| Abstract|| |
Introduction: One of the most common aesthetic concerns associated with the periodontal tissue is gingival recession. Covering the root surface exposed during the disease process with soft and hard tissue surgeries may decrease these problems. The aim of the study was to compare the clinical outcome of coronally advanced flap (CAF) procedure in root coverage with platelet-rich fibrin (PRF) or subepithelial connective tissue graft (SCTG) for the treatment of Miller's Class-I gingival recession. Materials and Methods: The split mouth design consisted of 15 patients with a total of 30 sites with bilateral Miller's Class-I recession on anterior teeth. They were randomly assigned into PRF group (test) or SCTG group (control). Statistical Analysis: The values obtained were tabulated and analyzed using Mann--Whitney U-test and repeated measure ANOVA test. All the statistical tests were carried out using SPSS software. Results: It was observed that both the autogenous grafts healed without any complications and at the end of 6 months the grafts were stable and recession coverage between 88-100% was achieved. Conclusion: CAF procedure with either PRF or SCTG were both effective in the treatment of Miller's Class-I gingival recessions. CAF with SCTG showed better root coverage than CAF with PRF. Use of PRF offered additional benefit of avoiding second surgical site. Therefore, PRF can be considered as a viable alternative to SCTG in certain cases.
Keywords: Coronally advanced flap, gingival recession, platelet-rich fibrin, root coverage, subepithelial connective tissue graft
|How to cite this article:|
Joshi A, Suragimath G, Varma S, Zope SA, Pisal A. Is platelet rich fibrin a viable alternative to subepithelial connective tissue graft for gingival root coverage?. Indian J Dent Res 2020;31:67-72
|How to cite this URL:|
Joshi A, Suragimath G, Varma S, Zope SA, Pisal A. Is platelet rich fibrin a viable alternative to subepithelial connective tissue graft for gingival root coverage?. Indian J Dent Res [serial online] 2020 [cited 2021 May 11];31:67-72. Available from: https://www.ijdr.in/text.asp?2020/31/1/67/281812
| Introduction|| |
One of the most common dental aesthetic concerns associated with the periodontal tissues is gingival recession. The predominant causes for localized gingival recession are tooth brushing trauma, periodontitis, tooth malposition, high frenal and muscle attachments that encroach on marginal gingiva. Other causes can also be chronic trauma, thin marginal soft tissue, and orthodontic tooth movement through a thin buccal osseous plate., Over the years, numerous surgical techniques have been introduced to correct gingival recession defects.,,,,,,, Coronally advanced flap (CAF) alone or in conjunction with root biomodifications, subepithelial connective tissue graft (SCTG), acellular dermal matrix (ADM), and enamel matrix derivative are the most commonly used techniques for treating gingival recession. CAF with SCTG has emerged to be superior and is considered as gold standard for root coverage procedures., CAF with SCTG has several disadvantages such as second surgical site to harvest the graft, patient discomfort, and increased surgical time.
Platelet-rich fibrin (PRF) was first developed in France by Choukroun et al. in 2001. PRF is a second generation platelet concentrate widely used to accelerate soft and hard tissue healing. PRF is just centrifuged natural blood and requires neither anticoagulants nor bovine thrombin during the preparation. PRF has a dense fibrin network with leukocytes, cytokines, structural glycoproteins, and growth factors, these growth factors are postulated as promoters of tissue regeneration.
The aim of the present split mouth study was to compare the clinical outcome of CAF procedure in root coverage with either PRF or SCTG for the treatment of Miller's Class-I gingival recession.
| Materials and Methods|| |
Seventeen subjects aged between 18-40 years with bilateral Miller's Class 1 recession on anterior teeth were recruited for the study from the department of periodontology of a dental college in India. The selected patients gave full written informed consent in accordance with the Helsinki Declaration of 2008 and the study protocol was approved by the ethical committee of the dental institution (Ref. no. KIMSDU/IEC/03/2015). All the subjects were having good systemic health, teeth involved with recession were vital and free of faulty restorations and sufficient palatal donor tissue of at least 2.5 mm thickness. Subjects who were pregnant or lactating, undergoing orthodontic treatment, severe maligned teeth that had undergone periodontal surgery within the last 6 months, with any habit of tobacco usage; teeth in traumatic occlusion were excluded from the study.
All the patients underwent initial treatment of thorough scaling and root planning. The patients were educated and motivated with emphasis on proper oral hygiene maintenance and any existing trauma from occlusion was eliminated. Two subjects who did not maintain good oral hygiene after phase I therapy were excluded from the study and the results from 15 subjects were considered for statistical analysis.
