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Table of Contents
CASE REPORT
Year : 2011  |  Volume : 1  |  Issue : 2  |  Page : 115-118

Platelet rich fibrin: A promising approach for root coverage


Department of Periodontics, St. Joseph Dental College and Hospital, Duggirala, Eluru, Andhra Pradesh, India

Date of Web Publication17-Sep-2011

Correspondence Address:
Aravind P Kumar
Department of Periodontics, St. Joseph Dental College and Hospital, Duggirala, Eluru, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.85033

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   Abstract 

Platelet rich fibrin is a novel treatment option available for various mucogingival defects with varied outcome. Although it is as its infancy, the best part of platelet-rich fibrin is acquirement of optimal esthetic results with excellent soft tissue contour and texture. This case reports highlights the usage of platelet rich fibrin membrane for the treatment of mucogingival defects such as gingival recession.

Keywords: Esthetics, flap, gingival recession, growth factors, mucogingival


How to cite this article:
Kumar AP, Fernandes B, Surya C. Platelet rich fibrin: A promising approach for root coverage. J Interdiscip Dentistry 2011;1:115-8

How to cite this URL:
Kumar AP, Fernandes B, Surya C. Platelet rich fibrin: A promising approach for root coverage. J Interdiscip Dentistry [serial online] 2011 [cited 2019 Oct 17];1:115-8. Available from: http://www.jidonline.com/text.asp?2011/1/2/115/85033


   Introduction Top


Marginal gingival recession can cause major functional and esthetic problems. It has been related clinically to a higher incidence of root caries, attachment loss, hypersensitivity, and smile related concerns. Etiological factors included are bone dehiscences, gingival quality and quantity, frenal pull, use of toothbrushes with hard bristles, traumatic tooth brushing, and malpositioned tooth. Among them traumatic tooth brushing and malpositioned tooth have been related most frequently to gingival recession. [1],[2],[3] Therefore, marginal gingival recession should be viewed both as a soft and hard tissue defect. [4] The surgical techniques used for root coverage are based on tissue displacement, whether by translation (i.e., pedicle flap procedure) or by grafting (i.e., free gingival or connective tissue graft [CTG] procedures). Modifications of these two basic techniques have been developed by combining with membranes or tissue-engineered material.

The goals of these techniques are the thickening of the gingiva, achieve perfect chromatic integration, and optimal aesthetics. Review of literature has shown that better results were obtained by using the connective tissue graft (CTG) rather than guided tissue regeneration (GTR). [5] The chemical treatment of the root surface does not have any influence. The subepithelial connective tissue graft is currently seen as the most predictable technique available to achieve root coverage, while maintaining high aesthetics. [6] The disadvantage of this procedure includes the need for an additional donor site, and its technical difficulty. [7],[8]

Platelet rich fibrin membrane

Platelet rich fibrin (PRF) is an enhanced concentrate of platelets derived from centrifuged blood. Platelet rich fibrin affects cellular activities at genetic and cellular levels. [9],[10] The action of growth factors present in platelet rich plasma (PRP) is more complex in that respect as they interact and regulate each other's effect. Platelet-derived growth factors (PDGF)-A and (PDGF)-B are major mitogens for human periodontal ligament cells. The transforming growth factor (TGF)-ί has a significant role in mitogenic and immune response. [11] The fibrin clot derived from PRP stimulates type I collagen synthesis. Platelet concentrate has a higher number of platelets per millimeter and, therefore, contain higher concentration of growth factors to enhance regeneration. [11] When using PRF membrane, the need for a donor site is eliminated, making this technique less invasive. This procedure lessens postsurgical discomfort, promotes rapid soft tissue healing with less edema compared to the connective tissue graft (CTG) and enamel matrix derivative (EMD) techniques.


   Case Reports Top


Case 1

A 44-year-old male reported to us with a chief complaint of hypersensitivity in the lower anterior tooth region. On intraoral examination, a class I gingival recession is seen in relation to left lower lateral incisor with a probing depth of 2 mm and clinical attachment loss of 4 mm [Figure 1].
Figure 1: Preoperative (case 1)

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Case 2

A 19-year-old man reported to us with the chief complaint of gingival recession in the lower anterior tooth region. Intra oral examination revealed 3 mm of recession on the buccal aspect of the right mandibular canine.

