Root Coverage of Multiple Gingival Recessions using Leukocyte- and Platelet-rich Fibrin Associated with Coronally Advanced Flap

Abstract

Periodontal plastic surgery is constantly seeking alternatives that can replace the use of connective tissue grafts, due to the need for a second surgical area and the possibility of reducing the morbidity of the procedure and providing better comfort to the patient. The use of leukocyte- and platelet-rich fibrin (L-PRF) in the treatment of gingival recessions (GRs) has been studied and its potential has been observed. We report a clinical case of a 49-year-old female patient, a non-smoker, with hypothyroidism and multiple gingival recessions (GRs) in the anterior teeth classified as Miller Class I or Cairo Type 1 (RT1-), which are not associated with a non-carious cervical lesion. The patient presented with aesthetic discomfort and dentin hypersensitivity. Root coverage of the recessions was performed with L-PRF membranes associated with a coronally advanced flap. After 8 months of follow-up, we observed complete coverage of the exposed roots, thickness keratinized gingiva gain, and patient satisfaction with gingival esthetics and dentin hypersensitivity.

Introduction

Gingival recession (GR) is the apical displacement of the gingival margin, which exposes the root surface of the tooth. This condition may be associated with complications such as dentin hypersensitivity, increased risk of root caries, and esthetic discomfort.[1] From multifactorial etiology, GRs can be triggered by anatomical factors, such as the position of the teeth and muscle frenulums or bridles, as well as inflammatory factors, such as clinical attachment loss (CAL) resulting from periodontitis, or traumatic and iatrogenic factors.[2]

Although subepithelial connective tissue grafting (SCTG) is widely recognized as the gold standard for gingival recession (GR) treatment, it has some disadvantages. The need for a second surgical area to obtain the graft, as well as risks and complications such as hemorrhage, edema, and postoperative pain can occur. In this context, new therapeutic approaches aimed at the treatment of single or multiple GRs have been investigated, such as leukocyte- and platelet-rich fibrin (L-PRF).[3,4]

L-PRF is a second-generation platelet concentrate obtained from the collection of autologous venous blood, subjected to a centrifugation process, without anticoagulants. Centrifugation results in a membrane dense in fibrin and leukocytes, enriched with growth factors, which are released gradually. This slow release promotes better tissue healing by stimulating essential biological processes, such as angiogenesis, granulation tissue formation, and epithelial migration.[5,6,7,8] The objective of this study is to report a clinical case of root coverage of multiple GRs in anterior teeth using a coronally advanced flap (CAF) with L-PRF membranes, with an 8-month follow-up.

Case Report

A 49-year-old female, nonsmoker, sought the dental clinic complaining of hypersensitivity and esthetic discomfort of the anterior teeth. Clinical examination revealed GR type 1 (RT1-) according to the Cairo classification[8] from the left second premolar to the right upper second premolar, not associated with noncarious cervical lesions [Figure 1a-c]. The etiological factor was associated with occlusal interferences, and for this purpose, occlusal adjustments were made with the aid of diamond tips and shimstock. After obtaining the patient’s informed and written consent, the treatments were proposed, and the patient opted for coverage of the GRs using CAF associated with L-PRF membranes.

Figure 1.

Initial appearance. (a) Right lateral view. (b) Frontal view. (c) Left lateral view

Ten milliliters (mL) of venous blood were collected from the cubital vein [Figure 2a] into a Vacuteiner^® tube (BD Vacutainer, New Jersey, USA). The tubes were then transferred to an Intraspin by Intralock^® centrifuge (Intra-Lock International, Inc., Florida, USA) and balanced [Figure 2b]. The centrifugation protocol was 2700 rotations per minute for 12 min, and the tubes were removed from the centrifuge [Figure 2c]. The red blood cells were separated [Figure 2d], a PRF box was used [Figure 2e], and the membranes were prepared for use [Figure 2f].

Figure 2.

