|Year : 2022 | Volume
| Issue : 6 | Page : 543-550
The efficiency of PRF, PTFE, and titanium mesh with collagen membranes for vertical alveolar bone addition in dental implant therapy: A narrative review
Imam S Azhar1, Disti Ayulita2, Harry Laksono2, Tamita A Margaretha2
1 Department of Prosthodontics, Universitas Airlangga, Surabaya, Indonesia
2 Department of Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia
|Date of Submission||07-Jan-2022|
|Date of Acceptance||29-Aug-2022|
|Date of Web Publication||30-Dec-2022|
Dr. Imam S Azhar
Jl. Major General Prof. Dr. Moestopo No. 47, Surabaya 60132, East Java
Source of Support: None, Conflict of Interest: None
Aim: In prosthodontics, adequate bone volume is required to place a dental implant. Augmentation treatment can increase bone volume if it is insufficient. The guided bone regeneration (GBR) approach can be applied for either horizontal or vertical alveolar ridge augmentation. The GBR approach requires material in the form of a membrane to prevent non-osteogenic cells from accessing the wound, thus preventing any disruption of the process of new bone creation. Typically, non-resorbable membranes like titanium mesh are used in the GBR procedure to augment bone vertical dimension volume. In order to improve healing and bone regeneration, titanium mesh can be coupled with several membranes, including collagen membranes, platelet-rich fibrin (PRF), and polytetrafluoroethylene (PTFE). This review sought to ascertain the effects of adding vertical bone to titanium mesh following GBR with a collagen membrane, PRF, and PTFE for dental implant treatment. Materials and Methods: In this review, the medical literature on membrane titanium mesh used for implant therapy with the GBR technique was gathered from journals and publications published in the PubMed and Google Scholar databases between 2015 and 2020. Experimental research, case reports, and randomized clinical trials (RCTs) were included. The keywords used were “titanium mesh membrane, titanium mesh guided bone regeneration, titanium mesh with collagen membranes, titanium mesh with PRF, and PTFE. Results: Thirteen publications were found and chosen which discuss the usage of titanium mesh in conjunction with collagen membranes, PRF, and PTFE as barrier membranes for GBR. Conclusion: The GBR technique, which combines titanium mesh with PTFE and collagen membranes, can improve alveolar bone vertical addition, and the combination of titanium mesh with PRF can help the healing process move faster.
Keywords: Titanium Mesh-guided Bone Regeneration, Titanium Mesh Membrane, Titanium Mesh with Collagen Membranes, Titanium Mesh with PRF, Titanium Mesh with PTFE
|How to cite this article:|
Azhar IS, Ayulita D, Laksono H, Margaretha TA. The efficiency of PRF, PTFE, and titanium mesh with collagen membranes for vertical alveolar bone addition in dental implant therapy: A narrative review. J Int Oral Health 2022;14:543-50
|How to cite this URL:|
Azhar IS, Ayulita D, Laksono H, Margaretha TA. The efficiency of PRF, PTFE, and titanium mesh with collagen membranes for vertical alveolar bone addition in dental implant therapy: A narrative review. J Int Oral Health [serial online] 2022 [cited 2023 Feb 2];14:543-50. Available from: https://www.jioh.org/text.asp?2022/14/6/543/366438
| Introduction|| |
Loss of teeth can cause alveolar bone atrophy, which will cause the ridge to become short and narrow. Changes in the alveolar bone can significantly affect the placement of prosthetic restorations as removable dentures, fixed dentures, and implants become difficult. The process of alveolar bone resorption in missing teeth is influenced by the number of teeth extracted, bone wall, bone density, infection, alveolar bone loss severity, and whether the teeth next to it are present or not.,,,,
In prosthodontic treatment with dental implants, it is necessary to have a good bone volume at the implant’s placement site. One can perform bone addition or augmentation procedures if there is poor or insufficient bone volume.,,,, The guided bone regeneration (GBR) technique is employed for ridge alveolar augmentation. The horizontal and vertical augmentation ridges, which impact implant resistance, have also been treated with the GBR approach. A membrane material is required in the GBR procedure to stop non-osteogenic cells from penetrating the wound and preventing the development of new bone. Osteogenic cells are cells found in bone regeneration using a membrane because the membrane regenerates the bone to form a well-vascularized granulation tissue by secreting pro-osteogenic factors.,,,,
