Fibrin glue application in conjunction with tetracycline hydrochloride root conditioning and semilunar coronally repositioned flap in the treatment of gingival recession.

The purpose of this case report is to present the results of Fibrin Adhesive System (FAS) application, a topical biological tissue adhesive in the treatment of maxillary buccal recessions. A 40-year-old male patient presented with a pair of class I buccal recession defects on maxillary cuspids. Clinical parameters were recorded at baseline, 1 month, and 3 months. Semilunar coronally repositioned flap (Tarnow's technique), root debridement, root conditioning with tetracycline hydrochloride solution and one of the defect was treated with FAS application. Significant recession, height reduction, and attachment gain were observed with the FAS application defect site. About 50% of root coverage was noted in the FAS-treated defect and almost no root coverage in the defect site with no FAS application. Semilunar coronally repositioned flap with FAS application is an effective procedure for root coverage in anterior teeth. The addition of FAS improves the amount of root coverage, especially in relatively shallow defects.

INTRODUCTION

In the changing era of periodontal surgeries, cosmetic procedures have become an integral part of periodontal treatment to meet the increasing desire for improved esthetics. Gingival recessions are both an esthetic as well as functional problem.

Gingival recession is the apical migration of the junctional epithelium with exposure of root surfaces.[1] Apart from esthetic problems, gingival recession also places the patient at risk for root caries, abrasion/erosion of roots and hypersensitivity of teeth. Various treatment modalities have been reported in literature for obtaining predictable root coverage.[2]

Tetracycline HCl root conditioning may potentially enhance periodontal wound healing. Besides the antimicrobial effect, tetracycline hydrochloride (TTC) root conditioning may regulate the adsorption of plasma proteins, enhance adhesion of the blood clot, and stimulate deposition of collagen against the root surface.[3]

Fibrin adhesive system (FAS) is a topical biological adhesive consisting of a solution of concentrated human fibrinogen, which is activated by the addition of bovine thrombin and calcium chloride. The resultant clot supports hemostasis and tissue sealing, and is completely absorbed during wound healing without foreign body reaction or extensive fibrosis. Fibronectin, a family of related proteins found in blood plasma and on fibroblast surfaces is a chemoattractant for fibroblasts and enhances the interaction and adherence of fibroblast to surfaces. Fibronectin may serve to anchor a blood clot to surrounding collagen owing to its property of being covalently linked to fibrin and collagen by factor XIII a.

Conventional sutures provide only a marginal fixation, while the fibrin sealing system makes the tissues adhere on its whole surface. It saves time and makes it easier to fix tissues.[4] In the field of medicine, fibrin sealant is indicated as an adjunct to hemostasis in surgeries involving cardiopulmonary bypass, treatment of splenic injuries and also closure of colostomies. It is a satisfactory hemostatic agent in fully heparinized patients undergoing cardiopulmonary bypass. In dentistry, fibrin-sealing system is effective as a means of fixing tissues after periodontal surgery. Sutures cause inflammation around themselves, while fibrin glue enhances early wound healing. In periodontal plastic surgeries of esthetically important areas, it gives better results than sutures. It has osteoconductive potential and significantly produces more new bone and new connective tissue when used with bone graft material like β-tricalcium phosphate.

Here, we present a case report of FAS application in conjunction with TTC root conditioning and semilunar coronally positioned flap procedure in the treatment of localized maxillary cuspid buccal gingival recession defects.

CASE REPORT

A 40-year-old male patient presented for routine dental prophylaxis to the Department of Periodontics, Krishnadevaraya Dental College and Hospital, Bangalore. The patient presented with no compromised systemic health. Clinical examination revealed the presence of a pair of Class I buccal recession defects on the maxillary cuspids with recession heights and widths of 3 mm and 4 mm, respectively, on the left maxillary cuspid, and 2 mm and 4 mm, respectively, on the right maxillary cuspid. At baseline, the patient presented with probing pocket depth (PPD) of 1 mm at both FAS-TTC and TTC application sites, width of attached gingival of 2mm for both sites and clinical attachment level (CAL) of 4 mm and 5 mm, respectively, for FAS-TTC and TTC application sites [Table 1].

Table 1

Clinical parameters before and after surgery

The patient was informed about the recession and also explained about the clinical procedures. A written consent was obtained from the patient before surgical procedures.

