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Barrier Membranes: Are there Alternatives?

posted in Active Posts, Bone Grafting, advice

« Treatment Plan for Fixed Partial Dentures? | Extraction Followed By Immediate Implant Placement: What Does De-Epithelialize the Extraction Socket Mean? »

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Dr. G. asks:
I am a general dentist and have been placing my own implants in many cases for over five years. Whenever I do a bone graft, I cover it with a resorbable collagen membrane. Sometimes I only need a tiny piece of membrane and have to throw out almost an entire piece of unused membrane. This is expensive and in this economy I am trying to find ways to reduce my overhead. Is there anything else I can use to cover these bone grafts that is cheaper and just as effective? Are there any materials that can be mixed and applied over the graft to harden and contain the graft material? Is there a reasonable alternative to barrier membranes?

25 Responses to “ Barrier Membranes: Are there Alternatives? ”

• eric-sb oms December 8th, 2009

  
  

  yes, membranes are expensive and you should not be throwing them away. here’s what i do:
  I cut, in a sterile fashion, the big membranes up into pieces - and then package individually (in a sterile fashion) the following sizes:
  1. Anterior tooth - buccal plate intact
  2. Anterior tooth - buccal plate defect
  3. Biscuspid size socket preservation
  4. Molar size socket preservation
  after doing hundreds of GBR / socket preservations, I know what sizes i need. there are also times when I need whole membranes, so i always have a bunch of them around.
  i can’t stress enough how important sterility is for this. these are dispensed as single patient products, and the companies will tell you this is wrong.
  if the above technique is done properly, there is no reason why you cannot get 2-4 procedures out of a single membrane. membranes are great for any GBR - socket preservation, and it sounds like you have all-ready figured this out. again, just be sure you use good sterile technique when you pre-divide the membranes.

• Wleed Haq December 8th, 2009

  
  

  Calcium sulphate can be mixed with the graft which hardens over time (several minutes) and is bacteriostatic. You can buy it separate or combined with your bone graft eg Vital (available in UK) or use a bone graft that does not require a membrane such as Easygraft. I’m sure Peter Fairbairn can ellaborate on this as he is on the cutting edge of this in the UK.

• Dr.Amit Narang December 8th, 2009

  
  

  You can try using PRF as membrane over your select cases… not all but many can be taken care off with only PRF over the graft material, and also its free of cost as we all know !!

• Joseph Kim, DDS December 8th, 2009

  
  

  Don’t repackage the membranes. If there is an infection in the area, or sepsis, you will be in trouble. Just order less expensive membranes such as PTFE or bulk quantities of resorbable collagen. I use ACE Surgical collagen membranes and Cytoplast teflon membranes.

• Richard Hughes, DDS, FAAID, FAAIP, DABOI December 8th, 2009

  
  

  Dr. Amit, I agree 100%.

• Manosteel December 8th, 2009

  
  

  We buy the 30×40 collagin RCM6 membranes from Ace Surgical and using sterile technique cut them into 1/4ths ie 15×20 and package them in autoclaved clear bags. This seems to be right for a single sight. Never really had a problem with it.

• Robert A Horowitz December 8th, 2009

  
  

  Since when were proper treatment and sterile surgical technique driven by profit? The membranes/barriers made by Osteogenics are outstanding. They are sold by numerous companies and have distinct advantages over other materials on the market. There are many papers (Bartee, Horowitz and others) demonstrating socket preservation and vital bone formation under their PTFE barrier. The collagen membrane is useful in many situations, lasts longer than others, handles very well and is not expensive at all.
  Calcium sulfate (Orthogen has the most experience with it) is sold by a different companies (Stem Vie by Sybron). Yes, as said, you can mix it with a graft and use it as a barrier as well. Handling is quite technique sensitive. HOWEVER, when you get there, it is worth it.