The study was designed as a split-mouth, randomized clinical trial treated with CAF + SCTG as control site (n = 15) and CAF + PRF as test site (n = 15). The selection of surgical procedure for root coverage was done by flip of a coin before the surgery. Surgical procedures were performed by a single-trained periodontist and an interval of 2 weeks was kept between the two surgical procedures in the patients. Following clinical parameters were considered for evaluating the surgical outcomes, probing pocket depth (PPD), clinical attachment level (CAL), vertical recession depth (VRD), keratinized tissue width (KTW), width of gingival recession (WGR), and percentage of root coverage (RC). These parameters were recorded in a predesigned proforma using a Williams periodontal probe (Hu-Friedy Mfg. Co., Rotterdam, Netherlands) and rounded up to the nearest millimetre at baseline, 2 months and 6 months follow-up period. PPD was measured from gingival margin to the bottom of gingival sulcus and CAL was measured from cemento-enamel junction (CEJ) to the bottom of gingival sulcus. KTW was measured from the gingival margin to the mucogingival junction (MGJ) at the mid-facial point of the designated tooth. VRD was measured from the CEJ to the deepest point on the margin of gingiva. WGR was measured 1 mm apical to the CEJ in the mesiodistal direction on the selected tooth. RC was calculated using the formula:
Other parameters evaluated were plaque index (PI), gingival index (GI), postsurgical patient discomfort (VAS), and number of analgesics consumed (AC), which were recorded at baseline, 1 week and 2 weeks postoperatively. A 10 point visual analogue scale was used to assess postsurgical pain wherein “0” indicated negligible discomfort and “10” indicated unbearable pain. Analgesics consumed to control postsurgical pain were noted through the patient.
Following asepsis, local anesthesia (LOX 2%, Neon Laboratories Group, Andheri, Mumbai) was administered to the patient at the site of interest [Figure 1]a and [Figure 2]a. Intrasulcular incisions were made on the facial aspect of the involved tooth. Horizontal incisions were made into the adjacent interdental papilla both mesially and distally, leaving the marginal gingiva of the adjacent teeth untouched. Two divergent vertical incisions were placed from the ends of the horizontal incisions crossing the MGJ into the alveolar mucosa. A trapezoidal full-thickness flap was raised upto the MGJ; and a partial-thickness dissection was performed to allow passive coronal positioning of the flap [Figure 1]b and [Figure 2]b. The exposed root surface was gently root planed with Gracey 1-2, 3-4 curettes (Hu-Friedy Mfg. Co., Rotterdam, Netherlands) and irrigated with sterile saline. The papillae adjacent to the involved tooth were de-epithelialized [Figure 2]b. The flap was replaced back to the recipient bed and covered with a saline soaked wet gauze piece to prevent its drying and dessication. An aluminium tin foil was used to measure the size of the defect from the recipient site.
|Figure 1: PRF group. (a) Baseline view. (b) Recipient site prepared. (c) PRF clot. (d) Flap coronally advanced and sutured along with PRF membrane. (e) Two months postoperative view. (f) Six months postoperative view|
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|Figure 2: SCTG group. (a) Baseline view. (b) Recipient site prepared. (c) Connective tissue graft harvested. (d) Flap coronally advanced and sutured along with SCTG. (e) Two months postoperative view. (f) Six months postoperative view|
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The donor palatal site was anesthetized and template of aluminium tin foil was used to outline the incisions at the donor site. A split thickness “trap door” flap, which consisted of two parallel incisions and a connecting incision were made with a no. 15 Bard Parker (B.P) blade to form three incisions. A rectangular incision was made in the connective tissue bed with a #15 B.P blade and a rectangular 1.5-2 mm thick connective tissue graft (CTG) along with the periosteum was harvested [Figure 2]c. The donor site was sutured using nonresorbable 3-0 silk suture (Mersilk, Ethicon, Johnson and Johnson Services, 501 Arena Space, Jogeshwari, Mumbai, India).
The CTG was trimmed to match the dimensions at the recipient site so that it completely covered the recession defect. The CTG was secured to the recipient site with 4-0 resorbable sutures (Vicryl, Ethicon, Johnson and Johnson Services, Arena Space, Jogeshwari, Mumbai, India). The flap was repositioned coronally to cover the CTG completely without tension, using 4-0 resorbable sutures [Figure 2]d.
