Annals of African Medicine
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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 20  |  Issue : 3  |  Page : 241-244  

Platelet-rich fibrin for root coverage: A plausible approach in periodontal plastic and esthetic surgery


1 Department of Periodontics, People's Dental Academy, Bhopal, Madhya Pradesh, India
2 Department of Conservative Denistry, People's College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh, India
3 Department of Periodontics, Vyas Dental College and Hospital, Jodhpur, Rajasthan, India

Date of Submission15-Apr-2020
Date of Acceptance13-Jun-2020
Date of Web Publication17-Sep-2021

Correspondence Address:
Dr. Anuj Singh Parihar
Department of Periodontics, People's Dental Academy, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aam.aam_31_20

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   Abstract 


Predictable esthetic root coverage has evolved into conventional treatment modalities making cosmetic procedures an integral part of periodontal treatment. The advent of second-generation platelet concentrates, i.e., platelet-rich fibrin (PRF), has broad clinical application in medical as well as dental field with its recent use for recession defects. The simplicity of PRF procurement and its low cost makes it most suitable for use in daily clinical practice. This particular case report foregrounds the benefit of PRF membrane along with coronally repositioned flap for mucogingival surgery on the labial surface of an upper anterior tooth.

   Abstract in French 

Résumé
La couverture radiculaire esthétique prévisible a évolué vers des modalités de traitement conventionnelles faisant des procédures cosmétiques une partie intégrante du parodontal traitement. L'avènement des concentrés plaquettaires de deuxième génération, c'est-à-dire la fibrine riche en plaquettes (PRF), a une large application clinique en médecine comme ainsi que le domaine dentaire avec son utilisation récente pour les défauts de récession. La simplicité de l'approvisionnement en PRF et son faible coût le rendent particulièrement adapté utilisation dans la pratique clinique quotidienne. Ce rapport de cas particulier met en avant les avantages de la membrane PRF avec le volet repositionné coronairement pour chirurgie mucogingivale sur la surface labiale d'une dent antérieure supérieure.

Keywords: Growth factors, platelet-rich fibrin, root coverage procedure, soft-tissue regeneration
Mots-clés: Facteurs de croissance, fibrine riche en plaquettes, procédure de couverture radiculaire, régénération des tissus mous


How to cite this article:
Parihar AS, Narang S, Dwivedi S, Narang A, Soni S. Platelet-rich fibrin for root coverage: A plausible approach in periodontal plastic and esthetic surgery. Ann Afr Med 2021;20:241-4

How to cite this URL:
Parihar AS, Narang S, Dwivedi S, Narang A, Soni S. Platelet-rich fibrin for root coverage: A plausible approach in periodontal plastic and esthetic surgery. Ann Afr Med [serial online] 2021 [cited 2021 Dec 4];20:241-4. Available from: https://www.annalsafrmed.org/text.asp?2021/20/3/241/326194




   Introduction Top


Gingival recession is defined as the apical migration of the gingival margin beyond the cementoenamel junction (CEJ).[1] The etiology of marginal tissue recession is multifactorial that can cause a significant esthetic as well as functional problem and has been associated clinically to a soaring incidence of attachment loss, hypersensitivity, root caries, abrasions, and smile-related problems.[2] Perioplastic surgery procedures have focused at the coverage of susceptible root surfaces with different success rates. The understanding and knowledge of the different stages and conditions of gingival recession are necessary for predictable root coverage.[3]

One of the most extensively employed procedures to cover exposed roots is the coronally advanced flap (CAF) procedure, with outcome rates between 10% and 90%.[4] Yet, data show unstable long-term results using CAF alone and little benefit in the apicocoronal dimension of keratinized tissue, which is an essential variable in preventing the relapse of gingival recession.[5] This report presents a case of root coverage using platelet-rich fibrin (PRF) and coronally repositioned flap.


   Case Report Top


A 29-year-old female patient reported to the Department of Periodontics at People's Dental Academy, Bhopal, with a chief complaint of sensitivity to cold water along with unesthetic appearance in the maxillary left front tooth region for the past 3 months. No pertinent medical and dental history was reported. Upon clinical examination, prism diopter Miller's Class I gingival recession of 3 mm was recorded in concerning maxillary left lateral incisor (marginal tissue recession not extending to the mucogingival junction with no interdental bone and soft-tissue loss).