In both the cases, taking into consideration the amount of vestibular depth and the presence of optimal quantity of keratinized tissue available, PRF membrane combined with coronally advanced flap was considered as the treatment option.

Surgical procedure

After proper isolation of the surgical field, the operative sites were anesthetized using 2% xylocaine hydrochloride with adrenaline (1:200 000). Two vertical incisions are given at the line angles of the two teeth adjacent to the operating tooth extending beyond the mucogingival junction [Figure 2]. Sulcular incision was given which connects the two vertical incisions. Full thickness mucoperiosteal flap was elevated followed by root planning.
Figure 2: Incision placement

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Preparation of the platelet rich fibrin membrane

The required quantity of blood was drawn into 10-ml test tubes. It was centrifuged immediately for 12 min at 2700 r/min without the addition of an anticoagulant.

The resultant product consisted of the following three layers:

  • Top most layer consisting of serum.
  • Platelet rich fibrin clot in the middle.
  • RBCs at the bottom.


Due to the absence of an anticoagulant, blood begins to coagulate as it contacts the glass surface. Therefore for successful preparation of PRF immediate centrifugation should be done to prevent the initiation of clotting cascade. Platelet rich fibrin can be obtained in the form of a membrane by squeezing out the fluids in the fibrin clot [Figure 3] and [Figure 4]. [12]
Figure 3: PRF gel

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Figure 4: PRF gel placed at the recipient site

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Postoperative care

After the surgery, patients was placed on Amoxycillin 500 mg tid, Hifenac bid for 5 days and 0.12% of chlorhexidine digluconate mouthrinse for four weeks. Patients were asked to follow the post surgical instructions. Patients were recalled after 1 week and the surgical site was repacked. Both dressings and sutures were removed 10 days after surgery. Postoperative review of case 1 revealed clinical attachment gain of 4 mm with a good color blend with the adjacent tissue. Postoperative review of case 2 revealed a reduction in probing depth and 3 mm gain in clinical attachment levels with restoration of physiological gingival contour. Postoperative review after 1 month in both cases revealed a good color match and gain in clinical attachment levels with almost 96% root coverage [Figure 5].
Figure 5: Postoperative (case 1)

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   Discussion Top


The ultimate goal of periodontal therapy is the complete regeneration of periodontal supporting tissue. Although the bilaminar technique using subepithelial connective tissue graft holds promising results in root coverage, histologic studies show unpredictable regeneration. This has encouraged investigations on techniques of a more regenerative nature. A recent innovation in dentistry has been PRF, a concentrated suspension of the growth factors found in platelets. These growth factors are involved in wound healing and promote tissue regeneration. Since PRF is both nontoxic and nonimmunoreactive, it is applied along with bone graft material for better bone regeneration and soft tissue healing. Platelet rich plasma can also be infused into resorbable barrier membranes to retard epithelial migration and to provide localized growth factors for hard and soft tissue maturation. Platelet rich plasma may be obtained from autologous blood by the use of plasmapheresis. Platelet rich fibrin was first developed in France by Choukroun et al. This second-generation platelet concentrate eliminates the risk associated with the use of bovine thrombin. Placement of PRF membrane in recession defects restores the functional properties of the labial gingiva of the mandibular anterior teeth by repairing gingival defects and re-establishing the continuity and integrity of the keratinized gingiva. [13]

Fibrin is a fibrillar protein that is polymerised to form a haemostatic plug (in conjunction with platelets) over a wound site. Fibrin is formed from fibrinogen, a soluble plasma glycoprotein that is synthesized by the liver. Fibrin is involved in biological processes like signal transduction, blood coagulation, platelet activation, and protein polymerization.

