|Year : 2016 | Volume
| Issue : 1 | Page : 33-38
Platelet-rich fibrin-reinforced periosteal pedicle graft with vestibular incision subperiosteal tunnel access technique for the coverage of exposed root surface
Awadhesh Kumar Singh, Abhisek Gautam
Department of Periodontology, Chandra Dental College and Hospital, Barabanki, Uttar Pradesh, India
|Date of Web Publication||10-Aug-2016|
Awadhesh Kumar Singh
Department of Periodontology, Chandra Dental College and Hospital, Barabanki, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Platelet-rich fibrin (PRF) has been shown to promote soft tissue healing because it contains growth factors. Periosteal pedicle graft (PPG) provides not only good and predictable root coverage, but also reduces the need for the second surgical site. Access to the surgical site is obtained by minimally invasive technique known as vestibular incision subperiosteal tunnel access (VISTA) technique. Therefore, the purpose of this case report was to evaluate the PRF-reinforced PPG with VISTA technique for the coverage of exposed root surface. A patient with Miller Class II gingival recession of 6.5 mm was treated by PRF-reinforced PPG with VISTA technique. PRF was prepared from whole blood and applied to the root surface. After 6 months, 5.5 mm, that is, 84.6% of the root coverage was obtained. PRF-reinforced PPG with VISTA technique can be predictably used for the achievement of successful root coverage. The long-term follow-up with histologic studies will be required to obtained more information about PRF-reinforced PPG with VISTA technique for the coverage of exposed root surface.
Clinical Relevance to Interdisciplinary Dentistry
PRF is a fibrin matrix network in which platelets are trapped. Platelets in PRF release high amount of growth factors which take part in soft tissue and hard tissue repair and regeneration. As PRF-reinforced PPG and VISTA technique for coverage of exposed root surface showing good promising results, PRF can be used in various aspects/disciplines of the dentistry as well as in interdisciplinary dentistry to reinforced natural tissue regeneration (NTR) and natural bone regeneration (NBR).
Keywords: Gingival recession, periosteal pedicle graft, platelet-rich fibrin, vestibular incision subperiosteal tunnel access technique
|How to cite this article:|
Singh AK, Gautam A. Platelet-rich fibrin-reinforced periosteal pedicle graft with vestibular incision subperiosteal tunnel access technique for the coverage of exposed root surface. J Interdiscip Dentistry 2016;6:33-8
|How to cite this URL:|
Singh AK, Gautam A. Platelet-rich fibrin-reinforced periosteal pedicle graft with vestibular incision subperiosteal tunnel access technique for the coverage of exposed root surface. J Interdiscip Dentistry [serial online] 2016 [cited 2020 Oct 21];6:33-8. Available from: https://www.jidonline.com/text.asp?2016/6/1/33/188167
| Introduction|| |
Gingival recession is defined as the exposure of root surface in the oral cavity, resulting from the detachment and migration of junctional epithelium toward the apex of the root. Gingival recession may be treated by different surgical techniques. Each technique has its own indications, contraindications, advantages, disadvantages, and success rates. Connective tissue graft (CTG) is considered the gold standard. A number of studies have described various tunnel approaches with CTGs or allografts that maintain papillary integrity and avoid vertical-releasing incisions. ,,, The current tunnel preparation techniques primarily use an intrasulcular approach to create either a sub- or supra-periosteal space to extend beyond the mucogingival junction, allowing graft tissue to be inserted under the gingival collar. The limitations of this tunnel access technique include the technically challenging nature of intrasulcular tunneling because of the need to obtain access through a small sulcular access point and the increased risk of traumatizing and perforating the sulcular tissues, yielding possible unfavorable healing outcomes. As a consequence of these limitations, the vestibular incision subperiosteal tunnel access (VISTA) approach was developed to avoid some of the potential complications of intrasulcular tunneling techniques. 
The CTG presents a number of disadvantages, including the need for harvesting at a distant donor site, limited tissue availability, and increased potential for postharvesting morbidity.  In light of the aforementioned limitations, periosteal pedicle graft (PPG) offers an effective alternative to CTG. In all age groups, the cells of the periosteum retain the capacity to differentiate into fibroblasts, osteoblasts, chondrocytes, adipocytes, and skeletal myocytes. The tissues produced by these cells include cementum, bone, and periodontal ligament with their fibers.  To promote healing and periodontal regeneration, various adjunctive agents such as enamel matrix derivative, recombinant human bone morphogenetic protein, recombinant human growth factors, and platelet concentrates as platelet-rich plasma or platelet-rich fibrin (PRF) have been applied. PRF, a leukocyte and matrix, was first described in 2001 by Choukroun et al. in France.  Platelets in PRF release a high amount of growth factors. Thus, PRF presents a specific biology for repair and regeneration. The aim of this case report was to evaluate the PRF-reinforced PPG with VISTA technique for the treatment of gingival recession in terms of root coverage, gingival height, and probing depth.
