Titanium wire mesh usually comes in two types of colors, one is made of pure titanium wire, coated with a graphite coating, and the surface is black. It is suitable for the manufacture of industrial filtration, packing, marine filtration, and seawater filtration titanium mesh.
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The other is a bright white surface with the graphite coating removed. This is suitable for making electrode mesh, battery collection mesh, and various fine chemical liquid filters.
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Guided bone regeneration (GBR) is an effective and simple method for bone augmentation, which is often used to reconstruct the alveolar ridge when the bone defect occurs in the implant area. Titanium mesh has expanded the indications of GBR technology due to its excellent mechanical properties and biocompatibility, so that the GBR technology can be used to repair alveolar ridges with larger bone defects, and can obtain excellent and stable bone augmentation results. Currently, GBR with titanium mesh has various clinical applications, including different clinical procedures. Bone graft materials, titanium mesh covering methods, and titanium mesh fixing methods are also optional. Moreover, the research of GBR with titanium mesh has led to multifarious progresses in digitalization and material modification. This article reviews the properties of titanium mesh and the difference of titanium mesh with other barrier membranes; the current clinical application of titanium mesh in bone augmentation; common complications and management and prevention methods in the application of titanium mesh; and research progress of titanium mesh in digitization and material modification. Hoping to provide a reference for further improvement of titanium mesh in clinical application and related research of titanium mesh.
This review summarized the properties of titanium mesh, differences of titanium mesh with other barrier membranes, current clinical application of titanium mesh in bone augmentation, common complications of titanium mesh and its management or prevention, and the research progress of titanium mesh. In order to provide a reference for the improvement of titanium mesh in research and clinical application.
The theory of GBR technology is to selectively prevent epithelial cells and connective tissue cells from bone defect area through barrier membrane based on different migration rate of various cells, allowing osteoblasts preferentially enter the bone defect area to complete bone induction and regeneration. Meanwhile, bone graft materials are placed in the bone defect area as scaffolds, and guiding osteoblasts and osteocyte to form new bone. 4 Previous studies have shown that, in the clinical application of GBR, the bone defect area’s spatial support may play a more critical role than the cell-selective isolation. 5 If the bone grafts in the defect area lack support, it may be forced to shift by local stress, resulting in the collapse of bone-augmented area, which cannot achieve the expected effect. Therefore, for the barrier membranes in GBR technology, on the premise of good biocompatibility, it is ideal to have sufficient stiffness, supportability, and retention capacity. However, although traditional barrier membranes (such as absorbable collagen membrane, nonabsorbable expanded polytetrafluorethylene membrane (ePTFE), etc.) have the property of cell-selective isolation, they are relatively soft and difficult to provide adequate retention and protection for the bone regeneration areas. 6 Hence, when the traditional barrier membranes be applied to large bone defects, limited by its stiffness, it is difficult to maintain a suitable and stable bone regeneration space, and is easy to generate micromotion that affects blood supply. 7 When the alveolar bone has severe vertical or horizontal bone defects, many clinical studies suggest that titanium mesh shows superior mechanical properties and great osteogenic performance during application. 8 – 10 Therefore, this review intends to discuss the application and progress of titanium mesh in GBR.
In oral implantology, the quality and volume of alveolar bone in the implant area affect implant position, primary stability and soft tissue shape recovery, and other critical factors related to satisfactory implantation restoration. 1 Generally, the alveolar bone will suffer secondary absorption and atrophy after tooth loss, the width and height of the alveolar ridge will decrease, and become insufficient for implantation over time. 2 Therefore, the reconstruction of alveolar bone in the implant area is a key point in oral implantology. There are many clinical methods for alveolar bone defect recovery, including guided bone regeneration technique (GBR), onlay bone grafting, bone extrusion technique, bone splitting technique, and distraction osteogenesis. Due to its simple operation, low technical sensitivity, osteogenic stability, and multidirectional osteogenesis ability, GBR is one of the most currently used technique to repair alveolar bone defects. 3
Titanium is widely used in surgical operations due to its high stiffness, low density, corrosion resistance, and good biocompatibility. Titanium mesh, as its application product, has unique characteristics as a GBR barrier membrane for bone augmentation.