• Peter Fairbairn December 9th, 2009

  
  

  Wleed it was good to meet you at my talk on Synthetics,as you know I have not used a traditional bio-resorbable membrane for 5 years and no autogenous for 4 years.
  The issue here is using graft materials that are their own cell occlusive membranes and are stable thus allowing the body to doits work withoput hinderance of the periosteal blood supply.There are a number of ways of achieving this.
  As Bob says Caso4 can be of use although technically difficult to use and in the UK we have Vital which is Beta TCP in a hydroxl sulphate matrix which allows it the “set” thus be cell occlusive for 3 to 5 weeks depedant on patient physiology. This product also has this benefit of a negative charge (Zeta potential ) which leads to a large increase of Osteoblasts at the site (Hunt and Cooper the significance of zeta potential in osteogenesis 2006). I have done hundreds of sucessful ,some extreme cases and routinely use it in the sinus where the lateral wall is sealed by the graft.
  Stability is another big issue as the satbility is throughout the graft material which improves the mesenchymal cell differentiation.
  For reading on this the best is a recent paper by L. Podaropoulus et al , bone regneration using B-TCP in a calcium Sulphat matrix , JOI , Vol XXXV/No 0ne /2009 and also the pares by Ralf Smeets , Stein et al A clinicalevaluation of a Biphasic grafting materialin the treatment of human perio bony defects;a 12 month RCT in the journal of Perio Vol 80 number 11 and Smeets et al other paper A new Biphasic osteoinductive ca composite materialwith negative zeta potential, Head Face Med 2009 ;5;13.
  Then is also Easygraft which is a Beta TCP coated with a pollactide and then when mixed with a medical biolinker becomes solid and cell occlusive. Here again we have treated a large number of cases sucessfully over thelast 2 years.
  The main benefit with these materials is that we help the body to return itself to its previuos healthy state as the materials a fully bio-resorbed at 6 to 9 months ( patient pyhsiology dependant)
  Whilst new these materials are showing remarkable results.
  Regards
  Peter

• Dr. Mehdi Jafari December 10th, 2009

  
  

  A few words from an old man who has been using barrier membranes and biomaterials for years;
  Patient’s own periosteum is the best choice to cover the grafted bony defects especially when biomaterials have been used. If one intends to impede any epithelial in-growth or down-growth, then an inexpensive collagen sheet works very well.

• satish joshi December 11th, 2009

  
  

  Dr.Jafari,
  I think we have discussed this issue before.As flaps are being rendered tension free to cover sockets or large defects,periosteum is incised to advance flaps and grafts may not be fully covered with periosteum.Please correct me if I am wrong.Collagen sheets like colatape resorb very quickly, otherwise it is very very inexpensive.
  I know Bob(Dr.Horowitz)is involved with research on this subject and I know he already had written article on socket grafting on this web site few years ago.So he has some ideas how these membranes work or don’t work.

• Dr. Mehdi Jafari December 12th, 2009

  
  

  Sir, It sounds to me that he is in favor of collagen sheet. However, every one is eligible to have and follow his own experience.

• Fabe December 13th, 2009

  
  

  Question to Eric SB OMS:
  Do you use reusable sterilization bag that allows you to sterilize it before you place the cut membrane in ?
  Please describe your protocol.
  Thanks

• SBoral surgeon December 13th, 2009

  
  

  Fabe,
  I use a sterile piece of gauze, wrap the piece of membrane in it, and then put the gauze into a small sterilization bag ( pre-sterilized )
  I take this very seriously as these products are not meant for multiple patient use. You cannot sterilize the membrane, I would imagine this would alter its structure. Others have mentioned other products. Use what you like. This is how I maximize the value of an extremely overpriced product in a safe way (biomend, bioguide.)

• Richard Hughes, DDS, FAAID, FAAIP, DABOI December 14th, 2009

  
  

  You may want to consider gas steralization.

• Peter Fairbairn December 15th, 2009

  
  

  Another key here is blood supply or rather the lack of, bio-resorbable membranes can impeded this vital periosteal supply to the graft site. There has been a drft back to Ti mesh and other membranes with larger pore size which are more efficient (recent research ) at prevention of soft tissue ingrowth.
  But still the graft materials that are their own membrane are nano-pourus to vascularisation thus improved blood supply.

• Dr S. December 15th, 2009

  
  

  As Dr. Horowitz said, calcium sulfate is a very effecttive and inexpensive choice. Some people find it technique sensitive, but if you get it right, nothing like it. There are quiet a few calcium sulfate materials out there (DentoGen by Orthogen). Since it is not expensive, it is really worth it to at least give it a try.