Five millilitres of intravenous blood was withdrawn with a 24-gauge needle from antecubietal fossa through routine method in a plain plastic vacutainer (Becton Dickinson India Private Limited, Hyderabad, Telangana, India). Collected blood was immediately centrifuged at 3,000 rpm for 10 min in a centrifuge machine (Remi R8C, Remi Laboratories, Jogeshwari, Mumbai, India). After centrifugation, PRF clot was removed from the tubes using sterile tweezers, platelet poor plasma at the top, and red blood cells at the bottom were discarded. PRF membrane was prepared by compressing the clot between two pieces of woven gauze [Figure 1]c. The PRF membrane obtained was trimmed till it completely covered the recession defects. The flap was repositioned coronally to completely cover the PRF membrane without tension similar to the SCTG group [Figure 1]d.
Postsurgical care and follow-up
All patients were given postoperative instructions and prescribed analgesics (tablet Diclomol, Win-Medicare Pvt. Ltd., Nehru Place, New Delhi, India). Patients were advised oral rinse with a 0.2% chlorhexidine digluconate (Clohex plus, Dr. Reddy's Laboratories, Hyderabad, Telangana, India) solution twice a day and gentle brushing with a soft-bristle toothbrush. All the patients were followed-up postoperatively for six months [Figure 1]e, [Figure 1]f and [Figure 2]e, [Figure 2]f with regular reinforcement of oral hygiene instructions.
Statistical analysis data were analyzed using SPSS software, version 20 (IBM Inc., New York, USA) through repeated Friedman ANOVA and Mann-Whitney test. Statistical significance was set at P < 0.05.
| Results|| |
The current split-mouth clinical study assessed the clinical outcome of root coverage procedure with PRF or SCTG as an adjunct to CAF in 15 patients with Miller's Class-I gingival recession. All enrolled patients complied with the study protocol and experienced no serious morbidities. No significant difference was observed for all parameters at the baseline. The descriptive statistics of PI, GI, VAS, and number of AC at baseline, 1 week and 2 weeks post-treatment between and within the groups are shown in [Table 1]. The values of GI at 2 weeks, VAS at end of 1 week, and AC at the end of both 1 and 2 weeks were significantly lower (P < 0.05) in PRF group [Table 1].
|Table 1: Descriptive statistics of plaque index (PI), gingival index (GI), postsurgical discomfort (VAS) and number of analgesics consumed (AC) at baseline, one week and two weeks post-treatment between and within the groups|
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The statistical data for PPD, CAL, KTW, VRD, WGR, and percentage of RC at baseline and 2 months and 6 months post-treatment between and within the groups are shown in [Table 2]. On intergroup comparison, the PPD, CAL, KTW, VRD, WGR, and RC were significantly better (P < 0.05) in the control group at 6 months follow-up [Table 2].
|Table 2: Descriptive statistics for probing pocket depth (PPD), clinical attachment level (CAL), keratinized tissue width (KTW), vertical recession depth (VRD), width of gingival recession (WGR) and percentage of root coverage (RC) at baseline, two months and six months post-treatment between and within the groups|
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| Discussion|| |
Over the years, several techniques have been proposed to achieve consistent and predictable root coverage. The average percentage of root coverage with different procedures ranges from 56-97.8%, but the treatment of gingival recession remains a major challenge to clinicians.
CAF + SCTG is considered the gold standard for root coverage procedures. The need for multiple surgeries to obtain adequate graft material and the shallow palate with decreased connective tissue limits its application.
PRF is a concentrated suspension of tissue regenerative growth factors found in platelets. PRF has been found to be promising in surgical procedures such as Grade II furcation, sinus floor augmentation during implant placement, and root coverage procedures.
In the current study, there was an increase in mean PI and GI scores till first week follow-up, which significantly decreased at subsequent second week follow-up appointment in PRF and SCTG groups. The control group presented significantly higher values than PRF group. This can be attributed to the increased soft tissue bulk at the SCTG-treated site, which contributed to more plaque accumulation and plaque-induced gingival inflammation as compared with PRF-treated site. These results are in agreement with study conducted by Kumar et al.
Patient's comfort regarding postsurgical pain and inflammation as denoted by VAS demonstrated a significant increase at 1 week in SCTG-treated group than PRF-treated group. These findings are supported by few authors who reported progressive reduction in postoperative discomfort during subsequent follow-up appointments.,
No statistically significant difference was observed in probing depth at the end of 6 months in the SCTG group and PRF group when compared with baseline scores. These observations were in accordance with some studies,, but contradictory to the study conducted by Kumar et al.
In the present study, there was a significant gain in CAL in SCTG group at 2 and 6 months as compared with PRF group and at 6 months. Jankovic et al. reported a nonsignificant gain in CAL in both PRF and CTG controlled sites, whereas Aroca et al. and Da Silva et al. reported statistically significant changes in SCTG-treated sites and PRF-treated sites, respectively. Improvement in CAL was because of recession coverage that results from the coronal shift of attachment apparatus after root coverage procedures.