The membrane used in GBR must have rigidity and resilience in maintaining space for implant placement, proper resorption time, and a non-cytotoxic effect. In addition to the vertical dimension of bone volume in the GBR technique, membranes commonly used are non-resorbable such as titanium mesh. One of the non-resorbable membranes employed in the GBR procedure is titanium mesh. There are lateral and papilla design variants of titanium mesh. Lateral structures are employed for either horizontal or vertical bone augmentation. The benefits of titanium mesh for GBR are that it is widely used for bone repair and dental implants in lateral and vertical bone augmentation., The use of titanium mesh as a membrane barrier for GBR offers various benefits. Enhancing factors for cell attachment include high mechanical strength, biocompatibility, corrosion resistance, and porous structure., Titanium mesh has rigidity characteristics, making it easy to adjust and shape. This rigidity characteristic of titanium can work as a scaffold in that it maintains the area necessary for bone regrowth in the case of extensive bone damage such as vertical dimension bone damage.,,, The rigidity characteristics of titanium mesh can prevent soft tissue from interfering with bone regeneration. According to numerous researches, titanium mesh can be mixed with collagen membranes such as platelet-rich fibrin (PRF) and polytetrafluoroethylene (PTFE) to enhance the benefits of healing and bone regeneration benefits.,,
The most often utilized membranes for bone augmentation are collagen membranes. They are derived from collagen types I and III porcine, which have the advantage of not causing inflammatory reactions or foreign bodies and being able to help the bone regeneration process well., PRF is a membrane consisting of a fibrin matrix containing platelets, leucocytes, and growth factors and can benefit from stimulating the setting during wound healing. PTFE is a fluorocarbon polymer produced by the polymerization of tetrafluoroethylene. Currently, only a few kinds of literature discuss the addition of collagen, PRF, and PTFE to titanium mesh to help increase the vertical alveolar bone. The authors want to examine whether adding vertical bone by adding collagen, PTFE, and PRF membrane materials to titanium mesh supports dental implant treatment.
| Materials and Methods|| |
In this literature review, the medical literature on membrane titanium mesh used for implant therapy with the GBR technique was gathered by the authors from journals and publications published between 2015 and 2020 in the PubMed and Google Scholar databases. Experimental research, case reports, and randomized clinical trials (RCTs) were the only papers published in these journals. The authors used the method of selected studies because more journals and articles will be found when using this research study. The keywords used were “titanium mesh membrane, titanium mesh guided bone regeneration, titanium mesh with collagen membranes, titanium mesh with PRF, and PTFE.” Journal searches were carried out using the following publications: Clinical Implant Dentistry and Related Research Published by WILEY, Case Report in Dentistry by Hindawi, Journal of International Medical Research, Dentistry Journal, Clinical Oral Investigations, F1000 Research, International Journal of Dentistry, Transplantation Proceedings by Elsevier, Journal of Periodontology, The International Journal of Periodontics and Restorative Dentistry, The International Journal of Oral and Maxillofacial Implants, and Implant Dentistry. Journals and articles were first filtered by title, abstract, and discussion. The criteria included an article on titanium mesh membrane and bone regeneration, a report on the development of titanium mesh, PRF, and PTFE, and an article on the relationship between titanium mesh and vertical bone alveolar dental implant. The excluded criteria include any article not updated, no new research date, and unrelated to bone regeneration. The problem, intervention, comparison, and outcome have been shown in [Table 1].
| Results|| |
This paper reviewed the process of adding vertical bone to the membrane titanium mesh by adding other materials such as collagen, PRF, and PTFE membranes, which aims to determine the difference in the effectiveness of the vertical bone addition process. From the 40 journals and research articles, screening was carried out with inclusion criteria using membranes titanium mesh by adding other ingredients to assist bone regeneration. Then, 13 journals and articles met the inclusion criteria, and they read the text from the journals and pieces.
In the search, 40 journals, articles, and 9 journals were excluded because they discussed titanium mesh combined with various types of excluded bone grafts, and 16 journals were excluded. After all, the authors did not discuss the inclusion criteria. After the initial screening stage, 15 journals met the inclusion criteria. The inclusion criteria the author wants are titanium mesh and adding other materials to assist bone regeneration. In the end, they selected 13 journals to be a literature review. One journal was excluded because it did not describe the advantages of collagen membranes and PRF when combined with titanium mesh in bone healing, and it excluded another because a possible healing-promoting effect of collagen membranes was not observed in that study.
