Dr. Enzo Foti
“Progressive Periodontal Healing of A Severe Two-Wall Intrabony Defect Treated by Fibrin Sealant-GTR Technique: Case Report with 15 Years of Follow-up”.
BACKGROUND
The role of the Fibrin Sealant (FS), obtained from human donors, in GTR and GBR is supported by many scientific evidence, but it is still at low knowledge in dentistry practice. The main actions of FS are: hemostatic, adhesive, sealant, insulating, impermeabilizing. At molecular level it is demonstrated that the fibrinogen, before its conversion to FS by means of the thrombin, induces: 1) angiogenesis 2) mesenchymal cells differentiation in osteoblasts and fibroblasts 3) extra cellular matrix formation thanks its high affinity with VEGF, FGF and other cytokines. So the fibrinogen stimulates the hard and soft-tissue formation. Finally the FS reinforces and stabilizes the natural clot and promotes the early wound healing.
OBJECTIVE
Application of FS to treat an intrabony defect of a my patient, according to scientific evidence in GTR, but modifying the thrombin concentration as in the study on GBR of Corrente G et Al. IJPRD 1997, confirmed later from Le Nihouannen D et Al. JMSMM 2008, to achieve also an inductive effect. In fact, the FS is produced for the great surgery where an immediate polymerization is required (due to high concentration of the thrombin: 500 UI/ml) to achieve quickly hemostasis of bleeding, to seal vascular anastomosis, parenchymas, skin grafts etc. Instead, in dental surgery it is necessary to dilute the thrombin at least 1:10 (from 500 UI/ml to 50 UI/ml) to delay the polymerization, so to have more time for the bone graft placement and to allow the inductive effect of fibrinogen. Otherwise the graft, if placed polymerized into defect, it is insulated from the bone and incapsulated by connective. So it does not integrates with host tissues.
CASE REPORT
A woman 53 years old comes to my office at the end of July 2003 for acute periodontal infection and mobility of tooth 1.1. Non smoker, no family history of periodontitis, no diabetes and immune diseases. The intra-oral exam demonstrates thick gingival biotype, suppuration and grade 2 mobility on tooth 1.1. Vestibular gingival recessions of 2-2-2 mm on tooth 1.2 and 3-2-2 on tooth 1.1. The FMPS, FMBS and the PPD on upper and lower jaw are regular except for the site 1.1 where is present distal calculus, BOP and 2-wall intrabony defect until the apex on the buccal and distal aspect (vestibular PPD 9-9-3). The vestibular CAL is 12-11-5. At X-ray the bone loss is wide, involving the apex of root. The facial marginal profile of the bone is not visible.
DIAGNOSIS
Localized severe acute periodontitis.
The patient is worried and anxious because she is afraid of losing the tooth and has to leave for the summer holidays. So I decide for an emergency periodontal surgery. Because of her anxiety, she refuses surgery photographs (but I show a video where the Fibrin Sealant-GTR Technique is applied on a similar case).
SURGICAL PROCEDURES
Oral therapy with Amoxicillin 2 gr. 1 hour before the surgery.
Elevation of a full-thickness vestibular flap to access at the defect, accurate root planing and debridement, root demineralization by EDTA, GTR with a mixture of FS and bovine heterologous graft inside the defect. The thrombin (1 ml) has been diluted 1:10 by means of saline solution (9 ml). The mix is placed when it has a wet sand appearance, that is before polymerization. No membrane. Waiting for 5 minutes the end of polymerization, before the flap closure, to achieve insulating action with barrier effect to contrast the epithelial connective invagination. Application of FS on the edges of the flap for faster wound healing. Resorbable vertical mattress sutures by 4/0 antibacterial polyglactin 910.
Antibiotic therapy with Amoxicillin 500 mg every 8 hours for 7 days. Chlorhexidine 0.12 % rinses every 12 hours for 1 month.
OUTCOMES
I review the patient after 1 month because of her holidays and I remove the sutures. The acute lesion has healed and the patient is more serene and optimistic. I can finally document this case. I establish a six-monthly periodontal maintenance that the patient is complying from 15 years.
After 6 months no BOP, grade 1 mobility tooth.
After 3 years: there is initial creeping of soft-tissue and initial papillae formation. The PPD of tooth is regular, no BOP, no mobility. At X-ray the graft is still present.
After 7 years: more papilla is visible between central incisors. The X-ray demonstrates partial resorption of the graft.
After 15 years: there are new soft-tissue marginal profile and new papillae compared to baseline. The reevaluation at periodontal chart demonstrates regular index and probing on upper and lower jaw. In particular, the vestibular PPD on tooth 1.1 is 2-1-1 compared to 9-9-3 of baseline. The vestibular CAL is 3-2-2 compared to 12-11-5 of baseline. At X-ray the graft has been totally resorbed and replaced by new bone. Now his facial marginal profile is visible.
CONCLUSIONS
The Fibrin Sealant-GTR Technique, modified, it turned out to be effective and uncomplicated approach in this case. The FS, according to scientific evidence in GTR, does not had detrimental effects, but favored a better and faster healing of soft-tissue. Furthermore, thanks to modify applied, the fibrinogen, before its conversion to FS, had inductive action on regenerative processes of the periodontal ligament and bone. I would like to underline the importance of the right preparation of the device (dilution of the thrombin at least 1:10) to avoid the negative effect of an encapsulation wich cause always the non-integration of the graft. Finally, the good clinical result about the new CAL is due also to the excellent oral hygiene of the patient and her compliance in respecting the six-monthly maintenance recalls.
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