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Fibrinogen-Induced Regeneration Sealing Technique (F.I.R.S.T.). An Improvement and Modification of Traditional GBR: A Report of Two Cases

Foti Vincenzo
Published: 8 July 2020
Modern Research in Dentistry , Volume 5, pp 476-485; doi:10.31031/mrd.2020.05.000609

Abstract: Foti Vincenzo* and Rossi Roberto Private practice, Genova, Italy *Corresponding author: Foti Vincenzo, Private practice, Piazza Borgo Pila 40, Genova, Italy Submission: June 09, 2020;Published: July 08, 2020 DOI: 10.31031/MRD.2020.05.000609 ISSN:2637-7764Volume5 Issue2 Guided bone regeneration is a technique widely known, clinicians know very well indications and limitations of this technique. One of the principles to achieve bone augmentation and formation resides in the stability of the blood clot forming under a barrier membrane. The technique proposed in this article has the goal of providing stabilization to the bone graft by adding fibrin sealant (FS) to the bone graft and also using the fibrin sealant to attach a bone membrane (cortical lamina) to the recipient site. This simple modification of the technique of guided bone regeneration is presented in two successful cases. Keywords: Cortical lamina; Fibrinogen; Fibrin sealant; Guided bone regeneration; Implants Fibrin Sealant Fibrin sealant (FS) is a medical device derived from human blood, used in surgery and in specialties since 1975 for his hemostatic and ahesive properties. The first application in the dental field dates to the 80’, in oral surgery for those patients with disorders of hemostasis [1]. In periodontology Pini Prato GP et al [1]. in 1988 treated infra-bony defects by using FS to stabilize membranes in guided tissue regeneration procedures [2]. The first application in guided bone regeneration was reported by Wittkampf in 1989. He described a simple way to handle granules of HA in the reconstruction of narrow alveolar ridges using the FS to keep the particles together [3]. Hotz [4] used FS as a biological resorbable glue (thrombin was diluted to 1U/ml) in socket preservation. The glue would keep the granules of HA in solid form until keratinized gingiva had sealed the socket [4]. Three years of clinical experience demonstrated the efficacy of the complex HA/FS in pre-prosthetic and reconstructive surgery [5]. The clinical study that demonstrated and a new peri-implant regenerative technique by adding the FS was the one of Corrente et al. [6]. The authors achieved supra-crestal regeneration without the use of a barrier membrane. The average vertical gain was 2.05mm and histology showed newly formed trabecular bone [6]. Cardaropoli D et al. [7] 2013 modified the technique of Corrente by adding a collagen membrane, with this addition they reported a mean vertical gain of 3.95mm [7]. In regenerative procedures, FS adds an excellent physical quality to the bone grafts, making them sticky, moldable and easy to adapt to local anathomy, without any waste of granules [8]. FS demonstrates an osteoinductive capacity when mixed with osteoconductive bio-materials [9-11]. Furthermore favors angiogenesis, thanks to the link of fibrinogen with VEGF growth factor, stimulating proliferation of endothelial cells [12]. Fibrinogen also induces formation of extracellular matrix to support blood supply, connective tissue and bone [13]. Linsley in 2012 demonstrated that fibrinogen induces growth of mesenchimal cells and their differentiation into osteoblasts [14]. One last effect of FS is to enhance and accelerate wound healing and closure [15]. Cortical Lamina The cortical lamina (Cortical Lamina Osteobiol, by Tecnoss, Coazze, Italy) is a membrane used in GBR made of collagenated porcine bone. This membrane is very versatile because is produced in three different versions, curved, soft and bone layer. These three version satisfy all the different applications in GBR whether we are dealing with horizontal, vertical or three-dimensional defects [16]. Rossi et al. [17] carried out a clinical and histological study on humans, a series of patients with severely resorbed mandibles were first treated by means of the cortical lamina associated with collagenated porcine bone xenograft (GenOs Osteobiol By Tecnoss, Coazze, Italy) mixed with the patient’s own blood clot. The lamina was positioned on top of the grafted edentulous ridge in the attempt of increasing the width and height. After healing periods of 6/8 months implants were inserted in the areas where the ridge augmentation took place, and careful biopsies were taken before inserting the fixtures. All implants achieved osseointegration and up to one year after final restoration did not show any modification of the crestal level. Biopsies showed that all areas augmented had live mineralized bone [17]. If curved lamina because of its stiffness and flexibility can be adjusted to local anatomy just by means of sutures, the soft lamina behaves like any resorbable membrane but, being made of bone, maintains a certain elasticity and needs to be fixed by pins or tacks. Same can be said for the bone layer that needs screws to keep it in place. Cortical lamina proves to be a reliable device to perform ridge augmentation, the application of FS to the soft lamina became crucial in the development of the F.I.R.S.T. technique. I.R.S.T In 2016 authors found in the FS the ideal material to achieve a perfect fixation of the cortical lamina, preventing the use of screws. The objective was to create a system where the bone graft and the cortical lamina become one whole complex. Stability of the graft represents one of the key factors in GBR [18]. Aside from that the hypothesis was that FS would improve regeneration through the osteoinductive activity of fibrinogen. The name “Fibrinogen-Induced Regeneration Sealing Technique” object of this paper generated from this thought. The patient was a woman 64-year-old with history of periodontal disease. Non-smoker, in good general health, she did not report allergies or intolerances to anesthetics and drugs. She presented with stage IV periodontitis and partial edentulism in the second quadrant with a horizontal bony deficiency. The first step represented full-mouth disinfection and systemic therapy with Metronidazole and Amoxicillin for...
Keywords: modification / membrane / augmentation / bone graft / Cortical Lamina / Regeneration Sealing Technique / Fibrinogen Induced Regeneration

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