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Titanium mesh has good mechanical properties, its high strength and stiffness enable space support for osteogenesis, its stability is necessary to maintain bone graft volume during wound healing, and the elasticity can reduce the oppression of oral mucosa.11 Due to its good plasticity, titanium mesh can adapt to various bone defects through bending and shaping. These features enable GBR with titanium mesh to show a high stable osteogenesis effect, and achieve coinstantaneous bone augmentation in horizontal and vertical directions.5
For different titanium mesh, the thickness and porosity are the key factors affecting its mechanical properties. Study suggested that the thickness of titanium mesh may affect the total amount of new bone formation, while the pore size may affect the proportion of bone tissue and soft tissue formation under titanium mesh.12 The thickness of titanium mesh is directly proportional to its mechanical properties, which commonly used ranges from 0.1 to 0.6 mm currently. Usually, the titanium mesh at 0.2 mm can be suitable for most instances.13 Under this thickness, titanium mesh can provide sufficient stiffness to maintain space and protect grafts, while offer appropriate flexibility that reduces the risk of tissue rupture. With the increase of reconstruction area of alveolar ridge, thicker titanium mesh should be used in GBR to maintain bone regeneration space. As for thick titanium mesh, there are often some sharp edges in the process of bending titanium mesh due to the decrease of plasticity, which is closely related to the mucosal rupture titanium mesh exposure, many researches focus on finding a more suitable thickness of titanium mesh. A study showed that 100–200 μm is the ideal thickness of titanium mesh to reconstruct a large number of bone defects.14 Consistent with the result, Rakhmatia et al. compared the bone augmentation effect with titanium mesh at 20, 50, and 100 μm in mouse model and concluded that compared with thinner Ti-mesh, the use of titanium mesh at 100 μm can achieve more extensive bone regeneration effect.12 Owing to the thinner titanium mesh is rarely used in clinic currently, when it comes to thinner titanium mesh’s clinical application, a balance between the strength for spatial stability and malleability for adapting adjacent bone contours must be found.
In terms of pore size, it also affects the performance of titanium mesh during bone augmentation. The pore of the titanium mesh is thought to play an essential role in establishing blood supply and facilitating metabolic processes of the grafts at the defect site.15 Celletti et al. demonstrated that without pores on titanium mesh, exposure of the mesh would occur in 3 weeks after surgery.16 However, the relationship between the pore size of titanium mesh and bone formation is still controversial. For the existence of pores on titanium mesh, it is difficult to achieve selective cell isolation, and soft tissue often grow under titanium mesh. Therefore, many studies have attempt to investigate the relationship between the pore size and the amount of soft tissue growth. A study suggested that compared to the titanium mesh with small diameter (0.6 mm), the titanium mesh with large diameter (1.2 mm) promoted more bone regeneration and prevented soft tissue growth more effectively.15 This phenomenon may be related to the increased distribution of blood supply, and diffusion of nutrients and oxygen leaded by the large aperture. On the contrary, a study showed that the use of titanium mesh with large diameter (>2 mm) may lead to more soft tissue growth upon the surface of new bone than the use of titanium mesh with small diameter.17 A similar result for GBR with polyester meshes in different pore size may explain this contradictory phenomenon: the larger the pore size of the barrier membrane, the more connective tissue grows between the membrane and the regenerated bone, and the more rapid bone regenerate, while the pore size does not make much difference to the amount of bone formation after the osteogenesis stabilized.3
Titanium mesh has good biocompatibility and can be compatible with tissues. The biocompatibility of materials can be divided into corrosion resistance and cytotoxicity. Due to its low electrical conductivity, titanium is prone to perform electrochemical oxidation to form a passive and inert oxide layer.18 This oxide layer can be retained under the pH of human body, leading to high and persistent corrosion resistance in titanium.19 Hence, little amount of metal particles can be released from titanium mesh, while the titanium particles has no significant effect on human cells’ relative growth rate.20 Study observed that after alveolar ridge reconstruction conducted by titanium mesh, a thin layer of 1–2 mm thick, soft tissue can often be found upon the regenerated bone surface, called “pseudo-periosteum”.21 The formation of this soft tissue layer may be related to the insufficient cell exclusion ability of titanium due to its pores. The role of pseudo-periosteum may be related to bone graft protection, graft infection prevention, and absorption. Currently, it is often be removed with titanium mesh in subsequent operation.22
