the two fragments are then
slowly pulled apart .
▫ guided tissue regeneration

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History :
▫ Hurley and colleagues were among the first to use
guided bone regeneration (GBR) in humans in 1959.
▫ In 1980s Karring and Nyman applied barrier
membranes to periodontal regeneration research and
discovered that the first cells to populate a wound area
would determine the type of tissue to ultimately
occupy that space.

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Def of guided tissue regeneration:  surgical procedure
aimed at regenerating lost periodontal attachment.creation
of secluded space favouring angiogenic and osteogenic
cells,protecting the vascular and cellular elements and
supporting accumulation of growth factors.(acc to
glossary of oral and maxillofacial implants).

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▫ Principle of GBR using barrier membranes, either
resorbable, is to exclude certain cell types such as
rapidly proliferating epithelium and connective tissue,
thus promoting the growth of slower‐growing cells
capable of forming bone. GBR is often combined with
bone grafting procedures.

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Barrier membranes:

▫ Guided bone regeneration is used to enhance bone

growth of the alveolus for implant placement and
around peri-implant defects.
▫ Barrier membrane has additional benefits , such as
protection of the wound from mechanical disruption
and salivary contamination.

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Ideal Requirements of barrier membrane:
▫ tissue adhesion without mobility
▫ block soft tissue in-growth,
▫ east to use
▫ maintains a space
▫ biocompatibility

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classifications
▫ Synthetic
1. Polytetraflouroethylene
2. Aliphatic esters
▫ Natural 
1. Collagen and extracellular matrices derived
bovine,porcine and human tissue.
2. Chitosan
3. Alginate 10
▫ Metals
1. Titanium and its alloys mesh
2. Cobalt-chromium alloys
▫ Inorganic compounds
1. Calcium sulphate
2. Calcium phosphate

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 Non resorbable membrane:
Polytetrafluoroethylene:
▫ With presentation of first case of guided bone regeneration
with PTFE this material had been widely used due to its
inert nature.

▫ Since the use of PTFE membranes have been documented

to result in successful GBR therapy, results obtained using
new materials should always be compared with results of
PTFE membranes. 12
 Titanium-reinforced( ePTFE):
▫ In situations where bone formation is desired in large defects or in
supracrestal areas, conventional ePTFE membranes do not
adequately maintain space unless supported by grafting materials.

▫ Titanium-reinforced membranes consist of a double layer of

ePTFE with a titanium framework interposed. Recent research has
demonstrated the successful use of these membranes in vertical
ridge augmentation and in the treatment of large defects in the
alveolar process. 13
 Titanium mesh:
▫ The use of titanium mesh which can maintain the space can be
a predictable and reliable treatment modality for regenerating
and reconstructing a severely deficient alveolar ridge.

▫ The main advantages of the titanium mesh are that it maintains

and preserves the space to be regenerated without collapsing
and it is flexible and can be bent.

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▫ It can be shaped and adapted so it can assist bone
regeneration in non-space maintaining defects.

▫ Due to the presence of holes within the mesh, it does not

interfere with the blood supply directly from the
periosteum to the underlying tissues and bone grafting
material. It is also completely biocompatible to oral
tissues
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 Resorbable Membranes:
Natural membranes

Collagen:
The source of collagen comes from tendon, dermis, skin or
pericardium of bovine, porcine or human origin.

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▫ The raw collagen material is processed and purified to remove
noncollagenous protein before forming the final product. Natural
collagen membranes are widely used in GBR, they perform the
function of a membrane barrier and may act to thicken the soft
tissue at the surgical site.

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▫ Cross-linking can provide some protection in premature
exposure by preventing early breakdown.

▫ Chemical cross-linking is done with a variety of methods

including glycosylation and exposure to formaldehyde and
glutaraldehyde, among other chemical agents.

▫ Nonchemical methods include ultraviolet radiation and

dehydrothermal cross-linking. 18
 Polymeric Membranes
▫ Polymeric membranes are valuable in preserving alveolar
bone in extraction sockets and preventing alveolar ridge
defects, as well as ridge augmentation around exposed
implants.

▫ Polymeric membranes are made up of synthetic

polyesters, polyglycolides (PGAs), polylactides (PLAs),
or copolymers
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▫ A clinical advantage of PGA, PLA, and their
copolymers is their ability to be completely
biodegraded to carbon dioxide and water via the Krebs
cycle.

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 Novel membranes:
Alginate membrane:
▫ It has close assimilation to bone surface and has no
inflammatory response.
▫ It has got easy handling properties .
▫ It is more effective than collagen membranes for
mandibular and tibial defect.

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Placental membranes:
▫ Placental allografts have been used in medicine for
>100 years.

▫ The currently available dental form of placental

allograft is composed of cryopreserved, dehydrated
amnion–chorion laminate.

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▫ ACMs possess a variety of proteins that provide a
bioactive matrix to facilitate wound healing, including
collagen types I, III, IV, V, and VI; laminin; platelet-
derived growth factor-a (PDGF-a); PDGF-b, fibroblast
growth factor; and transforming growth factor-b.