In the 13 selected and identified journals and articles (12 clinical studies and 1 experiment, the use of titanium mesh in conjunction with collagen, PRF, and PTFE membranes as a barrier membrane for GBR has been discussed. In combination with collagen membranes, a titanium mesh in four clinical studies,,, and an empirical study was found. Five clinical studies found the use of titanium mesh in combination with PRF.,,,, Then, titanium mesh in combination with PTFE can be found in six clinical studies.,,,,,
According to the study of Borges et al. [Table 2], the titanium mesh and collagen membrane GBR approach did not increase the quality of new bone in the rat femoral bone model, but it was affected by the titanium mesh’s pore size specification. The results obtained that the titanium mesh pore size is more than 1 mm. The value is 0.04–0.11 g/cm3, more significant than the pore size of 1 mm for bone mineral density.
In the study by Cucchi et al. in 2017, they compared the combination of titanium mesh with d-PTFE (group A) and crosslinked collagen (group B) in vertical bone formation after the GBR technique. They evaluated the level of surgical complications that occurred. Then, the average results of vertical bone growth in the two groups were 4.2 ± 1.0 mm for group A and 4.1 ± 1.0 mm for group B. The vertical bone growth and stability of implant complication rates between the two groups were not significantly different, according to the data.
The same vertical bone growth results in two groups after 9 months of membrane removal in the Cucchi study in 2019. In group A, the bone density was more significant than that in group B, so non-membranes resorbable resulted in higher bone density. The increased bone density of the combination of titanium mesh with d-PTFE, according to a 2019 study by Gallo and Díaz-Báez, can be used to treat complications in patients with graft loss. Difficulties can be caused by exposure and infection after the vertical and horizontal GBR processes. Regeneration using a membrane non-resorbable requires weekly follow-up to identify and treat complications promptly.
In a follow-up study by Cucchi et al. in 2019, the results of group B (titanium mesh + crosslink collagen) showed an increased bone tissue area and a lower region of soft tissue than group A (titanium mesh + PTFE). After 9 months of healing and after membrane placement, these results were evaluated and assessed to compare the two groups’ bone formation in terms of quality and quantity. A study by Almutairi in 2018 said that using PTFE material combined with titanium gave good implant placement results. After 5 months of the GBR procedure, the bone width was evaluated using a cone beam computed tomography (CT) scan. The bone width was 9 mm, which means that there is an increase in the bone of 6 mm. Combining membrane titanium mesh with e-PTFE can also provide good results for bone regeneration, a smooth healing process, and prosthetic rehabilitation that meets functional and aesthetic requirements. This research was conducted by La Monaca et al. in 2019 using allograft bone cancellous mineralized solvent-dehydrate. This study demonstrated effectiveness in obtaining the targeted functional and aesthetic results and preserving bone regeneration stability.
Cucchi et al. in 2020 continued their research to compare marginal bone loss and soft tissue evaluation that had vertical ridge augmentation, which is divided into two groups, namely, a combination of titanium mesh with d-PTFE (group A) and titanium mesh with crosslinked collagen membrane (group B) after 1 year of implant installation. The implant changed peri-implant bone levels (PBLs) from 0.12 to 0.76 mm after a year, with marginal bone losses of 0.67 and 0.61 mm for groups A and B, respectively, but no statistically significant difference was identified. The complex and soft tissues were stable in both the groups after 1 year, with less than 1.0 mm peri-implant bone loss in the first year.,
In addition to PTFE and collagen, titanium mesh was found in many publications to be merged with PRF. Using PRF as a membrane enhances the healing process of soft tissue wounds.,,, In a study by Baldan et al.,, in 2017, the results showed that bone formation and implants could be installed 8 months after the augmentation process using a combination of PRF and titanium mesh, which stably found no complications. Hartmann et al. in 2019 mentioned that the combination of PRF with titanium mesh gave good results in cases of dehiscence. In Hartmann et al.’s study, cases of dehiscence were the focus of assessment for impaired soft tissue healing and grafting. The PRF materials used are advanced platelet-rich fibrin (A-PRF) and injectable platelet-rich fibrin (I-PRF). In a follow-up study by Hartmann and Seiler in 2020, adding A-PRF can also improve soft tissue healing and prevent exposure to titanium mesh.
