Introduction 

Gingival recession is defined as location of gingival margin apical to cemento-enamel junction (Glossary of Periodontology, 4th edi.). It may be a common cause of concern for the patient for a number of reasons including aesthetic considerations, root hypersensitivity and/or, root caries (Paolantonio, 2002). The risk factors which have been postulated to play a role in the aetiology of gingival recession include tooth mal-position, path of eruption, tooth shape, profile and position in the arch, alveolar bone dehiscence, muscle attachment and frenal pull, periodontal disease and treatment, iatrogenic restorative or operative treatment procedures, improper oral hygiene methods, apart from numerous other self-inflicted injuries (Wennström, 1996). The most important factor increasing the risk of gingival recession is a thin gingival biotype (Muller et al., 1998). Gingival recession may occur on one or all surfaces of a tooth and thus, may affect a localized area or have a more generalized distribution within a dentition although many conditions or behavioral habits are also associated with an increased risk for gingival recession. Numerous periodontal plastic surgical procedures have been proposed in the treatment of gingival recession defects with varying predictability and success rates. One of the most widely employed procedures to cover denuded roots is the Coronally Advanced Flap (CAF) procedures with the treatment outcomes varying between 9-95% (Wennström et al., Muco-gingival Therapy: Periodontal Plastic Surgery, 5th edi.). However, data also reveals unstable long term results using CAF alone. Another limitation of this technique is the limited gain in the apico-coronal dimension of the keratinized tissues, which is an important parameter in preventing the recurrence of such treated gingival recession defects. Therefore, it appears that CAF alone is a less than optimal technique to achieve efficient root coverage despite its advantage of being associated with low morbidity. The predictability of this technique and procedure can however be increased by combining CAF with other regenerative techniques such as a connective tissue grafts, enamel-matrix derivatives, synthetic allografts, and autologous platelet concentrates including platelet-rich fibrin (PRF). Platelet- rich fibrin is a second generation platelet concentrate and is defined as an autologous leukocyte and platelet-rich fibrin biomaterial, first developed by Choukroun et al. (Dohan et al., 2006). It has been used extensively in combination with bone graft materials for periodontal regeneration, ridge augmentation, and sinus lift procedures for implant placement and for coverage of recession defects in the form of a membrane. This membrane consists of a fibrin-based, 3-D polymerized matrix, in a specific structure with the incorporation of platelets, leukocytes, growth factors and presence of circulating stem cells. This report presents a case of single tooth gingival recession defects treated with combined CAF and PRF technique.

 

Case Report

A 35 year old female patient reported to the Department with the chief complaint of sensitivity to cold water in the lower left back tooth region. No relevant medical and dental history was reported. On clinical examination, left mandibular first premolar was identified with gingival recession defects at multiple places (Figure 1). The recession defects, Millers’ Class I type, were measured by calculating the distance between the cemento-enamel junction and the gingival margin and recorded to be upto3mm. A hard tissue abrasion defect was not present on the tooth.

 

Figure 1 Left mandibular first premolar with gingival recession defects at multiple places

 

Figure 2 Surgical site delineated with two oblique releasing incisions at the mesial and distal aspects and sulcular incisions around the affected tooth

 

Pre-surgical procedure: The preparation of the patient included scaling and root planning of the entire dentition with oral hygiene instructions. The surgical procedure was explained to the patient and a written, informed consent was obtained.

 

Surgical procedure: The operative site was anaesthetized using 2% xylocaine with adrenaline. A coronally advanced flap technique was performed at the surgical site. This site was delineated by two oblique releasing incisions at the mesial and distal aspects and sulcular incisions around the affected tooth (Figure 2). A full thickness flap was elevated to expose at least 3mm of the marginal bone apical to the dehiscence area (Figure 3). A horizontal releasing incision was made in the periosteum at the base of the flap to facilitate tension free coronal advancement of the surgically created flap. The exposed root surfaces were scaled and root planed.

 

Preparation of PRF membrane: After the recipient site preparation was completed, the required quantity of blood was drawn in a 10ml test tube without an anti-coagulant and centrifuged immediately using a tabletop centrifuge for 10mins.at 3,000rpm. The resultant product consisted of the following three layers (Figure 4):

 

Top most layers consisting of acellular platelet-poor plasma (PPP);

 

PRF clot in the middle; and

 

red blood cells (RBCs) at the bottom.

 

After centrifugation, the PRF clot was removed from the tube using sterile tweezers, separated from the RBCs base using scissors, and placed in a sterile metal cup. At the recipient site, the PRF clot was placed over the denuded root surfaces and the flap was pulled over it. The area was compressed using digital pressure in order to obtain a PRF membrane and the flap was coronally advanced and sutured (Figure 5). A periodontal dressing was placed over the surgical area (Figure 6).

