Periodontal membranes – part 2

PERIODONTAL MEMBRANES – PART
2
DR. SHRUTI PATIL
DEPARTMENT OF PERIODONTOLOGY

INDEX
• NON-RESORBABLE MEMBRANE PLACEMENT
• RESORBABLE MEMBRANE PLACEMENT
• GUIDED BONE REGENERATION
• MEMBRANE COMPLICATIONS AND MANAGEMENT

Nonresorbable Membranes : Gore-Tex Barrier.
At the present time, e-PTFE or Gore-Tex is considered the “gold standard”
(Murphy and Gunsolly, 2003) by which all membranes are compared.
• It is a biocompatible porous material possessing two unique microstructures.
Open microstructure of its collar - designed to retard or inhibit the apical
proliferation of epithelium through contact inhibition
Cohen ES. Atlas of cosmetic and reconstructive periodontal surgery. PMPH-USA; 2007.

 Occlusive membrane –
• acts as a barrier to the gingival connective tissues and the underlying root
surface
• retards epithelial downgrowth.
The membrane comes in various sizes

Procedure Guidelines
PATIENT SELECTION:
• In the medically compromised patient the addition of a prosthetic device such
as Gore-Tex periodontal material may increase the risk of complication.
INDICATIONS.
1. Patients with good oral hygiene
2. Adequate keratinized gingiva
(material should be covered with a thick, heavy keratinized gingiva)

DEFECT SELECTION:
MOST PREDICTABILITY:
1. For grade II furcations on teeth with high interproximal bone
2. Two- to three-wall intrabony vertical defects ≥ 4 to 5 mm
MODERATE PREDICTABILITY:
1. Maxillary mesial or distal Class II furcations
2. Two-wall defects.

LOW PREDICTABILITY:
1. Class III furcation with high interproximal bone
2. One wall defect
LEAST PREDICTABILITY:
1. Class III furcations with horizontal bone loss
2. Horizontal bone loss

CONTRAINDICATIONS
1. In cases in which flap vascularity will be compromised
2. Very severe defects—minimal remaining periodontium
3. Horizontal defects
4. In case of flap perforation

SURGICAL PROCEDURE
• It is important to note that the surgical principles and procedures that apply to
membranes.
• The main differences will be in postoperative considerations and a lack of a
need for a secondary removal surgery in most cases.

PRIMARY INCISIONS:
Intramuscular incisions are made in preparation for a full mucoperiosteal flap.
Maximum conservation and preservation of the interdental papilla ensure total
material coverage and primary intention healing (Figure 11-6A).

• All residual pocket epithelium is removed after flap reflection.
• This will permit primary intention healing and integration between the e-PTFE
and the flap connective tissue.
• Incisions should extend one to two teeth mesial and/or distal of the area being
treated to permit adequate visualization.
• Vertical incisions should be placed mesially where necessary.
Cohen ES. Atlas of cosmetic and reconstructive periodontal surgery. PMPH-USA;
2007.

MEMBRANE SELECTION
NONRESORBABLE OR RESORBABLE
1. Maintain the sterility of the material.
2. Choose a size that offers the most ideal design for defect coverage

Shape the material with scissors. Avoid leaving sharp edges.
Enough material should be left to permit lateral and interproximal suturing while
leaving at least 3 mm apical and lateral overextension of the defect margin (see
Figure 11-6, E and F).

In the case of e-PTFE, do not remove the open microstructure or coronal
portion of the material.
It should be trimmed only on the lateral aspects.
The material should fit smoothly, avoiding folds, overlaps, and protrusions,
which may compromise the overlying gingival tissue.
In either periodontal or bony ridge defects, the amount of space beneath the
material determines the maximum potential regeneration.
Without space maintenance, regeneration is not possible.

Gore-Tex suture (provided with e-PTFE) is the recommended material for
stabilizing the e-PTFE membrane and for flap closure for all membranes
Silk or monofilament sutures may be used in areas away from the material.
Bioabsorbable sutures are recommended only for stabilizing resorbable
membranes.
SUTURE MATERIAL

• (Resolute® Adapt®,[W.L. Gore Inc, Flagstaff, Arizona]
• RCM6® [Ace Surgical Supply, Brockton, Massachusetts]) sling sutures
Gore-Tex are used and completed without engaging the flap or tissue
SUTURING TECHNIQUE

The material must fit tightly against the tooth surface at all points to prevent
epithelial proliferation between the tooth and the material and to help in
stabilizing the wound.
The flap margin should ideally be 2 to 3 mm coronal to the material.
Tight flap apposition is desired to avoid premature flap opening and material
exposure.
An apical horizontal periosteal releasing incision may enhance material coverage.
Do not compromise blood supply.