Al-Ardah et al. separated their study into four groups. Specifically, group 1 using titanium mesh with collagen membranes resulted in a vertical enlargement ridge of 4.5 mm. Then, in group 2, collagen membrane, titanium mesh, and PRF enlarged the vertical height by 4.6 mm. Then, group 3 used titanium mesh and different collagen membranes with collagen membranes in the first case, which enlarged the vertical ridge by 7.0 mm. Then, in the fourth group, titanium mesh, collagen membrane, and PRF were used to make an enlargement of the vertical height of 3.1 mm. Lorenz et al. in 2018 in their research mentioned that the combination of titanium mesh with a PRF matrix could reduce post-operative pain and the healing process is faster than that of the previous study. In addition, PRF was also concluded to help the augmentation process with the help of platelets, leucocytes, and growth factors needed to increase vascularity. The PRF materials used in this study were the same as those in Hartmann’s. The results of the clinical studies were summarized in [Table 3].
| Discussion|| |
In prosthodontics, implant treatment has been known as a treatment used in edentulous cases. However, treatment in prosthodontics requires good bone volume to obtain the desired aesthetic and functional results. Therefore, proper and healthy bone osseointegration is necessary for the long-term survival of dental implant therapy. If there is insufficient bone volume, bone addition or augmentation procedures can be performed.,,, The technique used to augur the ridge alveolar is GBR.
Titanium mesh is one of the non-resorbable membranes used in the GBR technique. The benefits of titanium mesh for GBR are that it is widely used for bone repair in treatment procedures and dental implants in lateral and vertical bone augmentation.,, In addition to using titanium mesh as a membrane in GBR, several membranes can be used in GBR procedures and have a good effect on bone formation, such as collagen, PRF, and PTFE membranes. Some journals and research articles can also combine titanium mesh with other membranes to achieve a better result of bone regeneration.
In the study by Borges et al., a combination of collagen membrane with a titanium mesh to see the effectiveness of new bone growth using titanium mesh in the GBR has different pore sizes. The collagen membrane is a membrane resorbable called the occlusive membrane because it can maintain the barrier temporarily and eliminate surgical procedures for membrane removal. Moreover, according to Cucchi, membrane resorbable is assessed to minimize the process of soft tissue genesis in the area of bone damage so that a combination of biomaterials is obtained that allows the formation of bone tissue of good quality.
However, research by Borges et al. in 2020 found that using a combination of collagen membranes with titanium mesh during the GBR technique did not improve the quality of newly formed bone in experimental studies using a rat femoral bone model. However, the quality of new bone formation was influenced by the pore size specifications of titanium mesh. No statistical differences were observed between the groups using collagen membranes and those not using collagen membranes. The results obtained at the pore size of titanium mesh greater than 1 mm obtained a value of 0.04–0.11 g/cm3, more incredible than the pore size of less than 1 mm for bone mineral density. In this study, titanium mesh with larger pore size has a higher mineral density than titanium mesh with less than 1 mm. This study also stated that the pore size factor of titanium mesh affects bone formation and material’s thickness, chemical makeup, biocompatibility, and usage of bone graft as a framework and its physical properties.,
In the study of Cucchi et al. in 2017, a combination of titanium mesh with a collagen membrane helped regenerate vertical bone by 4.1 mm. PTFE membranes reinforced with titanium resulted in vertical bone regeneration of 4.2 mm. The use of this collagen membrane is placed on a titanium mesh. This combination of materials is also used to evaluate complications in the GBR procedure. It is because exposure to titanium mesh can interfere with new bone formation.
In further research, Cucchi et al. used the same case as previous research in 2017 and found that the titanium mesh combined using the collagen membrane showed bone tissue development that was slightly larger and the formation of soft tissue that was lower than the PTFE membrane, which was reinforced with titanium. In histomorphometric data obtained in regenerated bone, bone tissue grew 7% for titanium-reinforced PTFE membrane and 1% for titanium mesh coupled with a collagen membrane. It may be because using a membrane resorbable has a better revascularization and mineralization effect than PTFE membranes due to the long-lasting impact of occlusive cells compared with PTFE membranes.
The study by Cucchi et al. in 2019 showed the same vertical bone formation results as in the previous survey. They assessed how the pseudo-periosteum, a layer of connective tissue built on top of the freshly created bone, was constructed. In this study, the titanium-reinforced d-PTFE membrane showed that type 1 on the pseudo-periosteum was less than 1 mm thick. Meanwhile, the titanium mesh combined with the collagen membrane showed a thickness of pseudo-periosteum of more than 3 mm.
Based on these findings, Cucchi et al. hypothesized that titanium membranes could enhance the quality of newly formed bone and decrease the layer of pseudo-periosteal tissue. However, it is still unclear whether the soft tissue beneath the membrane is mineralized after a long time due to low cellularity and lack of mineralization. Some believe that tissue pseudo-periosteal under the membrane is related to reduced bone regeneration or provides a protective effect on new bone formation. Additionally, the bone generated under the titanium mesh and collagen membrane was less dense than the bone formed under the titanium-reinforced d-PTFE membrane. It may be related to factors hosted, such as the potential for regenerative sites, but the small sample size did not show any significant correlation in the statistical analysis.
