Membranes Over Bone Grafts: Is This Really Necessary?

Dr. B ask,
I am a periodontist, and in my training, we were required to place membranes over every bone graft to prevent the in-growth of epithelium. This is a practice that I continue even to the present day in 99% of my cases. However, I have observed that some oral surgeons do not always use membranes to cover their bone grafts sites. I have experienced many difficulties with membranes – both resorbable and non-resorbable. They also can easily be dislodged and they compromise blood supply to the graft. I have been hearing more and more that the best membrane for grafts is the periosteum with primary closure. Have any of you been doing bone grafts without membranes? What is your success rate? Can you recommend any bone graft products to use without membranes?

19 thoughts on “Membranes Over Bone Grafts: Is This Really Necessary?

  1. This depends entirely on the graft material , it is critical on most graft materials BUT there a newer materials where the graft is both stable a cell occlusive. Thus we can dispense with the tradtional type membrane and utilize the periosteal blood supply for improved angiogenesis.
    Having done over 900 membrane free cases it appears to be of great benefit once the technical complexities have been mastered .The research is there but having met many surgeons getting similar results reassures me more than studies.
    Regards
    Peter

  2. Hard to recomend without the editor having a say , but you can use google. I have written an article in the new EDI journal which shows the use of one of the 3 I use.
    Regards
    Peter

  3. Thanks Peter. I have seen no difference personally on my grafts with or without membranes. In fact, the consensus report of the AO could not find a difference in the literature either.

  4. Dear Dr B . you still need membranes with most particulates to stabalize then ( prevent the result of HA with fibrous tissue ) and restrict soft tissue ingrowth. All the manufacturers of Xenografts would expect the use of a double layer of collagen membrane.
    BUT things have moved on with some newer materials , read Podoropolus et al ,09 journal of Oral Implantology, Vol XXV , 09 page 28.
    Totally agree about the critical need for the periosteal blood supply to our graft sites.
    Regards
    Peter

  5. I will only speak for myself in regards to the use of membranes. I think the bottom line is how many walls the defect has, where is the defect, and how wide is the defect?

    Personally, when I do extractions with socket preservation or immediate implant placement and there are 4 walls of bone, I do not use a membrane.

    In perio defects, if it is a 3-wall defect, I use autogenous, bovine, or allograft in combination with Emdogain and get nice results.

    2 walls or less and class II furcation defects, I get better results using a resorbable membrane.

    For Ridge Augmentations and lateral wall sinus lifts, always use a membrane.

    Ultimately, the reality and science is that in order to have periodontal regeneration or something just as good, you need to have a stable fibrin clot. Principles of LANAP, which I don’t do, use this theory. Once a clot is formed, there is occlusal adjustment to ensure that it doesn’t get dislodged.

    Another bottom line reality when it comes down to perio, whether you have regeneration, CT attachment, or long junctional epithelium, what is most important is to properly maintain these sites every three months and encourage proper home care. Otherwise, it doesn’t matter how and what you did.

  6. Spin a little blood in a 10cc vial and use the PRF over the graft. Still try to achieve primary closure but do not sweat it if you have PRP and PRF for soft tissue closure.

  7. The oral surgeons in my area have started to use PRP as part of their socket preservations. The total fee is somewhere around $1500 for the extraction and other materials. I am appalled at this fee. How much do you charge to “spin a little blood in a 10 cc vial”?

  8. Dr B asks “is a membrane over a bone graft necesasry”
    Sometimes otheres ask “”is a bone graft necessary when using a membrane?”

    A membrane is one solution to a surgical problem but what is the problem?
    – If it is clot or clot/graft stability and containement then alternative methods of stability exist such as the use of a form stable or setting graft.
    – If it is exclusion of soft tissue ingrowth then this can be combated by using a substitute with porosity too small for fibroblast invasion and or one which has a surface which repels or hinders fibroblast attachement in some way.

    The Podoropolous paper referenced by Dr Fairbairn can be seen on: http://allenpress.com/pdf/orim35.1_10.1563-2F1548-1336-35.1.pdf

    Robert

  9. In regards to the cost mentioned by SG for PRP costs, I have to say that the fee is totally in line. Unfortunately the costs for the kits per patient come with a high price tag as well as the centrifuge unit itself. For years I mixed PRP with my bone graft material for socket preservation and then covered with a membrane. The results were always consistent and excellent. Due to the cost of the procedure and the fact that I felt it swayed some patients aways from an implant ultimately, I have gone to just hydrating the particulate in sterile saline and covering with a non-resorable, exposed membrane that is removed at 21-30 days. I have found my results to be comparable to the PRP and much more affordable and acceptable to the patient. I continue to use PRP for large grafts and as studies have shown it is only helping with soft tissue healing and not bone growth anyway.

  10. One thing to consider is consistency of results – that what using a membrane can offer, whereas if you don’t use a membrane there is always a chance that the result can be compromised and, if you are augmenting prior to placing an implant, you may need to augment again due to a poor outcome.