According to the currently reported literature, GBR with titanium mesh has strong osteogenesis predictability, and both horizontal and vertical bone augmentation can be obtained in the process with delayed or simultaneous implantation. In the delayed implantation strategy of bone augmentation, most researchers have gained an average bone augmentation of 4–5 mm in bone width and 5–7 mm in bone height.10,23–26 While in the strategy of simultaneous implantation with bone augmentation, although there are few researches about three-dimensional bone increment, the realization of ~3–4 mm average bone gain in width and height seems feasible.27,28 However, a meta-analysis about the horizontal or vertical bone augmentation effect of titanium mesh could not be performed for the heterogeneity of the data.13
Compared to other methods, bone resorption due to infection is rare in the application of titanium mesh.29–31 As a small amount of peri-implant bone resorption usually occurs after implant loading,32,33 GBR with titanium mesh will also experience small amount of bone resorption. Zhang et al. showed that for a single anterior tooth defect, during the 41-month follow-up period after implant placement, the labial bone plate experienced an average of −0.81 ± 1.00 mm vertical absorption, which bone upon the implant absorbed at mean of 0.13 ± 1.19 mm in horizontal dimension.28 And the study conducted by Poli et al. showed that for a large range of GBR with titanium, the mesial and distal bone resorption were at an average of 1.743 ± 0.567 and 1.913 ± 0.71 mm, respectively, during the 88-month follow-up period after implantation.34 Therefore, the possibility of bone resorption also needed to be considered when performing bone augmentation with titanium mesh.
Nowadays, the barrier membranes commonly used in clinical can be divided into absorbable and nonabsorbable membranes according to their absorbability. The main absorbable membrane is collagen membrane, and the main nonabsorbable membranes are ePTFE, titanium-reinforced PTFE, and titanium mesh.35 Among the barrier membranes mentioned above, titanium mesh is the only one entirely made of metal. It exploit the advantages of titanium in mechanical and biological properties to the full, performing excellent in space maintenance and bone reconstruction.13 In comparison, though some enhanced absorbable collagen membranes can provide spatial protection to the bone graft material at the initial placement, they will gradually degrade with the absorption of the membrane, making them unable to achieve the same spatial maintenance ability as titanium mesh.7 Konstantinidis et al. compared the effect of collagen membrane and titanium mesh in the vertical bone augmentation, and found that the collagen membrane group gained 2.77 ± 1.97 mm bone height, and the titanium mesh group gained 4.56 ± 1.74 mm bone height (p < 0.05),36 which can be considered that titanium mesh has certain advantages in bone augmentation effect. Although Cucchi et al. proved that there is no significant difference (p < 0.05) between titanium mesh and titanium-reinforced PTFE in vertical bone augmentation and complication rates.27 Researches showed that different from absorbable membranes or other nonabsorbable barrier membranes like ePTFE, it is rare to observe consequent infection of bone regeneration failure in bone-augmented sites after exposure of titanium mesh.37,38 This may be related to the dense and surface structure of titanium that is less susceptible to be adhered by bacteria, and the protective effect of pseudo-periosteum formed under titanium mesh.37,39 Due to the presences of pores, titanium mesh may lead to spontaneously heal of mucosa upon bone reconstruction area after exposure, which means unlike ePTFE or titanium-reinforced PTFE, it may not need to remove titanium mesh immediately as there is no infection after mesh exposure.40
However, titanium mesh also has shortcomings. Unlike absorbable membranes, titanium mesh cannot be resorbed by the body, which means the titanium mesh and fixation screws need to be removal through second-stage surgery, causing trauma to the patients. Besides, different form other absorbable and nonabsorbable barrier membranes, due to its stiffness, titanium mesh needs to be shaped during surgery to adapt profile of alveolar ridge. This process is technically sensitive, time-consuming, and laborious. And the sharp edges will inevitably form during bending, which may stimulate the mucosa, leading to mucosal rupture and exposure of titanium mesh.41
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