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Current Knowledge and Future Perspectives of Barrier Membranes: a Biomaterials Perspective

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Current Knowledge and Future Perspectives of Barrier Membranes: a Biomaterials Perspective REVUE DE LA LITTÉRATURE / LITERATURE REVIEW Parodontologie / Periodontology CURRENT KNOWLEDGE AND FUTURE PERSPECTIVES OF BARRIER MEMBRANES: A BIOMATERIALS PERSPECTIVE Carole Chakar * | Sara Khalil** | Nadim Mokbel*** | Abdel Rahman Kassir**** Abstract: Periodontal regenerations and bone augmentations are common procedures practiced on a daily basis worldwide. This had led to the introduction of a wide number of barrier membranes, all aiming at regenerating a sufficient amount of bone while being safe, cost effective and easy to handle. Membranes have different characteristics that may influence their clinical properties and the result obtained. The article aims at presenting an overview of the different barrier membranes commonly used in the oral surgery field, while shedding light on the new advances in the third generation membranes. Keywords: Barrier membrane – periodontal regeneration – bone augmentation. IAJD 2020;11(1):43-50. CONNAISSANCES ACTUELLES ET PERSPECTIVES D'AVENIR DES MEMBRANES BARRIÈRES Résumé La régénération parodontale et les chirurgies d’augmentation osseuse sont des procédures courantes pratiquées quotidiennement dans le monde entier. Cela a conduit à l’introduction d’un grand nombre de membranes barrières, toutes visant à régénérer une quantité suffisante d’os tout en étant sûres, rentables et faciles à manipuler. Les membranes ont des caractéristiques différentes qui peuvent influencer leurs propriétés cliniques et le résultat obtenu. L’article vise à présenter un aperçu des différentes membranes barrières couramment utilisées dans le domaine de la chirurgie buccale, tout en mettant en lumière les nouvelles avancées des membranes de troisième génération. Mots-clés: membrane - régénération parodontale - augmentation osseuse. IAJD 2020;11(1):43-50. * Ass. Prof. ** Masters in Periodontics, Head of Department of Periodontology Department of Periodontology Saint Joseph University, Beirut, Lebanon Saint Joseph University, Beirut, Lebanon [email protected] *** Ass. Prof. **** Masters in Periodontics, Department of Periodontology Department of Periodontology Saint Joseph University, Beirut, Lebanon Saint Joseph University, Beirut, Lebanon 44 Revue de la littérature | Literature Review Issue 1 Introduction – Faced with different membranes body reaction in tissue. Expanded and bone replacement grafts, the cli- polytetrafluoroethylene is a polyte- Periodontal regeneration requires nician has a considerable number of trafluoroethylene subjected to tensile the coordinated formation of new combinations of biomaterials that stress during manufacturing, resulting IAJD Vol. 11 IAJD Vol. alveolar bone, dental cementum, and can be used depending on the clinical in differences in physical structure. It functionally oriented periodontal liga- situation and his personal experience. exhibits minimal inflammatory tissue ment interposed between these two The aim of this article is to present reactions and has been used as vascu- tissues. These requirements pose par- an overview of the most commonly lar graft material for over 20 years [10, ticular issues that are unique to the used barrier membranes in the oral 11]. There are two configurations of periodontal tissues. These include: (a) surgery field, helping the clinician e-PTFE membranes; trans-gingival and the requirement for the coordinated make a better selection and shedding submerged [9]. formation of the three tissues of the light on the new advances in the third The potential of these expanded periodontal ligament; (b) the potential generation membranes. polytetrafluoroethylene devices to role of bacterial contamination during support periodontal regeneration has healing; (c) the specific requirement 1. Non-resorbable membranes been demonstrated in canine, non- for dental cementum formation, a tis- Non-absorbable barriers were the human primate studies [5, 12, 13] and sue that is not seen in other parts of first generation of barrier membranes in different clinical settings [14-16]. In the body; (d) the requirement for coro- developed and approved for clinical fact, treatment of intra-bony lesions nal regeneration of tissues towards the use. They maintain their structural with e-PTFE membranes demonstrated overlying superficial tissues. [1]. integrity, and the essential features positive outcomes regarding clinical It is believed that the placement they possess for as long as they are attachment level (CAL) gain and resi- of a subgingival barrier achieves the left in the tissues. However, they dual probing depth [17]. following: require a second surgical procedure - Epithelial cells are impeded from for their removal. This is accompa- 