Titanium Mesh: Techniques and Pitfalls?

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Dr. L., from Washington, D.C., asks:

I am curious to know how many of you out there are using titanium mesh?

I graduated perio residency over a year ago and never used titanium mesh to build up a ridge. During residency I mostly used block autografts, block allografts or particulate grafting with titanium ePTFE or Ossix Membrane with tenting screws. However, recently I noticed advertising for titanium mesh systems in several dental implant journals, which piqued my interest.

I have several questions for experienced users: Have you used titanium mesh and what is your opinion? How was the outcome? What are some pitfalls, indications and contraindications? Describe how hard or easy is it to use? Decribe your surgical technique? Any good technique articles out there that you would recommend? Type of graft you favor with this technique? How hard is it to get the mess out at stage I?

Thanks for any responses.

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11 Responses to “ Titanium Mesh: Techniques and Pitfalls? ”

• John Highsmith October 2nd, 2007

  
  

  I’ve done several of these recently, mostly using the titanium mesh for tenting. I have placed the mesh and then placed a Zimmer pericardium membrane over it. Yes, probably belt and suspenders. Of course, very important to get tension free closure.
  I’ve done uncovery on two of these cases and was very happy with the bone we grew. Right up to the mesh. Really not a big problem to get it out–peels right off.
  John Highsmith
  Clyde NC

• piezo1 October 3rd, 2007

  
  

  I agree with Dr Highsmith about “belt and suspenders”: actually, there is no evidence that the use of a bioresorbable membrane on a Ti mesh is advantageous in order to achieve a larger amount of regenerated bone.
  Nevertheless, i have a quastion for Dr Highsmith: do you use bone tacks or bone screw to fix tha Ti mesh? Thanx in advance.

• Dr. Gerald Rudick October 3rd, 2007

  
  

  Years ago, one of the titanium kits to be sold was the TRAM technique (Titanium Ridge Augmentation Material) which was a fine titanium screen that came with a special screw, much in the same fashion as a tent pole, on to which snapped the titanium mesh.

  I have used “sugar mesh” which is titanium screening that is bendable and keeps its form. If it is well adapted, much like a saddle, it can be maintained just by reapproximating the gingival tissue flaps without the necessity of fixation screws.

  The problem with the titanium mesh, is that invariably,even though an attempt is made to have tension free closure, the mateial gets exposed.

  The edges of the titanium mesh are sharp, and causes gingival irritation, which can lead to infection.

  I have yet to see the soft tissues totally bury the titanium screen during the healing process.So, in order to prevent exposure, I place a non ridgid PTFE membrane over the the screen, so in the event of exposure, there is a barrier membrane. The results can be interesting, because the purpose of the titanium screen is simply that of a form, because it holds its shape.

  Recently, I have been using a pure PTFE membrane, 1/64th” thick, which can be molded and adapted over the ridge in the same fashion, and acts as a rigid form. When it does get exposed,there are no holes,so the barrier is intact.

  I will be writing an article on this material, which is not available commercially, but I am willing to supply, free of charge, these membranes to any dentist who is willing to fully document and share his/her findings with me.

  Please contact me at implants@total.net, subject PTFE for further information.

  Dr. Gerald Rudick, MOntreal

• L. Scott Brooksby, DDS, DICOI October 3rd, 2007

  
  

  I tried a full arch ridge augmentation about fifteen years ago, just after getting out of my residency. Getting tension free closure was difficult and despite the screws the mesh moved creating a double ridge. In retrospect I would have been way better off starting really small.

• JL: CT October 4th, 2007

  
  

  Who manufactures the best mesh?

• Dr L October 4th, 2007

  
  

  Thanks guys for some of your comments? Im looking for a little more info. Questions below:

  What are some pitfalls, indications and contraindications?

  Describe how hard or easy is it to use?

  Decribe your surgical technique?

  Any good technique articles out there that you would recommend?

  Type of graft you favor with this technique?

  Thank you for your help.

• Perioplasticsurgeon October 8th, 2007

  
  

  Dr L,

  The below isnt a bad article, but I to would be curious as to what people’s experience is with Mesh. I find it very technique sensitive and case selection is critical.