• dr rabbani December 17th, 2009

  
  

  dear dr.s
  can u please brief the technique how caso4 is used as a barrier membrane.i have been using collagen membranes like mem-lok but they are expensive.wanted to use caso4 and give it a try.

• Richard Hughes, DDS, FAAID, FAAIP, DABOI December 17th, 2009

  
  

  Using CaSO4 as a membrane is an old technique it is known as “barrier by bulk”.

• Joseph CHOUKROUN December 29th, 2009

  
  

  In Bone engineering, the behaviour of osteoblasts depend of the biomaterial type. If you use allogenic bone: it’s 90% of fibrous collagen.The collagen (organic) is the most attractive product for the osteoblasts. You can use only PRF Membranes. cheapest and get cell stimulation during more than seven days.Because with collagen, you have cells quickly in the site and can stimulate them. If your biomaterial is mineral (TCP, DBB, HA)you have not collagen in the site during the first days. This is because you need a collagen membrane, if you want to succeed. The way of fibrous collagen biomaterial(FDBA) and Growth fcators like PRF is really the more reasonnable and the more active.

• Robert J. Miller January 3rd, 2010

  
  

  Dr. Choukroun is correct in his assessment of collagen containing bone grafts and membranes. Osteoblasts produce Type I human collagen which acts as a scaffold for the first stage of bone mineralization. In addition to collagen, growth factors that cause genetic modification/potentiation of bone producing cells will accelerate bone growth. The factors PDGF, VEGF, and TGF beta will jump start this process. While you can incur considerable expense when using rhBMP and membranes, the cost effectiveness of an autologous fibrin membrane will give you similar results. PRF membranes contain all of the previously mentioned growth factors in addition to platelets and leukocytes.
  This mix of blood components gives you a durable membrane, with bacteriocidal and accelerated growth properties.
  RJM

• Dr S. January 6th, 2010

  
  

  Dr. Rabbani,

  Sorry for replying late, but I did not come back to the forum for a while. You can just add saline or setting solution to the calcium sulfate. As it starts to form a putty, you can mold it in the defect as a barrier. Hope this helps. Thanks.

• Dr. Gerald Rudick February 9th, 2010

  
  

  One of the main considerations in placing a biological separation barrier is whether to use a resorbable or removable type is required.

  Years ago I felt it was a big waste of money to have to cut a piece of the membrane to the required size, and then disgard the rest. The manufacturers of these membranes absolutely forbid the reuse of an open package, and rightly so. Dental offices do not have the sterility found in hospital operating rooms, and as such trying to repackage a piece of left over membrane is really against the law; should a problem arise.

  I felt that the removable PTFE type offered more protection,was stronger and would stay in place longer than the resorbable types.

  While in the plumbing section of a renovation center, I came across “plumber’s tape” which is PTFE. The ordinary teflon is too thin for dental use, but the Gas Line Teflon is thicker, and similar to Tefgen. The thicker variety is used in food processing plants to convey liquids, used in hospital piping for anaesthesia gases,etc. and can be steam sterilized.

  I cut out some pieces, placed them in gauze, and then into paper sterilzation bags. I took the samples to the bacterialogy lab and had them tested for sterility which proved to be 100% sterile. The Teflon manufacture’s label reads 100% pure PTFE, which is the same as those from the dental industry.

  I did a series of bone grafts using them, and obtained very similar results as those from materials purchased from the surgical supply dealers. I published the results in the 2003 September/October issue of Implants News and Reviews.

  The sterilization bag costs more than the enclosed PTFE membrane.Since the width is only 1/2″, we place them in shingle overlap fashion is a wider area has to be covered.

  Gerald Rudick dds Montreal

• Richard Hughes, SS. FAAID, FAAIP, DABOI February 10th, 2010

  
  

  Gerald: Yes the Gas PTFE works well.

• Greg Steiner February 19th, 2010

  
  

  Hello Dr. G
  Google “Socket Graft”. Socket Graft includes a covering called Socket Seal. If you choose a different graft material the seals are also sold seperatly.

• Jin Lee February 28th, 2010

  
  

  Gas PTFE does not change it’s structure after sterilization cycle? I’m assuming that you are not using directly from the role of tape.

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