1.3. d-PTFE apically migrating and interfering nied by concerns over patient accep- The high-density PTFE (d-PTFE) is with connective tissue-root surface tance, time, cost, and possible mor- made of pure medical-grade and inert interactions. bidity associated with any surgical PTFE, which is non-expanded and non- - The gingival connective tissue procedure [8]. Moreover, membrane permeable. These membranes have a from the flap is excluded from healing exposure caused by variable amounts porosity of up to one hundred times sites. of flap sloughing during healing has lower (0.2 µm) and are thinner (0.2- - Progenitor cells from the perio- been a frequent post-surgical compli- 0.3mm) than the e-PTFE (around 1mm) dontal ligament are favored to repopu- cation associated with non-absorbable membranes [18]. late the coronal root surface facilita- membranes. These characteristics eliminate ting formation of a new periodontium bacterial infiltration into the bone [2]. 1.1. Cellulose filters augmentation site, which protects - The membrane creates a protec- In the first guided tissue regenera- the underlying graft material and/or ted space for the organizing blood clot tion attempts, Nyman et al. [9] used a implant. Furthermore, primary soft tis- and prevents its collapse by the pres- bacterial filter produced from cellulose sue closure is not mandatory [19]. In sure from the tissue flap [3]. acetate as an occlusive membrane in fact, previous authors have reported - Particulate grafts are separated 1982. Histologic examination showed that it completely blocks the penetra- from the surrounding tissues allowing regeneration of the alveolar bone and tion of food and bacteria, and thus, for bone regeneration [4]. new attachment of new cementum even if it is exposed to the oral cavity, This phenomenon has been reco- with inserting periodontal ligament it still acts as an appropriate mem- gnized as “compartmentalized healing” fibers. Although this type of membrane brane barrier, and the risk of infection which permits exclusion of undesirable served its purpose, it was not ideal for remains lower than e-PTFE [20, 21]. cell populations and accommodates clinical application due to reported When no primary closure is realized the mitosis and chemotaxis of osteo- exfoliation and premature removal. the full width of keratinized mucosa is progenitor cells [3]. In order to achieve preserved [20] and they can be remo- the abovementioned functions, many 1.2. e-PTFE ved easily by pulling on the membrane authors [5-7] described five main crite- Polytetrafluoroethylene is a fluo- without lifting the mucosal flap, thus, ria a barrier membrane needs to fulfill : rocarbon polymer with exceptional not requiring a second surgery [22]. It biocompatibility, cell exclusion, space inertness and biocompatibility. It is is considered today the “gold standard” maintenance, tissue integration and non-porous, does not allow tissue of non-resorbable membranes [23]. ease of use/ clinical manageability. ingrowth and does not elicit a foreign- 45 Parodontologie / Periodontology 1.4. Titanium mesh / Titanuim-reinforced It appears that neither of the abo- Absorbable materials used for e-PTFE membranes vementioned materials fulfills yet the guided tissue regeneration (GTR) Titanuim reinforced barrier mem- design criteria for a guided tissue rege- or guided bone regeneration (GBR) branes provide advanced mechanical neration device [31]. devices fall into two broad categories: support (increased tent-like effect), Today, as evidence of the effecti- natural products and synthetic mate- which allows a larger space for bone veness of bioresorbable membranes rials [8]. and tissue regrowth. This is of special increases, non-resorbable membranes 2.1. Natural products importance when the defect morpho- are losing importance in clinical Natural membranes are made of logy does not create an adequate space practice and their use is increasingly collagen or chitosan. Successful treat- recognized as important requirement limited to specific indications. Since ment following the use of such barrier for achieving regeneration. However, the use of e-PTFE membranes has materials have been demonstrated, their main disadvantages remain the been documented to result in suc- but the results of studies vary [34]. increased risk of exposure due to their cessful GBR therapy, results obtained stiffness and a more complex secon- using new materials should always be 2.1.1.Collagen barriers dary surgery to remove them [9, 24]. compared with results of e-PTFE mem- Collagen constitutes almost one These membranes consist of a branes [26]. third of all protein in the body and is double layer of e-PTFE with a titanium a major constituent of natural extra- framework interposed [3, 25]. Recent 2. Resorbable membranes cellular matrix. It is (a) physiologically research has demonstrated the suc- Absorbable barriers
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