 

Figure 3 Full thickness flap elevated to expose 3mm of the marginal bone apical to the dehiscence area

 

Figure 4 Centrifuged blood consisting of three layers: Top most layer consisting of acellular PPP; PRF clot in the middle; and RBCs at the bottom

 

Figure 5 PRF clot placed over the denuded root surfaces with the flap coronally advanced and suture

 

Post-operative care: The patient was advised to use 0.2% chlorhexidine digluconate mouthrinse. Systemic antibiotics were prescribed and the patient was advised to follow routine post-operative periodontal instructions. Two weeks post-operatively dressing was removed and saline irrigation was done. The patient was monitored at regular intervals and was kept under maintenance therapy. At the end of 1 month, clinical examination was done (Figure 7). The recession defects showed signs of satisfactory healing and root coverage was accomplished without any post-operative complication.

 

Figure 6 Periodontal dressing placed over the surgical area

 

Figure 7 Post-op clinical photograph at the end of 1 month with the recession defects revealing signs of healing and root coverage accomplished without any post-operative complication

 

The ultimate goal of muco-gingival plastic surgery is aesthetic root coverage. Any therapeutic intervention aimed at root coverage should be to restore the tissue margin at the cemento-enamel junction and to achieve an attachment of the tissues to the root surface so that a normal healthy gingival sulcus with no bleeding on probing and a minimal probing depth is present (Gupta et al., 2006). Various surgical procedures have been described to treat gingival recessions, but these have been demonstrated to heal with a long junctional epithelium, and regeneration has been observed only in the most apical portions of the lesion. The coronally advanced flap procedure has been demonstrated to be a reliable treatment modality with a predictable outcome for obtaining root coverage in isolated gingival recession defects (Allen and Miller, 1989; Wennström and Zucchelli, 1996). Although the bilaminar technique using sub-epithelial connective tissue grafts still holds the most promising results in root coverage, histological studies show an unpredictable healing. The use of PRF membrane in our case to attain root coverage may alleviate the need for donor site procurement of connective tissue thereby, considerably reducing the morbidity which encourages investigations of a more regenerative nature. The scientific rationale behind the use of platelet preparations lies in the fact that the platelet alpha-granules are a reservoir of many growth factors that are known to play a crucial role in hard and soft tissue repair and regeneration mechanisms (Marx et al., 1998; Anitua et al., 2007). These include platelet-derived growth factors (PDGFs), transforming growth factor-beta (TGF-beta), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), and insulin-like growth factor-1 (IGF-1). Platelet-derived growth factors exhibit chemotactic and mitogenic properties that promote and modulate cellular functions involved in tissue healing and regeneration, as well as cell proliferation mechanisms (Dohan, 2010). There are many advantages of using PRF, a second-generation platelet concentrate. PRF does not use bovine thrombin or other exogenous activators in the preparation process thereby, reducing the chances of rejection by inducing auto-immune responses. It forms a gel-like matrix that contains high concentrations of non-activated, functional, intact platelets, contained within a fibrin matrix, that release, a relatively constant concentration of growth factors over a period of 7-days (Carroll et al., 2005). In the form of a membrane, it can be used as a fibrin bandage serving as a matrix to accelerate the healing of wound edges (Gabling et al., 2009; Vence et al., 2009). Being autologous in nature, it is relatively inexpensive, as no additional cost for synthetic membranes is incurred to the patients. Furthermore, the chair-side preparation of PRF is quite easy and processing is fast and simple. Del Corso M et al evaluated the use of PRF in the treatment of multiple gingival recession defects with coronally advanced flap procedures and found significant improvement during the early periodontal healing phases with a thick and stable, final remodelled gingiva (Del Corso et al., 2009). In the same year, Aroca S et al reported inferior root coverage of about 80.7% at the test site (CAF+ PRF) as compared to about 91.5% achieved at control site (CAF), but an additional gain in gingival/ mucosal thickness compared to conventional therapy (Aroca et al., 2009). An increase in thickness of the keratinised tissues reported in both studies may contribute to a long term stable clinical outcome with reduced probability of recurrence of recession. Pavaluri A K et al also found CAF to be a predictable treatment for isolated Miller's class I and II recession defects (Pavaluri et al., 2013). The addition of PRF membrane with CAF provides superior root coverage with additional benefits of gain in CAL and width of keratinized gingiva at 6-months post-operative follow-up. They stated that the treatment of isolated Miller′s class I and II gingival recession defects indicated that CAF surgery alone or in combination with PRF provide effective procedures to cover denuded root surfaces. The data obtained from a combination of CAF+PRF on a 6-months period of follow-up showed additional benefits along with mean root coverage in the treatment of Miller′s class I and II gingival recession defects when compared with the CAF technique alone. Thangavelu A et al found CAF and CAF+PRF treatment techniques resulting in a favourable clinical outcome in terms of root coverage obtained (Thangavelu et al., 2015). While comparing the two groups, there was no statistically significant difference for any of the clinical parameters except for an increase in gingival thickness in the CAF+PRF group that was a significant clinical outcome providing a definite advantage of the technique with a certainly reduced probability of the recurrence of such defects.

 

Conclusion

The use of autologous platelet preparations like PRF allows the clinician to optimize tissue remodelling, wound healing and local angiogenesis by the local delivery of growth factors and proteins. This case report reflects the success of this biomaterial for coverage of single tooth recession defects. The novel technique described enables the clinician to gainfully harvest the full regenerative capacity of this autologous biologic material.

 

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