The ultimate elimination of etiological factors determines the success of periodontal therapy. Generally, initial non-surgical treatment is not sufficient to eliminate etiological factors in some cases. In such cases, a surgical technique is advised, which includes open flap debridement.

Steps in Open Flap Debridement

1. Raising a full-thickness or partial flap

2. Debridement followed by root planing

3. Approximating the flap and stabilizing the tissues using sutures

The precise approximation and stabilization of tissues during periodontal surgery are crucial for healing, as they promote hemostasis, nutrition, and repair, leading to a good prognosis.

Suturing is a common procedure to approximate the tissues, but it has disadvantages such as post-operative discomfort, challenges in plaque control, increased tissue reactivity, and a higher infection rate. To overcome these drawbacks, alternative methods are being explored.

Fibrin glue is one such alternative and is considered a synthetic sealant used to create a fibrin clot.

It contains thrombin and fibrinogen, where thrombin, acting as an enzyme, converts fibrinogen to fibrin, which acts as a tissue adhesive.

Why Use Fibrin Glue as an Alternative to Sutures?

The mechanism of fibrin glue's formation of long fibrin strands makes it unique. The process involves the following steps:

After the clotting cascade is triggered, selective hydrolysis of prothrombin to thrombin occurs by activated factor X (serine protease). Fibrinogen is converted to fibrin in the presence of thrombin. Thrombin helps activate factor XIII (fibrin-stabilizing factor), which is present in the fibrinogen portion of fibrin glue. This helps stabilize the clot by promoting the cross-linking of fibrin chains in the presence of calcium ions to form long fibrin strands. This mechanism is common to both intrinsic and extrinsic pathways and is reproduced by fibrin glue to promote tissue adhesion. ⁽²⁾

Availability of Fibrin Glue

Fibrin glue is available commercially and as an autologous preparation.

Commercially Available:

• Tisseel® (Baxter Healthcare, Deerfield, Illinois, USA)

• Crosseal® (Omrix Biopharmaceuticals, Ltd., Israel)

• Evicel® (Johnson & Johnson, Europe)

• Quixil® (Johnson & Johnson)

• Beriplast® (ZLB Behring)

• Tachosil® (Nycomed)

• Reliseal® (Reliance Industries, India)

How Is Autologous Fibrin Glue Prepared?

1. Before closing the flap, collect 10 ml of the patient’s blood in sterile 0.9% sodium citrate-containing vacutainers. Centrifuge at 3000 rpm for 10 minutes.

2. The vacutainer will now contain three layers: a top layer of platelet-poor plasma, a middle layer of platelet-rich plasma, and a bottom layer of red blood cells (RBCs).

3. Aspirate the platelet-poor and platelet-rich plasma into a sterile syringe and transfer it to another test tube without anticoagulant.

4. Discard the RBC fraction.

5. Add 10 mg/ml of protamine sulfate to the platelet-rich and platelet-poor plasma to precipitate the maximum quantity of fibrinogen.

6. Centrifuge the test tube at 1000 rpm for 5 minutes. The centrifuged tube will contain a top layer of serum with thrombin (autologous) and a bottom layer of fibrinogen precipitate.

7. Discard the top serum, retaining 0.5 ml in the test tube to dilute the fibrinogen precipitate. Aspirate this into a separate syringe.

8. Load another syringe with calcium chloride (0.025 mmol/l). Apply both solutions in equal quantities under the flaps and maintain digital pressure for 2–3 minutes.

This simplified method allows for the preparation of autologous fibrin glue with minimal components in a normal chair-side setting. Fibrin glue facilitates tissue fixation after periodontal surgery, offering a quicker and easier alternative to sutures, which may promote faster and better healing. ⁽¹⁾

MedBound Times has connected with Dr. Lakshmi Sailaja Sistla, BDS, MDS in Periodontology and Implantology, to share her opinion about fibrin glue material and its importance in clinical practice over sutures.

In her words: "Science has been present ever since, but our understanding and its applications have been revolutionized by technology. We have all heard of the idiom 'A stitch in time saves nine.' We acknowledge the importance and necessity of sutures to close a surgical wound. Technological variations have made it possible to choose a sutureless surgical closure—a tissue adhesive saga.

Various classes of tissue adhesives, based on their chemical composition, are available. Fibrin glue is one such agent. Fibrin glue fundamentally comprises fibrin and thrombin, which mimics the natural process of clot formation.

The intraoral environment is a breeding hub for microorganisms, considering the favorable niche it provides. Additionally, the wicking of oral fluids into the suture material is of great concern. Conventional wound approximation with sutures is technique-sensitive and cumbersome. Fibrin glue is easier to use and also overcomes the wicking effect of sutures.

Its applicability ranges from use in periodontal flaps to periodontal plastic/esthetic surgeries.

Fibrin glues have provided psychological relief to patients who are phobic of suture needles, dislike the feeling of suture material in their mouths, or experience foul odors due to the wicking of sutures. Glues have eased the burden of additional care required to keep the suture line clean and eliminated the need for additional visits for suture removal (if non-absorbable material is chosen). Most importantly, similar or superior healing results have been achieved with the use of fibrin glue.

However, it has a few limitations—some gum surgical procedures cannot go sutureless, and fibrin glues may supplement sutures."

References:

1. Dave, B. P., and S. Sathyanarayana. "Periodontal Flap Closure Using a Simplified Autologous Fibrin Glue Preparation: A Report of Two Successful Cases." Journal of Indian Society of Periodontology 24, no. 6 (2020): 579. Accessed January 13, 2025. https://www.researchgate.net/publication/345334517_Periodontal_flap_closure_using_a_simplified_autologous_fibrin_glue_preparation_A_report_of_two_successful_cases.

2. Athal, B., A. Trivedi, and N. Bhavsar. "Use of Fibrin Glue in Periodontal Flap Surgery." Journal of Indian Society of Periodontology 12, no. 1 (2008): 21–25. Accessed January 13, 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC2813549/.

By Dr. Lakshmisahithi Tanneru