The gain in KTW was significant in both the PRF and SCTG groups with higher values observed in SCTG group from baseline to a period of 2 months follow-up. On comparison, both the groups showed nonsignificant decrease in KTW values at the end of 6 months. These results were in accordance with several previous studies,,, whereas Eren and Atilla reported contradictory results. Increased KTW in the CTG group is related to the ability of the connective tissue of the palatal graft to induce keratinization of the epithelium. Notably, gain in KTW obtained in the group treated with the PRF membrane may be attributed to gingival or periodontal fibroblast proliferation that is influenced by the growth factors from platelets entrapped in the fibrin mesh. However, this statement must be proven clearly and scientifically in further research.
The results of the present study indicated that PRF + CAF and SCTG + CAF techniques produced significant reduction in VRD and improvement in percentage root coverage. Eren and Atilla reported that CAF + PRF resulted in higher percentage of complete root coverage as compared with CAF + SCTG. These results are contradictory to the current study where a lower percentage of complete root coverage in PRF-treated sites was observed.
There was a significant decrease in WGR from baseline to 2 and 6 months in both the groups. Similar results were reported by Eren and Atilla where they observed greater reduction in recession width in CTG-treated sites as compared with PRF-treated sites after 6 months.
Two weeks postoperatively, patient discomfort was less in PRF-treated group, resulting in reduced consumption of analgesics by the patients as compared with SCTG-treated group. None of the patients consumed any analgesics after the end of 2 weeks in both treatment groups.
The homogenous porous 3-dimensional fibrin network in PRF is considered as healing biomaterial containing platelets, growth factors, and cytokines that enhance soft tissue wound healing. Jankovic et al. also reported improvements in early wound healing ( first and second week postsurgery) in PRF-treated group as compared with CTG-treated group.
PRF can be suggested in patients who do not have adequate gingival thickness at the donor site or in patients unwilling to undergo a graft harvesting procedure. However, when some disadvantages with SCTG are overlooked, evidence from the current study and previous clinical studies support the finding that CAF + SCTG provides predictable root coverage and tissue stability than CAF + PRF.
| Conclusion|| |
CAF procedure with either PRF or SCTG are both effective in the treatment of Miller's Class-I gingival recessions. CAF with SCTG showed better root coverage than with PRF, whereas use of PRF offered additional benefit of avoiding second surgical site. Therefore, PRF can be considered as a viable alternative to SCTG in certain cases.
| Limitations of the Study|| |
Small study sample size and short postoperative follow-up period resulting in failure to record additional root coverage through creeping attachment are the limitations of the current study.
| Future Perspective|| |
A histological examination can be performed to evaluate the regenerative capacity of PRF. The assessment of gingival biotype of the treated site can be considered as an additional clinical parameter.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
The American Academy of Periodontology. Glossary of Periodontal Terms. 4th
ed. Chicago: American Academy of Periodontology; 2001.
Kassab M, Cohen R. The etiology and prevalence of gingival recession. J Am Dent Assoc 2003;134:220-5.
Tugnait A, Clerehugh V. Gingival recession-its significance and management. Review. J Dent 2001;29:381-94.
Miller PD. Root coverage using a free soft tissue autograft following citric acid application. Part II. Treatment of the carious root. Int J Periodontics Restorative Dent 1983;3:38-51.
Langer B, Langer L. Subephithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20.
Grupe HE, Warren RF Jr. Repair of gingival defects by a sliding flap operation. J Periodontol 1956;27:92-5.
Cohen D, Ross S. The double papillae flap in periodontal therapy. J Periodontol 1968;39:65-70.
Pennel BM, Higgison JD, Towner TD, King KO, Fritz BD, Salder JF. Oblique rotated flap. J Periodontol 1965;36:305-9.
Tarnow DP. Semilunar coronally positioned flap. J Clin Periodontol 1986;13:182-5.
Amarante ES, Leknes KN, Skavland J, Lie T. Coronally positioned flap procedures with or without a bioabsorbable membrane in the treatment of human gingival recession. J Periodontol 2000;71:989-98.
Pini Prato G, Tinti C, Vincenzi G, Magnani C, Cortellini P, Clauser C. Guided tissue regeneration versus mucogingival surgery in the treament of human buccal gingival recession. J Periodontol 1992;63:918-28.
Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions: A systematic review. J Clin Periodontol 2002;29:178-94.