  J Oral Implantol. 2006;32(5):237-47.Links
  Use of titanium mesh for staged localized alveolar ridge augmentation: clinical and histologic-histomorphometric evaluation.Proussaefs P, Lozada J.
  Dentalimplants@sbcglobal.net

  The use of titanium mesh for localized alveolar ridge augmentation was evaluated by clinical, radiographic, laboratory, and histologic-histomorphometric evaluation. Seventeen patients participated in this study. All patients required localized alveolar ridge augmentation before placement of dental implants. An equal mixture of autogenous bone graft and inorganic bovine mineral (Bio-Oss) was used as a bone graft material. Autogenous bone graft was harvested intraorally. Titanium mesh was submerged for 8.47 months (SD 2.83). Impressions were taken intraorally before bone grafting, 6 months after bone grafting, and 6 months after implant placement. Impressions were used to measure the volume of alveolar ridge augmentation and provide linear laboratory measurements regarding the results of bone augmentation. Bone quality (type II-IV) was recorded during implant surgery. Standardized linear tomographs were taken before bone grafting and before implant placement. A biopsy was harvested with a trephine bur from the grafted area during implant surgery for histologic-histomorphometric evaluation. In all cases the grafted area had adequate bone volume and consistency for placement of dental implants. Early mesh exposure (2 weeks) was observed in 2 patients, and late exposure (>3 months) was observed in 4 patients. Volumetric laboratory measurements indicated 0.86 cc (SD 0.69) alveolar augmentation 1 month after bone grafting, 0.73 cc (SD 0.60) 6 months after bone grafting, and 0.71 cc (SD 0.57) 6 months after implant placement. This indicated 15.11% resorption 6 months after bone grafting, and no further resorption occurred after implant placement. Linear laboratory measurements indicated vertical augmentation of 2.94 mm (SD 0.86) 1 month after bone grafting, 2.59 mm (SD 0.91) 6 months after bone grafting, and 2.65 mm (SD 1.14) 6 months after implant placement. The corresponding measurements for labial-buccal augmentation were 4.47 mm (SD 1.55), 3.88 mm (SD 1.43), and 3.82 mm (SD 1.47). Radiographic evaluation indicated 2.56 mm (SD 1.32) vertical augmentation and 3.75 mm (SD 1.33) labial-buccal augmentation. Histomorphometric evaluation indicated 36.47% (SD 10.05) new bone formation, 49.18% (SD 6.92) connective tissue, and 14.35% (SD 5.85) residual Bio-Oss particles; 44.65% (SD 22.58) of the Bio-Oss surface was in tight contact with newly formed bone. The use of titanium mesh for localized alveolar ridge augmentation with a mixture of autogenous intraorally harvested bone graft and Bio-Oss offered adequate bone volume for placement of dental implants. Intraorally harvested autogenous bone graft mixed with Bio-Oss under a titanium mesh offered 36.47% new bone formation, and 15.11% resorption occurred 6 months after bone grafting.

• Dr. Ollerton October 9th, 2007

  
  

  I have used ti mesh several times. Ace surgical sells it in two different thicknesses. I like the thinner of the two. It can be bent to conform to the shape that you want.

  The first time I used it gave me the very best grafting results I had ever obtained. Since that time I have used it under various circumstances with success and failures.

  Problems:
  1. You must cut the mesh to fit the site. That leaves sharp edges which can cause exposure.

  Solution: Use orthodontic instruments to make the sharp areas curve towards bone instead of the soft tissues. Place a barrier over the mesh (my preference is collagen soaked in prp). Lastly tack the mesh occlusally and apicallty so that it will not move.

  2. Exposure. My only advice is that if it does get exposed, to remove it asap and cover the grafted area with collagen or alloderm.

  3. Removal. Some times it works so well that bone grows through, not just under the mesh. Also, it can become imbedded in soft tissue.

  Solution: Just allow more time for removal.

  When placing ti mesh, always extend the flap at least one tooth mesial and distal to the graft site. Score the flap to obtain primary closure.

  An additional use for ti mesh is during implant placement. If at implant placement you know from x-ray studies that part of the coronal area of the implant will be supra-crestal, you can cut a piece of titanium mesh to extent around the exposed area, place autogenous bone from the osteotomy site over the exposed area and fixate the titanium mesh with the cover screw. For good measure I usually place a collagen barrier over the mesh.

  Give ti mesh a try. It is versatile. Often the hardest part is the fixation step. Placing screws or tacks in every area of the mouth can be a challenge.

  Good luck!

• Joe October 25th, 2007

  
  

  I am curious-have any of you heard of “tenting” the ridge with mini-implants with a slow resorbing membrane like Zimmers pericardial with the graft taking?

  At the ICOI Tarranou last year in NYC a dentist from Europe showed a great result. I do not remember what membrane HE used, but I do not think it was mesh.

  Comments.

• Docindeed January 16th, 2008

  
  

  There is actually a new membrane that is meant to fully replace titanium mesh all together. It is a resorbable membrane that is just as rigid as titanium. I believe Curasan (Cerasorb) carries it. Either way, it was half the cost and it eliminated the need for a 2nd surgical procedure. The results were amazing, having the membrane fully resorb in 14 weeks.

• almez March 29th, 2008

  
  

  best tx: send pt to an oral surgeon who can evaluate the site, quantity, quality of bone needed, and proper graft technique and stabilization

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