Interproximal incisions approximating the material are closed first.
The flap is sutured with Gore-Tex or Vicryl sutures and left for 2 weeks

MATERIAL REMOVED (E-PTFE)
Removal should be 4 to 8 weeks after placement or any time a serious
complication occurs.
If the material cannot be removed with a gentle tug, sharp dissection is
recommended.
A sulcular incision is made to extend one tooth mesially and distally.

Extreme care should be used to avoid damaging the underlying new granulation
tissue.
Sharp dissection is used to reflect the overlying tissue
A small tissue forceps is used to remove the material

Light curettage of the inner flap surface is recommended for removal of any
epithelial remnants.
Do not instrument the new regenerated tissue.
The flap is reapproximated over the new tissue and sutured with Gore-Tex or
Vicryl sutures.

CASE REPORT 1
Guided tissue regeneration of an
intrabony defect and incipient
furcation.
A, Before treatment.
B, Two-surface three-wall defect
exposed with incipient furcation.
C, Demineralized freeze-dried bone
allograft
placed.
D, Expanded polytetrafluoroethylene
membrane placed.

E, Flap repositioned.
F, Reentry after 1 year. Note complete fill of the defect
and incipient furcation

Peri-implant infection treated by guided tissue regeneration. A, Before. B, Buccal and
C, occlusal views showing peri-implantitis. D, Membrane with hole
to fit over implant. E, Buccal and F, occlusal views of implant placement after DFDBA

Resorbable Membranes
(Bunyaratavaj and Wang, 2001), a meta-analysis (Murphy and Gunsolley, 2003), and the
AAP position paper on regeneration (2005)
found that there are no differences between resorbable and nonresorbable membranes.
e-PTFE (G-TAM®, [W.L. Gore Inc, Flagstaff, Arizona]), is still the gold standard.
Wang HL, Carroll WJ. Guided bone regeneration using bone grafts and collagen membranes. Quintessence international.
2001 Jul 1;32(7).
Murphy KG, Gunsolley JC. Guided tissue regeneration for the treatment of periodontal intrabony and furcation defects. A
systematic review. Annals of periodontology. 2003 Dec;8(1):266-302.
Wang HL, Greenwell H, Fiorellini J, Giannobile W, Offenbacher S, Salkin L, Townsend C, Sheridan P, Genco RJ. Position paper-
Periodontal regeneration. J Periodontol. 2005;76:1601-22.

Resorbable membranes are recommended :
• only when membrane support is present (moderate horizontal bone
deficiencies)
• space maintenance is not required (sinus bone augmentation procedures
• primary closure is achieved
In selecting a resorbable membrane, the clinician must choose one with proven
histologic evidence of long term resorption

Defect Selection:
The defects selected may or may not be associated with implants.
Osseous Defects.
1. Residual defects
2. Extraction sockets
Peri-implant Defects.
1. Fenestration
2. Dehiscence
3. Intraosseous
4. Extraction sockets—fresh and residual
5. Peri-implantitis

Geistlich Bio-Gide® Perio
Schlegel AK, Möhler H, Busch F, Mehl A. Preclinical and
clinical studies of a collagen membrane (Bio-Gide®).
Biomaterials. 1997 Apr 1;18(7):535-8.

CASE NO 1
Presurgical vertical measurement at the control site with the stent AND presurgical IOPA

Furcation defect upon flap
Furcation defect with the bone graft

Furcation defect with the GTR membrane in place Flap sutured at the desired position

Kamat SM, Khandeparker RV, Akkara F, Dhupar V, Mysore A. SauFRa Technique for the Fixation of Resorbable Membranes in
Horizontal Guided Bone Regeneration: A Technical Report. The Journal of oral implantology. 2020 Nov 1;46(6):609-13.

