Improving GBR with an Amnion Chorion Membrane: Dual Layer Technique

Amnion Chorion membranes have been used very successfully in other medical fields, such as ophthalmology, but are still somewhat new in dentistry. However, amnion chorion membranes, which are rich in growth factors, show great potential in many dental applications, including tissue regeneration and wound healing.¹

In this specific case of a failed implant site and subsequent graft failure, the DALI Amnion Chorion Membrane was an excellent choice to facilitate a successful GBR procedure. Ultimately, the Amnion Chorion Membrane was employed in a dual, or double, layered membrane technique where the membrane was layered over a porcine collagen membrane. The efficacy of the dual, or double, layered membrane technique is well-documented in the literature. ^2,3 Usually the technique is employed using 2 collagen membranes or a collagen membrane + PTFE membrane. In this case, an Amnion-Chorion Membrane was chosen as the secondary membrane layer, due to the many beneficial properties of the Amnion-Chorion Membrane.⁴

The specific case shown here involved a failed implant at #27 from another surgeon. The implant was removed and the site was grafted at the time of implant removal.  When the case was referred for a new implant, the site was re-entered and when the flap was opened all that remained was a bunch of graft material that didn't take. The site was cleaned out and prepared for new implant placement. It was clear that alot of regeneration was still required at the site, but there was room for optimism for GBR because there was really nice bone peaks on the adjacent teeth, and the new implant was placed well within the alveolar housing.

The GBR procedure involved the use of an OsseoSeal collagen membrane, which was first tucked under the lingual flap. DALI Mineralized Cortical Cancellous Bone Mix, was then added at the top of and around the implant, after which the OsseoSeal membrane was then placed over the graft, extending onto native bone. Finally, a DALI Amnion / Chorion Membrane was layered on top of the OsseoSeal Membrane for enhanced healing. It's important to remember that you should handle the DALI Amnion Chorion Membrane when it is dry, because once it gets wet it is very difficult to manipulate. Primary closure was achieved following specific suturing techniques (see Suturing for Tension-Free Primary Wound Closure).

At 3 Months follow up, the site was opened revealing great soft issue healing, an increase in ridge contour, and a well integrated implant, along with successful GBR. Interestingly, in this case, some root coverage was achieved as well following the GBR, which could possibly have been a side benefit of using the Amnion Chorion Membrane.

 References

1. Front. Bioeng. Biotechnol., 10 June 2021 Sec. Regenerative Medicine Volume 9 - 2021. Surgical Application of Human Amniotic Membrane and Amnion-Chorion Membrane in the Oral Cavity and Efficacy Evaluation: Corollary With Ophthalmological and Wound Healing Experiences Stéphane Odet et al.

Both amnion and chorion contain mesenchymal stromal cells (MSCs) ( and variable quantity of growth factors depending on the fetal membranes... To date, ophthalmology is one of the most popular applications of hAM in routine use. The tissue is used as a graft, spread onto the ocular surface to treat epithelial defects or ulcers, or as a bandage to cover the ocular surface to promote healing. Since the mid-1990s, there has been a growing interest in using hAM for oral surgery to accelerate tissue regeneration. Chorion and amnion-chorion membrane (ACM) products are also very popular in this indication because they provide not only better handling and thickness, but also provide intrinsic growth factors. Two recent systematic reviews examined hAM, chorion and ACM benefits for wound healing in various areas of oral reconstruction...Because Amnion Membrane (hAM) does not have any space maintenance capabilities, some authors suggested using multiple hAM layers and reported its usefulness as a barrier. Two layers of hAM can be folded over bone allograft, delaying its degradation or enhancing its barrier function without any consequences.

2. Clin Oral Implants Res. 2009 Oct;20(10):1124-32. The efficacy of a double-layer collagen membrane technique for overlaying block grafts in a rabbit calvarium model Su-Hwan Kim 1, Do-Young Kim, Kyoung-Hwa Kim, Young Ku, In-Chul Rhyu, Yong-Moo Lee

Furthermore, the double-layer technique using non-cross-linked collagen membranes (BioGide((R))) can enhance the efficacy of the onlay block bone graft technique in terms of both bone resorption and augmentation compared with a single-layer collagen membrane.

3. J Periodontal Implant Sci. 2011 Oct; 41(5): 253–258. Secondary closure of an extraction socket using the double-membrane guided bone regeneration technique with immediate implant placement Jeong-Ho Yun,corresponding author Choong Man Jun, Nam-Sik Oh.

This last issue is addressed herein using the double-membrane (collagen membrane+high-density polytetrafluoroethylene [dPTFE] membrane) technique in two clinical cases of posterior immediate implant placement...Secondary closure of the extraction socket and immediate guided bone regeneration using the double-membrane technique may produce a good clinical outcome after immediate placement of a dental implant in the posterior area.

4. Compend Contin Educ Dent . 2022 May;43(5):E1-E4. Use of a Sugar-Crosslinked Collagen Membrane in Conjunction With a Dehydrated Amnion/Chorion Membrane for Guided Bone Regeneration Around Immediate Implants Matthew J Fien et al.

The use of a collagen membrane in combination with a dehydrated amnion/chorion membrane (dHACM) can facilitate stabilization of the bone graft and membrane by providing the benefits of a long-lasting bioabsorbable collagen membrane in addition to the unique benefits of an amnion/chorion membrane, which has been shown to provide growth factors to the surgical site that have potential to enhance regenerative outcomes.