| Case report|| |
A 35-year-old female patient had the complaint of receding gum in the lower front tooth region. On intraoral examination, an isolated Miller Class II gingival recession at the labial surface of the lower left central incisor (number 31) was present due to the deposition of plaque and calculus initially and subsequently, combined with the frenal pull [Figure 1]. The recession length was 6.5 mm recorded using the University of North Carolina-15 periodontal probe, measured from the cementoenamel junction (CEJ) to the gingival margin [Figure 2]. The recession width was 3.0 mm [Figure 3]. Gingival height was 0.0 mm as the gingival margin located at the mucogingival line and probing depth was 3.0 mm when measured from the bottom of the sulcus to the most coronal end of the alveolar mucosa. Intraoral periapical radiograph showed no bone loss [Figure 4].
|Figure 1: Miller Class II gingival recession in the lower left central incisor|
Click here to view
The patient underwent basic periodontal treatment of Phase I therapy including scaling by dental Piezo Ultrasonic Scaler (SATELEC® P5 Booster, Acteon, North America), root planing by Gracey Curettes (API® , Germany), and instructions for proper oral hygiene measures. A coronally directed "roll" technique was advised for tooth with gingival recession to minimize toothbrush trauma of the gingival margin. Surgical treatment of gingival recession was not scheduled until the patient could able to maintain full-mouth bleeding score  of ≤20% and full-mouth plaque score  of ≤20% along with the absence of plaque, that is, "plaque-free" (area where plaque could not be removed with a manual probe) and bleeding on probing at the surgical tooth site.
The PRF was procured according to Choukroun et al.  PRF was prepared without biochemical manipulation of blood and required neither anticoagulant nor bovine thrombin. Prior to surgery, 10 ml of venous blood was drawn from the patient by venipuncture of the antecubital vein into a sterile glass test tube (vacutainer) of 10 ml without any anti-coagulant and centrifuged immediately at 3000 rpm (approximately 400 g) for 10 min using a tabletop centrifuge (Remi Elektrotechnik Limited, Thane, Maharashtra, India). Because of the absence of an anticoagulant, blood begins to coagulate as soon as it comes in contact with the glass surface. Therefore, for a successful preparation of PRF, speedy blood collection and immediate centrifugation before the clotting cascade is initiated are essential.  Due to differential densities, centrifugation resulted in the separation of three basic layers in the tube: Red blood cells layer at the bottom, acellular platelet-poor plasma as a supernatant at the topmost layer, and PRF clot in the middle between the two layers. A total of 2-3 ml of the top layer was pipetted out with the sterile dropper; the middle layer PRF clot was removed and placed in a sterile Dappen dish. The PRF clot was then transformed into a membrane by compression between two cotton gauze pieces.
The patient was instructed to do presurgical rinse by 0.2% chlorhexidine (Eludril® Perio, Win-Medicare, Pvt. Ltd., New Delhi, India) solution of 10 ml for 1 min vigorously around the teeth and gums and then spit out the solution. The facial skin around the mouth was cleaned with spirit (isopropyl alcohol, 70%) and scrubbed by 7.5% povidone-iodine (Betadine® , Win-Medicare, Pvt. Ltd., New Delhi, India) solution. Intraoral surgical site was painted with 5% povidone-iodine (Betadine® , Win-Medicare, Pvt. Ltd, New Delhi, India) solution.
After proper part preparation, 2% lignocaine hydrochloride with 1:200,000 adrenaline (Xylocaine® , AstraZeneca Pharma India Limited, Bengaluru, Karnataka, India) was administered after a test dose with adequate precaution to cope with any adverse reaction to anesthetize the right and left mental nerves. Later, a vestibular incision was made using a number 15 surgical Bard Parker blade in the vestibule extending from canine to canine [Figure 5]. A split-thickness flap was reflected sharply by number 15 surgical Bard Parker blade, dissecting muscle fibers and tissue from the periosteum. A strip of periosteum was then removed by Molt periosteal elevator, causing a periosteal fenestration exposing the bone. Care was taken not to remove the periosteum strip completely and to leave pedicle to the bone and the rest of the surrounding periosteum at the lateral end [Figure 6].  Subperiosteal tunnel was created by passing the incision through the periosteum and inserting Molt periosteal elevator between the periosteum and bone through the vestibular access incision [Figure 7].  The PPG was then moved vertically toward the recession area, passing through the tunnel [Figure 8]. The PRF was applied over the exposed root surface [Figure 9] and stabilized with a 5-0 vicryl suture (absorbable surgical suture, Ethicon, Johnson & Johnson, Ltd, Aurangabad, Maharashtra, India) by horizontal mattress suturing technique in the intended position. The PPG was then coronally advanced, osteoperiosteal surface closely adapted to completely cover the PRF [Figure 10] and secured in place using 3-0 black silk suture (Mersilk, Nonabsorbable Surgical Suture, Ethicon, Johnson & Johnson, Ltd, Aurangabad, Maharashtra, India) by sling suturing technique [Figure 11]. Coe-Pak periodontal dressing (Regular Set, GC, America Inc., Alsip, Illinois, USA) was applied [Figure 12].