• A full-thickness trapezoidal mucoperiosteal flap with vertical releasing incisions including
the distal papilla of teeth on either side of the defect was raised.
• If implants were planned simultaneously with GBR, then implant placements were carried
out.
• A horizontal periosteal-releasing incision was made 5 mm coronal to the base of the
mucoperiosteal flap.
• Blunt dissection was carried out to expose the connective tissue and divide the
periosteum into apical periosteum and coronal periosteum
• Approximately 8–10 mm of overlap over the palatal/ lingual flap and approx.
• 5–6 mm beyond the grafted area was mandatory for a successful GBR procedure.
• Blunt dissection was accomplished posterior to the apical periosteum to separate the
periosteum from the connective tissue and a pocket was developed.
• A bilayer resorbable membrane (BioGide, Geistlich, Wolhusen, Switzerland) was then
introduced anterior to the pocket and was sutured to the apical periosteum, using
horizontal mattress sutures and making certain that the knot was tied toward the
connective tissue.
Kamat SM, Khandeparker RV, Akkara F, Dhupar V, Mysore A. SauFRa Technique for the Fixation of Resorbable Membranes in
Horizontal Guided Bone Regeneration: A Technical Report. The Journal of oral implantology. 2020 Nov 1;46(6):609-13.

Representative intraoperative photographs of guided tissue regeneration procedure using GuidOss (NIBEC,
Jincheon, Korea). (A) A deep intrabony defect on the upper second premolar was detected. The defects and
root surfaces were thoroughly planed and debrided. (B) The bone mineral was applied on the intrabony defect.
(C) After grafting of bone mineral, a porous nonchemical cross-linking collagen membrane (GuidOss) was
trimmed and adapted over the defect. The entire defect and 2-3 mm of the surrounding alveolar bone were
completely covered with a membrane. (D) The flap was sutured and completely closed without membrane
Cohen ES. Atlas of cosmetic and
reconstructive periodontal surgery.
PMPH-USA; 2007.

CASE NO 3
• Gengigel® (Ricerfarma, Milano, Italy) contains high molecular weight
fractions of HA in gel formulation with 0.2% concentration.
• It is a composite membrane consisting of pluripotent cellular element
embedded in a semipermeable membranous structure.
• Existence of pluripotent stem cells possessing the ability of
transdifferentiation to other cellular elements of periodontium makes it a
suitable candidate for guided tissue regeneration (GTR).
Mahgoub MA, Ammar A, Fayez M, Edris A, Hazem A, Akl M, et al. Neovascularization of the amniotic membrane as a
biological immune barrier. Transplant Proc 2004;36:1194-8
Jones CJ, Jauniaux E. Ultrastructure of the materno-embryonic interface in the first trimester of pregnancy. Micron
1995;26:145-73.

• Amniotic membrane maintains the structural and anatomical configuration of
regenerated tissues.
• Contribute to the enhancement of healing through reduction of postoperative
scarring and subsequent loss of function and providing a rich source of stem
cells.
• Amnion has shown the ability to form an early physiologic "seal" with the host
tissue precluding bacterial.
Koizumi NJ, Inatomi TJ, Sotozono CJ, Fullwood NJ, Quantock AJ, Kinoshita S. Growth factor mRNA and protein in preserved
human amniotic membrane. Curr Eye Res 2000;20:173-7.
Hao Y, Ma DH, Hwang DG, Kim WS, Zhang F. Identification of antiangiogenic and antiinflammatory proteins in human
amniotic membrane. Cornea 2000;19:348-52.

Figure 1: Preoperative radiograph showing furcation defect
having ~ 3 mm vertical dimension (a and b) (Also, arrow
showing large intrabony defect on the mesial of right
mandibular first molar)
Figure 2: Crevicular incision
Kalra SH, Monga C, Kalra KH, Kalra SH. A roentgenographic assessment of regenerative efficacy of bioactive Gengigel(®) in
conjunction with amnion membrane in grade II furcation defect. Contemp Clin Dent. 2015 Apr-Jun;6(2):277-80.

Figure 3: Exposure of defect site after
debridement
Figure 4: Intra-operative furcation
defect measurement using Q2N Naber's
probe having horizontal dimension ~ 3
mm (Grade II furcation)

Figure 5: Application of Gengigel® (0.2%
Hyaluronic acid) in the defect site after
presuturing
Figure 6: Placement of bioactive amnion membrane to cover
the Gengigel®

Figure 8: Six months postoperative radiograph showing almost complete furcation defect
fill having vertical residual radiolucency of <0.5 mm (a2 and b2)

GUIDED BONE REGENERATION
Wang et al 2001:
1. Local alveolar ridge deficiencies (horizontal or vertical).
2. Osseous fill around immediate implants.
3. Dehiscence and fenestrations associated with implants.
4. Bone defects associated with failing implants.
5. Residual bone lesions.
6. To aid in repair of sinus membrane perforations.
Gher ME, Quintero G, Assad D, Monaco E, Richardson AC. Bone grafting and guided bone regeneration for immediate
dental implants in humans. Journal of periodontology. 1994 Sep;65(9):881-91.

