Platelet-Rich Fibrin for Root Coverage: A Plausible Approach in Periodontal Plastic and Esthetic Surgery

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.

INTRODUCTION

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

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

Figure 2.

Platelet-rich fibrin clot

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

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

Figure 5.

Six-month postoperative view

DISCUSSION

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

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.