Preparation of leukocyte- and platelet-rich fibrin (L-PRF) membranes. (a) Obtaining venous blood from the cubital vein. (b) Balancing the centrifuge. (c) Prepared L-PRF membrane. (d) Separation of red blood cells. (e) PRF-Box. (f) Membranes prepared for use

Before starting surgery, the patient was instructed to rinse 15 mL of 0.12% chlorhexidine for intraoral antisepsis, followed by extraoral antisepsis with 0.2% chlorhexidine. Infiltration anesthesia was performed using 4% articaine (40 mg/ml) and epinephrine 1:200,000 (5 µg/ml) to block the anterior and middle superior alveolar nerve. After anesthesia, the flap was performed using a 15C scalpel blade (Swann-Morton Scapel Blades, Sheffield, England) maintaining the periosteum [Figure 3a-c]. Then, the exposed roots were scaled and root planed [Figure 3d], and ethylenediaminetetraacetic acid gel was applied for 2 min for root biomodification [Figure 3e]. After this, L-PRF membranes were inserted [Figure 3f] and stabilized [Figure 3g] with Vicryl^® 5-0 resorbable suture thread (Ethicon Inc., Johnson and Johnson, New Jersey, USA) and CAF positioned to allow coronal displacement 1–2 mm below the cementoenamel junction [Figure 3h], using 5-0 nylon thread (Ethicon Inc., Johnson and Johnson, New Jersey, USA) and suspensory sutures [Figure 3i]. Postoperative care was dipyrone 1 g (Medley, Campinas, Sao Paulo, Brazil) every 12 h for 3 days and ibuprofen 600 mg (Medley, Campinas, Sao Paulo, Brazil) every 8 h for 3 days, in addition to cleaning the operated area with mouthwash based on 0.12% chlorhexidine digluconate every 12 h for 7 days.

Figure 3.

Surgical procedure. (a and b) Initial incisions. (c) Prepared partial flap. (d) Scaling and root planing. (e) Root biomodification with 24% ethylenediaminetetraacetic acid gel for 2 min. (f and g) Introduction and stabilization of leukocyte- and platelet-rich fibrin membranes with resorbable sutures. (h) Coronally advanced flap. (i) Suspensory sutures and immediate postoperative period

Postoperative control was performed after 7 days [Figure 4a], and the sutures were removed after 15 days [Figure 4b]. Follow-up was performed after 30 days [Figure 4c], 60 days [Figure 4d], 90 days [Figure 4e], and 8 months [Figure 4f]. After 8 months of follow-up, the initial appearance [Figure 5a and b], root coverage stability, and the volume of keratinized gingiva obtained [Figure 5c-e] were compared.

Figure 4.

Postoperative follow-up. (a) 7 days. (b) 15 days. (c) 1 month. (d) 2 months. (e) 3 months. (f) 8 months

Figure 5.

Before and after. (a and b) Initial appearance. (c and d) Final appearance after 8 months of follow-up. (e) Keratinized gingiva thickness after 8 months of follow-up

Discussion

This study describes a clinical case in which the use of L-PRF membranes associated with a coronally positioned flap allowed complete root coverage of GRs with 8 months of follow-up.

In this case, we highlight occlusal factors as causes of GRs. Studies show the impact of occlusal interferences on the periodontium, in the presence of group function occlusion, occlusal interferences, and Class III malocclusion.[9,10] Occlusal adjustment prior to surgical root coverage treatment is crucial for case resolution and maintenance of long-term results.

SCTG remains the gold standard in the GRs’ treatment, especially in cases of limited or scarce keratinized gingiva.[11] However, in the presence of adequate height and thickness of keratinized gingiva, as in the present clinical case, other alternatives may be useful in the GRs’ treatment. The presence of Cairo type 1 GRs, associated with adequate keratinized gingival thickness (=4 mm), encouraged us to use only L-PRF membranes as grafts associated with the CAF, as an alternative to STCG.[7,11,12]

Randomized clinical studies have shown satisfactory results from the use of L-PRF in the coverage of RGs compared to SCTG.[2,12,13] The authors highlight the potential of this alternative in CAL gain, coverage percentage, probing depth, complete root coverage, and patient perception. A systematic review with meta-analysis highlighted additional benefits of L-PRF compared to STCG in patient-reported outcomes (PROms) regarding patient comfort and pain reduction, as well as the patient reported in this case. This is due to the need for SCTG of a second surgical site. This analysis, focused on patient perception, represents an important concern in clinical practice.[14]

We can conclude that L-PRF associated with CAF can be considered an alternative in the treatment of multiple GRs, with better patient comfort and stability of long-term results.

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.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.