Urban technique
Urban et al. described the utilization of a 1:1 mixture of autogenous and
xenogenic graft material, covered by a resorbable collagen membrane that is
stabilized by titanium pins.
Urban I.A., Nagursky H., Lozada J.L., Nagy K. Horizontal ridge augmentation with a collagen membrane and a combination
of particulated autogenous bone and anorganic bovine bone-derived mineral: A prospective case series in 25 patients. Int.
J. Periodontics Restor. Dent. 2013;33:299–307.

Urban I.A., Nagursky H., Lozada J.L., Nagy K. Horizontal ridge augmentation with a collagen membrane and a combination of
particulated autogenous bone and anorganic bovine bone-derived mineral: A prospective case series in 25 patients. Int. J.
Periodontics Restor. Dent. 2013;33:299–307.

Daniel Buser technique
Buser D, Dahlin C, Schenk RK. Guided bone regeneration. Chicago Quintessence. 1994.

Buser D, Dahlin C, Schenk RK. Guided bone regeneration. Chicago Quintessence. 1994.

Study concluded that double-layer technique using non-cross-linked collagen
membranes (BioGides) may enhance the efficacy of the onlay block bone graft
technique in terms of both bone resorption and augmentation compared with a
single layer collagen membrane.
Kim SH, Kim DY, Kim KH, Ku Y, Rhyu IC, Lee YM. The efficacy of a double‐layer
collagen membrane technique for overlaying block grafts in a rabbit calvarium
model. Clinical oral implants research. 2009 Oct;20(10):1124-32.

There is limited evidence to support the effectiveness of barrier membranes in the treatment
of bone deficiencies. Membranes do not increase postoperative infection, wound dehiscence,
or membrane/bone graft exposure in either human or animal models.
Khojasteh A, Soheilifar S, Mohajerani H, Nowzari H. The effectiveness of barrier membranes on bone regeneration in
localized bony defects: a systematic review. International Journal of Oral & Maxillofacial Implants. 2013 Aug 1;28(4).

FACTORS AFFECTING TREATMENT RESULTS
Barrier- Independent Factors
Barrier Dependent Factors
Post-surgical factors
Fontana F, Maschera E, Rocchietta I, Simion M. Clinical classification of complications in guided bone regeneration
procedures by means of a nonresorbable membrane. International Journal of Periodontics and Restorative Dentistry. 2011
Jun 1;31(3):265.

Barrier Dependent Factors
• Inadequate barrier adaptation
• Non-sterile technique (plaque or saliva contamination)
• Instability (movement) of barrier against root
• Premature exposure of barrier to oral environment and microbes
• Premature loss or degradation of barrier.
Hom-Lay Wang, R. Lamont MacNeil. Guided Tissue Regeneration, Absorbable Barriers. Advances in periodontics. Part II.
Dent Clin N Am 1998;42:502-522

COMPLICATIONS
• Perforation of membrane :
If the margins of the bone defect are sharp.
• Tearing of membrane while placing a sling suture:
• Exposed margins of membrane:
Promotes faster membrane degradation and bacterial aggregation.

MEMBRANE EXPOSURE MANAGEMENT
Classification of in GBR with non-resorbable membranes
class I Small membrane exposure (≤ 3mm) without purulent exudate
class II large membrane exposure (> 3mm) without purulent exudate
class III Membrane exposure with purulent exudate
class IV
Abscess formation without membrane exposure with purulent
exudate
Fontana F, Maschera E, Rocchietta I, Simion M. Clinical classification of complications in guided bone regeneration
procedures by means of a nonresorbable membrane. International Journal of Periodontics and Restorative Dentistry. 2011
Jun 1;31(3):265.

Management of Class I Healing Complications
• Moniter weekly to clean the membrane with chlorhexidine 0.12%.
• Digital pressure was applied near the exposure borders to examine for the
presence of purulent exudate.
• Postsurgical indications and care comprised gentle brushing to prevent the
zone of membrane exposure from enlarging and applying chlorhexidine gel
0.12% twice a day
• Antibiotics were not used to prevent infection in any class I cases
Gallo P, Díaz-Báez D. Management of 80 complications in vertical and horizontal ridge augmentation with nonresorbable
membrane (d-PTFE): a cross-sectional study. The International journal of oral & maxillofacial implants. 2019 Jul 1;34(4):927
35.