A complete hemogram was done to rule out any contraindication for the surgical procedure, and the values were found to be within usual limits (hemoglobin was 13.8 g/dL). An intraoral periapical radiograph was taken to exclude any interdental bone loss that may affect the outcome of the procedure.

Treatment plan for the patient included scaling and root planing of the entire dentition along with oral hygiene instructions, and the complete surgical procedure was explained to the patient, and informed consent was obtained before the commencement of the procedure [Figure 1]. Ten milliliters of intravenous blood from the antecubital vein was collected in a sterile test tube without anticoagulant and centrifuged using a tabletop centrifuge at 3000 revolutions per minute for 10 min.[6] After centrifugation, the PRF clot sandwiched between the bottom layer of red blood corpuscles and a top layer of platelet-poor plasma was separated from the tube using sterile tweezers. The PRF clot was separated using scissors, preserving a small red blood cell layer, and transferred on to clean gauze piece [Figure 2]. The PRF clot was carefully pressed into the membrane with sterile gauze.[7]
Figure 1: Preoperative view

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Figure 2: Platelet-rich fibrin clot

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The operative area was anesthetized using 2% xylocaine along with adrenaline (1:80,000), and a CAF procedure was performed at the surgical site. At the level of CEJ, two oblique apically divergent vertical releasing incisions were given at the distal as well as mesial aspects of the affected tooth, which was connected with a sulcular incision. A full-thickness flap was elevated to exhibit 3 mm of marginal bone apical to the dehiscence zone, followed by a split-thickness flap to release the tension and achieve better coronal displacement. The exposed root surface was scaled and root planed. The PRF membrane was applied over the denuded root surface and stabilized [Figure 3]. The flap was then advanced coronally to cover the membrane entirely and acquired using sling sutures. The surgical site was smothered with a periodontal dressing.
Figure 3: Flap elevated and platelet-rich fibrin membrane stabilized

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In this particular case, there was no postoperative complication, and healing was uneventful [Figure 4]. Complete coverage was achieved 6 months following the procedure, having excellent tissue contour and color [Figure 5].
Figure 4: Two-week postoperative view

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Figure 5: Six-month postoperative view

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   Discussion Top


Treatment of gingival recession aims to satisfy the patient's demands, thereby increasing their esthetic appearance. Numerous surgical techniques have been reported to treat gingival recessions.[8] Still, these have shown healing by long junctional epithelium, and regeneration has been observed only in the most apical section of the lesion.[8] The CAF procedure has been indicated reliable for obtaining root coverage in isolated types of gingival recessions, as seen in our case.[8]

The scientific logic beyond the use of platelet preparations lies in the fact that the platelet α-granules are a reservoir of many growth factors such as platelet-rich plasma, PRF, fibrin sealants, and platelet growth factors, and they exhibit chemotactic and mitogenic properties and play a crucial role in hard- and soft-tissue repair process.[9]

The PRF membrane is a gel-like fibrin matrix polymerized in a tetramolecular structure that incorporates leukocyte, cytokines, and platelets, along with circulating stem cells. The membrane has a very significant obtuse-sustained release of essential growth factors for at least 7 days and up to 28 days, simulating a physiological healing response.[10]

In our case, the PRF procurement was done once the surgical site was exposed. In addition, the fibrin matrix itself shows mechanical adhesive properties and functions such as fibrin glues, thereby maintaining the flap in a high and stable position, reducing necrosis and shrinkage of the flap, and thus guaranteeing maximal root coverage.[11]

A 10-month research evaluated the use of PRF in the treatment of multiple gingival recessions with CAF process and established a significant improvement during the early periodontal healing phase with a thick and stable final remodeled gingiva.[8] Another randomized clinical trial reported inferior root coverage of about 80.7% at the test site (CAF + PRF) as equated to about 91.5% achieved at the control site (CAF). Still, an additional gain in gingival/mucosal thickness compared to conventional therapy.[12],[13],[14]

PRF membrane has several advantages of a clear, easy, fast, along with cost-effective processing procedure of autologous blood without the use of any anticoagulant along with a sustained release of growth factors, thereby giving it an upper hand over PRP in the fibrin technology.[15],[16],[17],[18],[19]


   Conclusion Top


The utilization of autologous platelet preparations such as PRF has established to be clinically efficient, economical, and straightforward than any other obtainable regenerative materials. This biomaterial has proved to be successful for coverage of an isolated recession defect and reestablishing the thickness of the keratinized gingiva. However, long- and short-term controlled clinical trials will be necessary to know its clinical, histological, and radiographic effect over bone regeneration and soft-tissue healing.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Anson D, Horowitz RA. Sulcular modified internal labial enhancement (SMILE) technique for gingival augmentation. Compend Contin Educ Dent 2020;41:224-30.  Back to cited text no. 1
    