  11. Wendy, thank you for your comments. I think that all too often we remove ourselves from some of the financial concerns of our patients. Many individuals really do want to avail themselves of the services that we have to offer, but they need some “assistance” from us in helping to make the total package of the treatment affordable. I did have a question on your use of a non-resorbable membrane and leaving it in place for up to 30 days. I personally have been using resorbable membranes that are “fibroblast-friendly” and allow fibroblast migration, but also stay around long enough to delay epithelial downgrowth into the healing socket. I have gotten away from non-resorbable membranes because of the unfavorable soft tissue response, and the need for a second surgical procedure. I am curious about your thoughts on this. Thank you.

  12. If the purpose of using a membrane is to prevent epithelial cell migration into the grafted area, the question we should be asking is which of these modalities is closest to the physiologic cascade of wound healing. Non-expanded PTFE membranes are relatively safe in that they prevent bacterial invasion and epithelial downgrowth. However, they lose out on the perfusion of gases from periosteum that maintains the viability of any live cells within the graft mileu. Expanded PTFE membranes solve this problem but must have primary closure to prevent bacterial colonization. Resorbable collagen membranes are cell occlusive and do not need primary closure as you will get creeping epithelialization over the membrane in about 4 weeks. However, they exclude perfusion of gases as do the non-expanded PTFE membranes. The only membrane that is cell occlusive, allows perfusion of gases and recruitment of stem cells from periosteum, AND contains growth factors/live cells to ramp up early bone growth is PRF. The growth factors PDGF, VEGF, and TGFb speed up early angiogenesis, are chemotactic for early healing cells, compress the maturation cycle of blood vessels in the graft area, and increase osteoblastic activity by ramping up alkaline phosphatase production. These are the parameters that we should be concerned with, not how long a membrane takes to resorb. We live in a biologic world, not an instrument-based one.
    RJM

  13. Interesting read Robert , the idea of accelerated and early angiogenesis is very much the future .
    We work with out over a 100 year old friend CaSuphate , but who has recently been developed in many interesting ways , NanoGen , Bond Bone and the material I use Vital ( Genex in the US )all have very interesting variations to improve their performance parameters.
    As we all know Ca Sulphate is Bio-compatable , bacteriostatic , bio-absorbable and readilly available.These factors and its ability to be soft tissue cell occlusive make it a valuble “membrane”.
    By shifting the Zeta potential of the material to negative we find an big increase in proteins, Osteocalcin, Osteopontin , CBFT , collagen type 1 at the graft site and hence there is a sustantially increased presence of early osteoblatic activity . ( research Hunt and Cooper 07 )
    We can thus upregulate the host response in regeneration with dramatic clinical results.
    Regards
    Peter

  14. For those who are using PRF, is necessary the primary closure? The same question for the Calcium Sulphate.

  15. PRF, whether in membrane or plug form, does not need primary closure. It is a mature superclot, much more dense and elastic than a normal clot from a bleeding site. This makes it elastic (it can stretch 1.8X it’s relaxed length), can be sutured, and will not wash out like early RBC clots. It is equivalent to a normal clot that has progressed through the first 2-3 weeks of healing.
    With regard to calcium containing bone grafts, we do,in fact, see earlier angiogenesis, fewer infections, and earlier bone growth. This is because free cytosolic calcium ramps up the production of MAP kinases within the target tissues, thereby increasing cell metabolism and production of proteins involved in tissue regeneration. It is interesting to note that implants from Intra-Lock International, with the OSSEAN surface, have exactly the same biologic effects on bone. Free ionic calcium is released from the surface, upregulating osteoblastic synthesis of type III human collagen, the first building block of bone. This is apparently the reason for the 500% faster bone bonding at one week than Osseospeed and Nanotite.
    RJM

  16. I read that Calcium Sulphate also stimulates angiogenesis. This plus the properties listed by Dr Fairbairn gets very near the list of Dr Miller….

    Combine this as an “all in one” with the osteoconductive scaffold of bTCP and (-ve) control the surface to generate an “osteo-stimulatory” effect and you have some interesting technology.
    Look up Fortoss VITAL to learn more.

  17. If I must use a graft material, usually an alloplast, I will use a bTCP. This will release the highest level of ionic calcium. However, the choice of using a bone graft as opposed to PRF is directly related to defect size and number of walls. In a graft site of 4-5 walls, where the graft will be surrounded and supported by bone, we use PRF exclusively. This way, we do not have to go through a resorptive phase before going to anabolic bone growth. This will protect thin facial plates and almost eliminate resorption of residual bone. However, it is not robust enough and will resorb too quickly for use as an onlay graft. We will use either autogenous block, titanium mesh with graft, or a membrane with titanium reinforcement with graft. The profligate use of graft materials can actually accelerate bone loss in many cases because of an extended catabolic (resorptive) phase. Better to select your biomaterials based on the biology of the osteotomy rather than solely use a material that is described as “osteo-stimulatory”.
    RJM

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