Protocol

Preparation of TTC* solution

Fresh tetracycline hydrochloride solutions were prepared at room temperature by weighing 100 mg of pure tetracycline hydrochloride powder and dissolving it in 1 ml of distilled water. (*Karnataka Antibiotics and Pharmaceuticals LTD, Quality assurance department, Bangalore)

The fibrin adhesion system#

Fibrin Sealant, 1 ml and 0.5 ml kit. [Figure 1] system was used.

Figure 1

Fibrin glue kit

The system contained

1 vial [Yellow Capped] of Freeze Dried Human Fibrinogen

1 vial [Blue Capped] of Freeze Dried Human Thrombin

1 vial [Red Capped] of Aprotinin Solution (Bovine)

1×5 ml plastic ampoule of sterile water for injection I.P.

4×2 ml graduated sterile syringes with four disposable needles (21G) and two blunt application needles (20G)

1 Applicator with two mixing chambers and one plunger guide

# Fibrin Adhesive System - Reliseal™

Solutions were then combined by using duploject syringe [Figure 2] and the reconstituted components in the solution were applied locally as soon as possible, and not later than 4 hours. Partially used vials were discarded.

Figure 2

Duploject syringe

Pre-surgical treatment

Prior to the surgery, oral hygiene instructions were given to eliminate habits related to the etiology of recession and to improve gingival health. The patient underwent initial phase of treatment i.e., thorough scaling and root planing. Pre-operative photographs were taken [Figures 3–6]. The surgical procedures were performed only after the plaque index (PI) demonstrated acceptable oral hygiene standards and gingival health. After the phase of initial treatment, the gingivae in relation to 13 and 23 demonstrated thick biotype. The baseline clinical parameters, i.e., recession width, recession height, probing pocket depth (PPD, width of attached gingiva, CAL were recorded using Williams periodontal probe [Table 1].

Figure 3

Pre-operative recession height (Control site)

Figure 6

Pre-operative recession width (Test site)

Pre-operative recession width (Control site)

Pre-operative recession height (Test site)

Surgical procedure

One of the recession defect the right maxillary cuspid (experimental site) was treated with topical FAS application in addition to TTC root conditioning and SCRF (FAS+TTC site). The other recession defect the left maxillary cuspid (control site) was treated with TTC root conditioning and a semilunar coronally repositioned flap (SCRF) procedure without FAS (TTC site). The defects were assigned randomly to each treatment. Both the defects were located on the maxillary canines.

Cotton pellets soaked in TTC solution (100 mg/ml solution) were burnished on the root surface with light pressure for 3 minutes[5] [Figure 7]. Cotton pellets were changed at 30 seconds interval to maintain fresh TTC solution in contact with the root surface. The root surfaces were then rinsed with saline. Surgical procedures were performed using Semilunar coronally repositioned flaps according to the method described by Tarnow[6] [Figures 8 and 9]. A semilunar incision was made following the curvature of the receded gingival margin and ending about 2 to 3 mm short of the tip of the papillae. A split thickness dissection was then performed coronally from the incision and connected to an intrasulcular incision. The flap was displaced coronally and for the defect in the FAS-TTC site, about 0.1 ml of FAS was applied over the conditioned root surface after gently lifting the displaced flap [Figure 10]. The defect in the TTC site received no additional treatment. The flap was held in its new position for 2 minutes with moist gauze. Sutures were not placed. A periodontal dressing was placed [Figure 11].

Figure 7

Tetracycline hydrochloride application

Figure 8

Flap displaced coronally

Figure 9

Periodontal dressing placed

Figure 10

Fibrin glue placed

Figure 11

Periodontal dressing placed

Procedures on both the sides were performed in the same appointment to avoid any clinical variability from the clinician's side. The patient was placed on analgesic and 0.2% chlorhexidine mouth rinse twice daily for 2 weeks. Patient was advised to take soft diet and not to brush at the surgical site for atleast 2 weeks after the day of surgery.

Data collection

The clinical follow-up and photographic documentation of the surgeries were done at baseline, 1 month and 3 months. Immediately before the surgery, all the baseline clinical parameters were recorded [Table 1]. After 1 week, the patient answered a questionnaire regarding pain, edema, and bleeding. One and three months post-operatively, the baseline parameters were reevaluated using the cemento-enamel junction as the fixed point. Also, the patient provided his opinion about the best side regarding surgical recovery according to the symptoms experienced. Post-operative photographs were taken.