Platelet rich fibrin belongs to a new generation of platelet concentrates with simplified processing without the need for biochemical blood handling. Dohan et al investigated the platelet-associated features of this biomaterial and stated that on centrifugation degranulation of platelets occur leading to cytokine release. Concentrated platelet rich plasma platelet cytokines have already been quantified in many technologic configurations. To carry out a comparative study, they undertook to quantify platelet derived growth factor (PDGF)-B, transforming growth factor (TGF) beta-1,and insulin like growth factor (IGF)-1 within platelet-poor plasma (PPP) supernatant and platelet rich fibrin clot exudate serum. These initial analysis revealed that slow fibrin polymerization during platelet-rich fibrin processing leads to the intrinsic incorporation of platelet cytokines and glycanic chains in the fibrin meshes. This result would imply that PRF, unlike the other platelet concentrates, would be able to progressively release cytokines during fibrin matrix remodeling. Such a mechanism might explain the clinically observed healing properties of platelet rich fibrin. [14]

The above two cases demonstrated that complete root coverage was achieved in a less invasive way. The conventional subepithelial connective tissue graft requires harvesting of graft from a different site which requires precision and is time consuming. Platelet rich fibrin requires no second surgical site and the color, contour, and texture is enhanced and blends imperceptibly with the adjacent tissues.


   Conclusion Top


The two cases presented here illustrate that the use of platelet concentrate may be an effective and less invasive way of treating gingival recession compared to the traditional autogenous graft. Optimal esthetic results with excellent soft tissue contour and texture were observed. Future clinical and histologic investigations should be conducted on this technique to assess its short and long-term effectiveness.

 
   References Top

1.Lost C. Depth of alveolar bone dehiscences in Gingival recession. J Clin Periodontol 1984;11:583-89.  Back to cited text no. 1
    
2.Trott JR, Love B. An analysis of localized gingival recession in 766 winnipog high school students. J Dent Prac 1996;16:209-13.  Back to cited text no. 2
    
3.Gorman WJ. Prevalence and aetiology of gingival recession. J Periodontol 1967;38:316-22.  Back to cited text no. 3
[PUBMED]    
4.Griffin TJ, Cheung WS. Treatment of gingival recession with a platelet concentrate graft: A report of two cases. Int J Periodontics Restorative Dent 2004;24:589-95.   Back to cited text no. 4
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5.Bernimoulin JP, Curilovic Z. Gingival recession and tooth mobility. J Clin Periodontol 1997;4:107-14.  Back to cited text no. 5
    
6.Nelson SW. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987;58:95-102.  Back to cited text no. 6
[PUBMED]    
7.Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz M. Treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective tissue graft: A clinical report. Int J Periodontics Restorative Dent 1999;19:199-206.  Back to cited text no. 7
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8.Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions: A systematic review. J Clin Periodontol 2002;29:178-96.  Back to cited text no. 8
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9.Ito K, Ito K, Owa M. Connective tissue grafting for root coverage in multiple Class III gingival recessions with enamel matrix derivative: A case report. Pract Periodontics Aesthet Dent 2000;12:441-6.  Back to cited text no. 9
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10.Ito K, Akutagawa H. Periosteal connective tissue grafting or root coverage with enamel matrix derivative: A case report. J Esthet Restor Dent 2001;13:172-78.  Back to cited text no. 10
[PUBMED]    
11.Kawase T, Okuda K, Wolf LF, Yoshie H. Platelet-rich plasma-derived fibrin clot formation stimulates collagen synthesis in periodontal ligament and osteoblastic cells in vitro. J Periodontol 2003;74:858-64.  Back to cited text no. 11
    
12.Sunitha Raja V, Munirathnam Naidu E. Platelet-rich fibrin: Evolution of a second-generation platelet concentrate. Indian J Dent Res 2008;19:42-6.  Back to cited text no. 12
    
13.Anilkumar K, Geetha A, Umasudhakar, Ramakrishnan T, Vijayalakshmi R, Pamela E. Platelet-rich -fibrin: A novel root coverage approach. J Indian Soc Periodontol 2009;13:50-4.  Back to cited text no. 13
    
14.Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part II: Platelet-related biologic features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e45-50.  Back to cited text no. 14
[PUBMED]  [FULLTEXT]  


    Figures

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


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