Exposure of d-PTFE membrane: remove or leave as is?
I have a case where I needed to perform ridge augmentation. The bone graft was covered with d-PTFE membrane and stabilized with screws. Primary closure was achieved with mattress and single sutures. Some weeks after suture removal, the membrane became exposed. I know d-PTFE membrane can be left exposed, but it’s also recommended that the membrane be removed at around 4 weeks. My question is: In my case do I try to remove the membrane or just leave it as is? My concern is that the exposure is going to widen and soft tissue will not grow over the membrane. If I do need to remove the membrane, do I flap the gum again to remove the screws and the membrane?
19 Comments on Exposure of d-PTFE membrane: remove or leave as is?
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Mouhamad Ahmad
11/22/2016
Thats a great question. I think you can leave the membrane up to 6 weeks. Then go back and flap to remove screws and membrane
Michael S
11/22/2016
Thanks for the advice. So you don't think the soft tissue is going to close via secondary intention.
Dr. Elijah Arrington III
11/23/2016
The membrane is fine to leave. Epithelium will grow under the membrane, allowing you to remove it when you ready. Make sure the patient is using chlorohexidine with a cotton swab gently 3 x day to keep it clean. Non compliant patients have brought them back to me in 8 plus weeks and they have done fine. I ask that you look into cytoplast dpfte( registered trademark) membranes which are meant to used in cases of secondany intention. They cost a little more, but the security that they give is well worth the cost.
Dr KJ R S Das
11/22/2016
Hi,
If the exposure is more than 1 mm I would remove the membrane verty carefully so as not to disturb the underlying graft, If you do have access to A PRF then a place Bioguide over the graft and place the APRF over it and suture the soft issue back again. It will work perfectly . But you would still have to do a bit of tissue release,
Hope that helps
Dr K R S Das FRACDS MSc( Implants) Frankfurt
Michael S
11/22/2016
Thanks for the advice. So basically I would have to perform second surgery to remove the membrane. Yikes, I don't think the patient is going to like that too much.
KRS Das
11/22/2016
If the exposure is large then you may try cutting through the exposed ptfe membrane very precisley undermining so that you have soft tissue beyond the cut membrane and create a bit of bleeding so as to induce sec healing
Its a gamble you can try and if still no improvement in a week dont wait any longer remove the membrane and cover as told earlier
I am telling you this from previous experience only and it works well if the pt takes extreme care as well using chlorhex gel at night over the exposed part and using a peroxide mouthwash during the day
Das
Gustavo Herrera Gayol
11/24/2016
Michael,
The exposure of membranes occurs and is a very frustrating situation.
Never leaves a exposure longer than 5 weeks.
Then remove the membrane and the screws but don't touch the red gel look tissue under the membrane.
Then closure.
Regards,
Gustavo
Haydar Alkhatib
11/22/2016
Autogenous bone block graft? If yes I think it's necrotic now remove the block ASAP , else remove the membrane and try refreshing the site and PRF patch with chlorhexidine swabs several times aday
ZORAN STAJCIC
11/22/2016
Hi Michael,
You can leave the membrane exposed. Cytoplast membrane has the advantage of being exposed without compromising GBR. You will see the soft tissue coverage underneath the membrane once you remove it. I would not be worried. If you wish I can provide some photos.
Best regards
Elijah Arrington III
12/8/2016
I concur Mike.
William Davenport
11/22/2016
I would try not to re-open the wound but rather remove the screws through small incisions directly over the screw heads. The membrane will usually slide out with little effort and little discomfort. If it were not for the screws holding the membrane, I would expect you to be able to engage an edge of the membrane with an explorer or cotton forceps and simply slide it out. Topical anesthetic is usually sufficient. It will leave a bed of granulation tissue over the graft that will eventually epithelialize. Unfortunately, some of the graft volume is likely to be lost.
EZ
11/22/2016
Great answer, I totally agree... To all readers, .Re. screws , I find the membranes perform well without screws so I rarely use them. When do you all decide to use screws ?
KRS Das
11/23/2016
I always use screws( Tacking Pins) when using A Ti Reinforced Cytoplast membrane or even Biogiode, iT HELPS TO STABILISE THE GRAFT. It is the standard procedure advocated by all leading Graft Gurus like Istvan and Pikos
Gustavo Herrera Gayol
11/24/2016
EZ,
Screws allways when are using PTFE membranes with or without titanium reinforcements.
Collagen, may be.
Regards,
Gustavo Herrera Gayol
Phil
11/23/2016
Great topic. By the way, in the future, I would recommend looking into Cytoflex micro-porous ePTFE membranes. d-PTFE membranes are manufactured specifically to eliminate expansion, and greatly reduce pores (submicron (0.2 μm) pore size). Because of this tiny pore size, bacterial infiltration into the site is eliminated with d-PTFE, but at the same time the non-porous nature of the barrier limits nutrient permeation across the membrane. With the micro-porous ePTFE membranes the micro-pores are miniscule enough to block bacterial penetration keeping the site safe from infection (so can be used in primary coverage and non-primary coverage situation), but the micro-porous material still allows nutrient permeation across the membrane.
Michael S
11/25/2016
Thanks for all the wonderful suggestions. I'm just surprised that Osteogenics never mentions how to remove the d-PTFE membrane when it's tacked or screwed. They just claim how it's so easy to remove when it's not stabilized. I guess maybe my situation is not so unique after all.
Sb oms
11/25/2016
Chlorhexidine is not the best thing to put on a wound dehiscence.
Research has shown (sorry don't have time to look up the source) that it is cytotoxic to early fibroblasts.
Warm water and hydrogen peroxide works well for me in the past.
Elijah Arrington III
12/8/2016
Understanding that fibroplast are affected, optimal hygiene can still be achieved by allowing the patient to perform this mechanical agitation with the antimicrobial rinse chlorhexidine. Fibroplast will still proliferate and maturate, because the of the limited frequency that they are engaging in agitation. Keeping the area free of plaque/ infected biofilm will actually allow for increased maturation or proliferation (hyperplasia) of the fibroblast.
Ankur
12/1/2020
I was wondering if instead of stabilizing the membrane with the bone tacs, would not it be better to give membrane stabilizing sutures . There would be no need to bother about removing the screws also.