RESULTS

Clinical healing progressed uneventfully on both sides except that edema was noted in the control site during the immediate post-operative period. Following fourteen days, the general aspect of both the sites was pale pink, which was close to the normal shade of the gingiva. The recession height and depth pre-operatively were 2 mm and 4 mm on the maxillary left maxillary cuspid and it was reduced to 1 mm and 3 mm on the left maxillary cuspid 3 months post-operatively. The recession height and width pre-operatively were 3 mm and 4 mm, respectively, on the right maxillary cuspid and no reduction was observed [Figures 12 and 13].

Figure 12

Control site - 3 months post-operatively (TTC site)

Figure 13

Test site - 3 months post-operatively (TTC-FAS site)

At the test site, there was an increase in the width of attached gingiva from 2 mm to 3 mm, and CAL reduction from 4 mm to 3 mm, three months post operatively.

DISCUSSION

In the present case, the adjunctive effect of FAS application in association to TTC root conditioning and the semilunar coronally repositioned flap procedure in the treatment of maxillary anterior buccal recession defects was evaluated. The results demonstrated that periodontal healing following surgery resulted in clinical and esthetic improvements and the adjunctive application of the FAS significantly enhanced the clinical outcome.

Fibrin sealant simulates key features of the physiological blood clotting mechanism. The fibrinogen solution, which also contains Factor XIII, and bovine aprotinin (a fibrinolysis inhibitor) when applied to the wound area along with a solution of thrombin and calcium chloride, a fibrin clot is formed through cleavage of fibrinogen by thrombin. Factor XIII, activated by thrombin, catalyses the formation of cross links within the fibrin clot and a stable clot is formed at the site of application.

Factor XIII also catalyses the covalent linkage of the naturally existing antifibrinolytic agent antiplasmin to fibrin, protecting the clot against plasmin degradation.

This cross-linking helps increase the mechanical strength of the fibrin clot and retard proteolytic degradation. Aprotinin, an effective antifibrinolytic agent acts by delaying the rapid plasmin-mediated lysis of the fibrin clot. The application of tissue adhesive may assist the overcoming of any mechanical and anatomical limitations of flap adaption and stabilization.

The decision to use the SCRF technique as designed by Tarnow,[6] was dependent on factors related to height and class of gingival recession. SCRF was designed to cover minimal (1–3 mm) gingival recessions.[7] The results of the test site were better than the control site, which may be attributed to the application of the tissue adhesive fibrin glue and flap fixation. Further, the results of the present study should not be regarded as the assessment of the effectiveness and predictability of the SCRF procedure in treating gingival recessions, since adjunctive treatments, i.e., TTC and FAS were employed.

The observation in this case was that the application of a tissue adhesive may assist overcome mechanical and anatomical limitations of flap adaptation and stabilization as reported by Caton et al.,[8] the assumption being that collagen fibrils exposed during TTC conditioning may effectively bind the fibrin-fibronectin sealing system and this in turn, secures the gingival flap to the root.

It has been previously observed by Ripamonti et al.[9] that the amount of flap contraction during wound healing was minimized by the adjunctive application of a fibrin-fibronectin adhesive system to demineralized root surfaces in experimentally induced osseous defects in non-human primates.

FAS contains factors such as thrombin, fibrin, fibronectin and platelet-derived growth factor, which are known to retain their biologic activities on cell proliferation and differentiation. These factors may potentially enhance regeneration of hard and soft tissue components of the attachment apparatus of the tooth. However, reviewing the results of the preclinical studies evaluating this biochemical approach to periodontal regeneration, support of the hypothesis is not conclusive. Judged from other experiments, however, when extracellular matrix proteins or blood clot elements including fibronectin have been added to the root surface to enhance periodontal regeneration, the effect of such biochemical conditioning appears to be ambiguous.[10]

It is imperative to note that there is a need to elucidate the findings of the present case by comparing it with a larger sample size of patients. Hence, additional studies of these variables with large sample sizes are needed to validate the present findings.

CONCLUSION

The surgical approach presented here may suggest that fibrin adhesive represents a viable tissular adhesive. The use of SCRF followed by the application of TTC with FAS is an effective procedure for root coverage in anterior teeth, especially in relatively shallow defects. Nevertheless, well-controlled clinical studies should be conducted to evaluate the clinical advantages and disadvantages of the material.