▫ In addition to providing a bioactive matrix, studies have

shown placental barriers to have antibacterial properties
and to reduce inflammation via inhibition of macrophages
and polymorphonuclear neutrophils.
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chitosan
▫ Chitosan is a polysaccharide comprising copolymers
of glucosamine and N-acetylglucosamine and can be
derived by partial deacetylation of chitin from
crustacean shells.
▫ Chitosan is biocompatible, biodegradable, and
antimicrobial and can be used as hydrating agent.

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▫ In rat, chitosan membranes showed a good cell
occlusion and beneficial osteogensis effect in
comparison to those in the control group.

▫ The strength of the chitosan membrane is less when

compared to rest of the resorbable membrane and so to
improve the mechanical properties it is incorporated
with other material and surface morphology has been
modified.
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Fate of the membrane
▫ An experimental study revealed that compared with no
treatment,the application of a non-resorbable PTFE
membrane promoted earlier generation and a higher
number of core-binding factor alpha 1 osteo progenitor
cells.

▫ At 8 and 10 days of healing, the presence of the PTFE

membrane enhanced the expression of the bone-related
gene osteocalcin (OC) . 26
▫ Another study also documented enhanced osteogenic
activity demonstrated high immunoreactivity of bone
morphogenetic proteins (BMPs) (BMP-2, BMP-4, and
BMP-7), osteonectin (ON) and bone sialoprotein (BSP) as
well as higher mRNA transcript levels of BMP-2 and BMP-
4 in the tissue formed directly underneath the PTFE
membrane compared to the undetectable or very low
reactivity in untreated defects after 6 weeks of healing .
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▫ Naturally derived, resorbable, collagen membranes
promote an early coupled upregulation of genes
related to bone formation (OC) and bone remodelling.

▫ The presence of a collagen membrane above the defect

appeared to fine-tune the expression of the
proinflammatory cytokine tumour necrosis factor
alpha (TNF-α) during the different phases of GBR .

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 The role of scaffolds/grafts in combination
with the GBR membrane:
▫ The membrane isolates the bone defect site from non-
osteogenic soft tissue, whereas the bone substitute
constitutes a three-dimensional scaffold that supports
osteogenic cells and the promotion of bone formation
during healing as well as prevents the membrane from
collapsing.

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▫ Certain animal studies showed that deproteinized
bovine bone inhibited osseous healing, and applying
only a dome-shaped PTFE membrane led to better
bone formation.
▫ Another animal study in dog revealed that the
combination of anorganic bovine bone matrix (ABM)
with an e-PTFE membrane enhanced the
osseointegration of implants placed into extraction
sockets. 30
▫ similar studies done with resorbable membrane didn’t
bring much change in the formation of bone,but when it
was doped with strontium ions and used with the same
collagen membrane, the formation of new bone was
significantly increased in the defect.

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 The role of mechanical stability :
▫ It is known that micromovements between bone and any implanted
material prevent bone formation, resulting in the development of
fibrous tissue.

▫ New vascular network formation, which is a prerequisite for bone

formation, is also highly sensitive to mechanical conditions with
delayed mechanical loading significantly enhancing bone
formation and stimulating vascular remodelling by increasing the
number of large vessels and decreasing the number of small
vessels. 32
▫ Bioresorbable membranes are flexible and they cannot be
applied without additional fixation is required. To maximize
stability of the membrane, the use of membrane-fixing pins has
been suggested.

▫ High shear strain and fluid flows stimulate fibrous tissue

formation, whereas lower levels stimulate formation of
cartilage, and even lower levels favor ossification.

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The role of porosity and topography of the
barrier membranes:

▫ The pore size of the barrier membrane is very

important in order to prevent excessive penetration of
fibrous tissue into the bone defect (soft tissue
ingrowth) but to allow neovascularization and bone
formation.

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▫ Pores in excess of 100 μm are required for the rapid
penetration of highly vascular connective tissue, and small
pores tend to become filled with more avascular tissue , as
they are inadequate for penetration of capillaries.

▫ A pore size of 50 to 100 μm allows bone ingrowth, but size

greater than 150 μm is required for osteon formation.

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▫ In addition to the porosity, the tridimensional
topography of the membrane with interconnecting
pores and channels is also important, as it can alter the
cell occlusion properties and the biologic response of
different cell types to the membrane.

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 Conclusion:
▫ The concept of barrier membranes for restoration of large bone
defects has been developed in an effort to simplify their
treatment by offering a sinlge-staged procedure and to
overcome the limitations of current bone regeneration
strategies.
▫ Since every membrane offers both advantages and
disadvantages, a membrane should be selected based on a
thorough understanding of the benefits and limitations inherent
to the materials in relation to the functional requirements in the
specific clinical application. 37
 References
▫ “Current barrier membranes: Titanium mesh and other membranes for guided bone
regeneration in dental applications” Journal of Prosthodontic Research 57 (2013) 3–14
▫ “Bone augmentation by means of barrier membranes” Periodontology 2000, Vol. 33, 2003,
36–53
▫ “The role of barrier membranes for guided bone regeneration and restoration of large bone
defects: current experimental and clinical evidence” BMC Medicine 2012, 10:81
▫ “Randomized controlled clinical study assessing two membranes for guided bone
regeneration of peri-implant bone defects: 3-year results” Clinical Oral Implant Research.
2018;1–9.
▫ “On the search of the ideal barrier membrane for guided bone regeneration” J Clin Exp Dent.
2018;10(5):e477-83. 38
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