Management of Class II Healing Complication
• Monitored using the same protocol for class I complications.
• As long as they were not infected, the membrane would remain in the mouth
for at least 6 to 8 weeks.
• After 6 to 8 weeks, if the exposed membrane presented excess dental plaque,
it was removed to prevent the patient from coming to the next follow-up visit
with purulent exudate.
35.

• The postsurgical indications were to clean the exposed membrane with
moistened gauze dipped in chlorhexidine three times a day.
• Only horizontal defects treated with d-PTFE membranes that had class II
exposure were left in place 8 weeks before removal.
• The membrane was pulled for removal, without the need for surgery.
35.

Management of Class III Healing Complications
• Patients who presented with membrane exposure with purulent exudate
were immediately prescribed antibiotics (amoxicillin/clavulanic acid, 1 g every
12 hours for 7 days).
• Schedule for immediate membrane removal.
• Graft contraction and replacement of soft tissue under the membrane were
observed on the follow-up CBCT.
• All granulomatous tissues found between the membrane and bone graft were
removed.
membrane (d-PTFE): a cross-sectional study. The International journal of oral & maxillofacial implants. 2019 Jul 1;34(4):927 35.

Management of Class IV Healing Complications
• Immediate removal of the membrane, soft tissue, and mobile graft particles
and placement of a collagenous membrane.
• Immediate regeneration was not performed in any of these cases, and after 3
months, it was reconsidered to be new treatment.
• If the membrane is not removed immediately or the infection is too
aggressive, the graft can be compromised and there may be basal bone
resorption.

• Therefore, the membrane was immediately removed with ongoing antibiotic
treatment starting before the surgery and continuing 7 days after the surgery
(amoxicillin/clavulanic acid, 1 g every 12 hours)

CASE REPORT
Exposure of the d-PTFE membrane 14 days after GBR
procedure.
No evidence of an epithelial seal at the site involved, with no detachment on probing or
suppuration. The problem was managed by continuing chlorhexidine mouthwashes
(0.12%) for 30 days, applying 1% chlorexidine gel twice a day until the re-opening
procedure and removing any plaque once a week at the office.
Ghensi P, Stablum W, Bettio E, Soldini MC, Tripi
TR, Soldini C. Management of the exposure of a
dense PTFE (d-PTFE) membrane in guided bone
regeneration (GBR): a case report. Oral
Implantol (Rome). 2017 Nov 30;10(3):335-342..

The patient was monitored closely for
plaque and it was decided to remove the
membrane after 4 months.
When the site was reopened the original
defect appeared to have been filled, so
two fixtures (CLC Conic; CLC Scientific,
Vicenza, Italy), respectively of 4×10 mm
and 5×6 mm in size, were inserted in first
premolar and fist molar position .
Some minor dehiscences were filled with
deproteinized bovine bone and covered
with resorbable membrane.
Ghensi P, Stablum W, Bettio E, Soldini MC, Tripi TR, Soldini C. Management of the exposure of a dense PTFE (d-
PTFE) membrane in guided bone regeneration (GBR): a case report. Oral Implantol (Rome). 2017 Nov
30;10(3):335-342..

Post-op (6 months)
Ghensi P, Stablum W, Bettio E, Soldini MC, Tripi TR, Soldini C. Management of the exposure of a dense PTFE (d-
PTFE) membrane in guided bone regeneration (GBR): a case report. Oral Implantol (Rome). 2017 Nov
30;10(3):335-342..

REFERENCES
• Aghazadeh A., Rutger G., Persson, Renvert S. A single-centre randomized controlled
clinical trial on the adjunct treatment of intra-bony defects with autogenous bone or a
xenograft: results after 12 months. J. Clin. Periodontol. 2012;39:666–673. - PubMed
• Chan H.L., Lin G.H., Suarez F., Maceachern M., Wang H.L. Surgical management of
peri-implantitis: a systematic review and meta-analysis of treatment outcomes. J.
Periodontol. 2014;85:1027–1041. - PubMed
• Chrcanovic B.R., Albrektsson T., Wennerberg A. Bone quality and quantity and dental
implant failure: a systematic review and meta-analysis. Int. J. Prosthodont.
2017;30:219–237. - PubMed
• el Chaar E.S., Jalbout Z.N. Regeneration of an osseous peri-implantitis lesion.
Periodontal. Clin. Investig. 2002;24:5–10. - PubMed
• Higgins, J., Green, S., 2011. Cochrane Handbook for Systematic Reviews of
Interventions Version 5.1.0 (updated March 2011) [Online]. The cochrane
collaboration. Available: http://handbook-5-1.cochrane.org/

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