The bone volume obtained peri-implant that ranged from 0.12 to 0.76 mm, with marginal bone loss of 0.67 and 0.61 mm for PTFE membrane reinforced with titanium and titanium mesh plus collagen membrane, respectively, in a follow-up study performed by Cucchi et al. in 2020. This study evaluated the hard and soft tissues around the implant placed in the posterior mandible after a vertical ridge augmentation after 1 year by comparing the combination of the same membrane materials as in the previous study. From the results obtained, the comparison of PTFE reinforced with titanium and added to a collagen membrane which is a titanium mesh did not get significant results to establish the ideal material mix and to obtain high-quality hard tissue and soft tissue after 1 year only, which received less than 1.0 mm of bone loss peri-implant. In a research study, Gallo and Díaz-Báez mentioned that the high-density titanium-reinforced PTFE membrane could treat complications in lost patients’ grafts and achieve final rehabilitation without additional surgery. Regeneration using a membrane non-resorbable requires follow-up weekly to identify and treat complications on time.,,,,,
After horizontal and vertical augmentation, it takes 6–9 months for the bone to mend by stopping the regeneration process by creating fibrous tissue. However, the simultaneous placement of implants after bone healing can affect bone remodeling and mineralization grafts. Using PRF as a membrane enhances the healing process of soft tissue wounds.,
In the Hartmann and Seiler study in 2020, the combination of titanium mesh with PRF gave less exposure to titanium mesh. Titanium mesh exposure is a common complication, but this exposure does not always lead to poor treatment outcomes. In addition, the combination with PRF affects the healing process of soft tissue because PRF acts as a biodegradable scaffold made of leucocytes, platelets, and fibrin that can increase micro-vascularization and migration of epithelial cells. This study also mentioned that the combination of titanium mesh with PRF could be used to treat cases of dehiscence because of the effect of PRF, which can help primary wound closure in the area above the graft during the augmentation process which has growth factors and cytokines. However, further studies are needed to evaluate proper soft tissue healing using PRF.,,,
Lorenz et al.’s research shows that titanium mesh combined with a solid and liquid PRF matrix can reduce post-operative pain and accelerate healing. The PRF matrix contains regenerative substances such as platelets, leucocytes, growth factors, and fibrin that enhance the biological properties of bone substitute materials. Using a combination of titanium mesh and PRF affects biomaterials to induce cellular tissue reactions released by mononuclear cells. Therefore, the presence of the PRF matrix can accelerate the migration of osteoprogenitor cells into the augmentation layer by releasing growth factors, thereby increasing bone regeneration.,,
Baldan et al.’s study utilizing titanium mesh and PRF to augment the alveolar ridge had good bone regeneration results. This study used a combination of PRF and titanium mesh in the entire edentulous maxilla and was associated with severe atrophy. However, a study conducted by Al-Ardah et al. in 2017 showed that PRF could not prevent exposure to titanium mesh in this study. However, exposure to titanium mesh on bone volume is still unclear because some authors say that exposure to the volume of bone graft or that exposure to titanium mesh has a favorable effect on bone loss.,,,,
In contrast to Hartmann’s 2020 study, the combination of titanium mesh with PRF resulted in less exposure to titanium mesh and the said exposure to titanium mesh was a common complication. However, this exposure did not always give a bad outcome for treatment. In good prosthetic implant treatment, good quality bone is needed. Changes in the alveolar bone can affect the prosthetic restoration treatment plan, which is especially important for areas requiring esthetics, such as the maxillary incisors.,,
| Conclusion|| |
At the end of this narrative review, the authors concluded that the combination of titanium mesh with collagen, PRF, and PTFE membranes is effective for the vertical addition of alveolar bone in dental implant therapy because the combination of titanium mesh with PTFE and collagen membranes has the more significant result for increase in alveolar bone’s vertical addition and the combination of titanium mesh with PRF has the minor effects of speeding up the healing process.
There is no acknowledgement to declare.
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Conflicts of interest
There are no conflicts of interest.
Each author made a substantial contribution to the conception or design of the work and in the acquisition, analysis, and interpretation of data for the work. Each author has a role in structuring the work and revising it critically for important intellectual content. Each author gives final approval of the version to be published and they agree to be responsible for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are investigated and properly resolved.
Ethical policy and Institutional Review Board statement
Patient declaration of consent
There is no patient informed consent for this review article.
Data availability statement
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[Table 1], [Table 2], [Table 3]