2.
Reddy S, Prasad MJ, Agnihotri J, Amudha D, Singh S, Krishnanand P. Management of multiple recession defect using modified coronally advanced flap alone or with PRF. Int J Health Sci Res 2013;3:133-8.  Back to cited text no. 2
    
3.
Wennström JL. Mucogingival therapy. Ann Periodontol 1996;1:671-701.  Back to cited text no. 3
    
4.
Wennström JL, Zucchelli G, Prato P. Mucogingival therapy-periodontal plastic surgery. In: Lindhe's Clinical Periodontology and Implant Dentistry. 5th ed. New Jersey: Wiley-Blackwell; 2008. p. 955.  Back to cited text no. 4
    
5.
McGuire MK, Cochran DL. Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 2: Histological evaluation. J Periodontol 2003;74:1126-35.  Back to cited text no. 5
    
6.
Choukroun J, Adda F, Schoeffer C, Vervelle A. PRF: An opportunityin perio-implantology. Implantodontie 2000;42:55-62.  Back to cited text no. 6
    
7.
Aravindaksha SP, Batra P, Sood V, Kumar A, Gupta G. Use of platelet rich fibrin (PRF) membrane as palatal bandage. Clin Adv Periodontics 2014;4:246-50.  Back to cited text no. 7
    
8.
Wennström J, Zucchelli G. Increased ginigival dimensions. A significant factor for successful outcome of root coverage procedures? A 2-year prospective clinical study. J Clin Periodontol 1996;23:770-7.  Back to cited text no. 8
    
9.
Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85:638-46.  Back to cited text no. 9
    
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Choukroun J, Diss A, Simonpieri A. Plateletrich fibrin (PRF): A second-generation platelet concentrate. Part IV: Clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:56-60.  Back to cited text no. 10
    
11.
Del Corso M. Choukroun's platelet-rich fibrin membranes in periodontal surgery: Understanding the biomaterial or believing in the magic of growth factors? Re: Letters to the Editor. J Periodontol 2009;80:1694-7.  Back to cited text no. 11
    
12.
Allen EP, Miller PD Jr. Coronal positioning of existing gingiva: Short term results in the treatment of shallow marginal tissue recession. J Periodontol 1989;60:316-9.  Back to cited text no. 12
    
13.
Culhaoglu R, Taner L, Guler B. Evaluation of the effect of dose-dependent platelet-rich fibrin membrane on treatment of gingival recession: A randomized, controlled clinical trial. J Appl Oral Sci 2018;26:e20170278.  Back to cited text no. 13
    
14.
Li R, Liu Y, Xu T, Zhao H, Hou J, Wu Y, et al. The additional effect of autologous platelet concentrates to coronally advanced flap in the treatment of gingival recessions: A systematic review and meta-analysis. Biomed Res Int 2019;2019:2587245.  Back to cited text no. 14
    
15.
İzol BS, Üner DD. A new approach for root surface biomodification using injectable platelet-rich fibrin (I-PRF). Med Sci Monit 2019;25:4744-50.  Back to cited text no. 15
    
16.
Kuka S, Ipci SD, Cakar G, Yılmaz S. Clinical evaluation of coronally advanced flap with or without platelet-rich fibrin for the treatment of multiple gingival recessions. Clin Oral Investig 2018;22:1551-8.  Back to cited text no. 16
    
17.
Uzun BC, Ercan E, Tunalı M. Effectiveness and predictability of titanium-prepared platelet-rich fibrin for the management of multiple gingival recessions. Clin Oral Investig 2018;22:1345-54.  Back to cited text no. 17
    
18.
Turer OU, Ozcan M, Alkaya B, Surmeli S, Seydaoglu G, Haytac MC. Clinical evaluation of injectable platelet-rich fibrin with connective tissue graft for the treatment of deep gingival recession defects: A controlled randomized clinical trial. J Clin Periodontol 2020;47:72-80.  Back to cited text no. 18
    
19.
Sriwil M, Fakher MA, Hasan K, Kasem T, Shwaiki T, Wassouf G. Comparison of free gingival graft and gingival unit graft for treatment of gingival recession: A randomized controlled trial. Int J Periodontics Restorative Dent 2020;40:e103-10.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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