Oates TW, Robinson M, Gunsolley JC. Surgical therapies for the treatment of gingival recession. A systematic review. Ann Periodontol 2003;8:303-20.
Choukroun J, Adda F, Schoeffler C, Vervelle A. Une opportunité en paro-implantologie: Le PRF. Implantodontie 2001;42:55-62.
Pini Prato G, Pagliaro U, Baldi C, Nieri M, Saletta D, Cairo F, et al
. Coronally advanced flap procedure for root coverage. Flap with tension versus flap without tension: A randomized controlled clinical study. J Periodontol 2000;71:188-201.
Henderson RD, Drisko CH, Greenwell H. Root coverage using Alloderm®
acellular dermal graft material. J Contemp Dent Pract 1999;1;24-30.
Henderson RD, Greenwell H, Drisko C, Regennitter FJ, Lamb JW, Mehlbauer MJ, et al
. Predictable multiple site root coverage using an acellular dermal matrix allograft. J Periodontol 2001;72:571-82.
Sharma A, Pradeep AR. Autologous platelet-rich fibrin in the treatment of mandibular degree II furcation defects: A randomized clinical trial. J Periodontol 2011;82:1396-403.
Mazor Z, Horowitz RA, Del Corso M, Prasad HS, Rohrer MD, Dohan Ehrenfest DM. Sinus floor augmentation with simultaneous implant placement using Choukroun's platelet-rich fibrin as the sole grafting material: A radiologic and histologic study at 6 months. J. Periodontol 2009;80:2056-64.
Eren G, Atilla G. Platelet-rich fibrin in the treatment of localized gingival recessions: A split-mouth randomized clinical trial. Clin Oral Invest 2014;18:1941-8.
Jankovic S, Aleksic Z, Klokkevold P, Lekovic V, Dimitrijevic B, Kenney EB, et al.
Use of platelet-rich fibrin membrane following treatment of gingival recession: A randomized clinical trial. Int J Periodontics Restorative Dent 2012;32:e41-50.
Kumar GV, Murthy KV. A comparative evaluation of subepithelial connective tissue graft (SCTG) versus platelet concentrate graft (PCG) in the treatment of gingival recession using coronally advanced flap technique: A 12-month study. J Indian Soc Periodontol 2013;17:771-6.
] [Full text]
Eren G, Atilla G. Platelet-rich fibrin in the treatment of bilateral gingival recessions. Clin Adv Periodont 2012;2:154-60.
Bittencourt S, Del Peloso Ribeiro E, Sallum EA, Sallum AW, Nociti FH Jr, Casati MZ. Comparative 6-month clinical study of a semilunar coronally positioned flap and subepithelial connective tissue graft for the treatment of gingival recession. J Periodontol 2006;77:174-81.
Agarwal SK, Jhingran R, Bains VK, Srivastava R, Madan R, Rizvi I. Patient-centered evaluation of microsurgical management of gingival recession using coronally advanced flap with platelet-rich fibrin or amnion membrane: A comparative analysis. Eur J Dent 2016;10:121-33.
] [Full text]
Cortellini P, Tonetti M, Baldi C, Francetti L, Rasperini G, Rotundo R, et al
. Does placement of a connective tissue graft improve the outcomes of coronally advanced flap for coverage of single gingival recessions in upper anterior teeth? A multi-centre, randomized, double-blind, clinical trial. J Clin Periodontol 2009;36:68-79.
Elif Öncü. The use of platelet-rich fibrin versus subepithelial connective tissue graft in treatment of multiple gingival recessions: A randomized clinical trial. Int J Periodontics Restorative Dent 2017;37:265-71.
Da Silva RC, Joly JC, De Lima AF, Tatakis DN. Root coverage using the coronally positioned flap with or without a subepithelial connective tissue graft. J Periodontol 2004;75:413-9.
Wang HL, Bunyaratavej P, Labadie M, Shyr Y, MacNeil RL. Comparison of 2 clinical techniques for treatment of gingival recession. J Periodontol 2001;72:1301-11.
Trombelli L, Scabbia A, Tatakis DN, Calura G. Subpedicle connective tissue graft versus guided tissue regeneration with bioabsorbable membrane in the treatment of human gingival recession defects. J Periodontol 1998;69:1271-7.
Aroca S, Keglevich T, Barbieri B, Gera I, Etienne D. Clinical evaluation of a modified coronally advanced flap alone or in combination with a platelet-rich fibrin membrane for the treatment of adjacent multiple gingival recessions: A 6-month study. J Periodontol 2009;80:244-52.
Department of Periodontology, School of Dental Sciences, Krishna Institute of Medical Sciences, Karad - 415 110, Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2]