|Figure 6: Periosteal pedicle graft rising sufficiently to reach up to the cementoenamel junction|
Click here to view
|Figure 10: Periosteal pedicle graft placed over the platelet-rich fibrin|
Click here to view
|Figure 11: Periosteal pedicle graft sutured overlying the platelet-rich fibrin|
Click here to view
Antibiotic (amoxicillin 500 mg, 1 tablet every 8 h, for 7 days) and analgesic (ibuprofen 400 mg, 1 tablet every 8 h, for 3 days) were prescribed. The patient was instructed to be extremely cautious during mastication at meals and no toothbrushing or eating on the surgical area for 21 days. After this period, the patient was advised to mechanical cleaning of the surgical area using an extra soft toothbrush by coronally directed "roll" technique. Plaque control was obtained by 0.2% chlorhexidine mouthwash (Eludril® Perio, Win-Medicare, Pvt. Ltd., New Delhi, India) of 10 ml for 1 min, twice a day for 14 days, and then local application of 0.2% chlorhexidine gel (Elugel™, Win-Medicare, Pvt. Ltd., New Delhi, India) 2-3 times in a day for another 14 days. The patient was instructed not to vigorously rinse mouthwash around the teeth and gums, spit out after 1 min, do not rinse mouth with water or consume food immediately, and apply gel with the help of fingertip or a very soft toothbrush onto the surgical area.
Sutures were removed 14 days after the surgery. The patient was recalled for clinical follow-up four times, two times, and one time in the first, second, and subsequent postsurgical months up to 6 months, respectively. At each visit, recall programs including professional tooth cleaning and reinforcement of daily oral hygiene measures were conducted.
Healing was uneventful. The patient's desires were fulfilled from the outcomes of this surgical treatment. As the postsurgical time goes on, anatomic and morphologic resemblance was observed. After 6 months, 5.5 mm, that is, 84.6% of root coverage, 5.5 mm of gingival height, and 1.0 mm of probing depth were obtained [Figure 13].
|Figure 13: Six-month postoperative period showing predictable root coverage|
Click here to view
| Discussion|| |
The ultimate goal in the treatment of the soft tissue marginal recession is the complete coverage of the denuded root, resulting in an esthetic and natural appearance of the newly gained tissue.  Complete root coverage has been defined in clinical terms according to the following four criteria: The soft tissue margin must be at the CEJ, clinical attachment to the root, the sulcus depth 2 mm or less, and no bleeding on probing.  According to the Miller classification, Class I and II type recession defects, in which the interdental support is intact, have the best potential for complete root coverage, whereas Class III recession has the predictability of partial coverage and Class IV has no predictability of coverage.  In this case report of Class II recession, 5.5 mm, i.e., 84.6% of root coverage was obtained after 6 months.
The minimally invasive VISTA approach presented in this case report affords a number of unique advantages to the successful treatment of gingival recession defects. The VISTA approach overcomes some of the shortcomings of intrasulcular tunneling techniques used for periodontal root coverage. In the VISTA technique, access is broader and is made in the vestibule, where a single vestibular incision can provide access to an entire region, including visual access to the underlying alveolar bone and root dehiscence. The remote incision reduces the possibility of traumatizing the gingiva of the teeth being treated. 
The PPG has its own blood supply and has the potential for promoting the regeneration of lost periodontal structures. The periosteum contains three zones.  Zone I, also called germinative layer, is the thinnest part of periosteum, consists mainly of osteoblasts arranged in the layer adjacent to the bone surface and a supraosteoblast layer of smaller, compact cells, the osteogenic progenitor cells which differentiate into osteoblasts. The collagen fibers and small amount of elastic fibers are present, but fibroblasts are scarce and blood vessels are almost completely lacking. Zone II, also called transparent zone, is the thickest part of periosteum, consists of capillaries, endothelial pericytes, amorphous extracellular matrix, fibroblasts, and collagen fibers. Pericytes have the ability to differentiate into numerous cell types, including osteoblasts, serve as a supplementary source of osteoprogenitor cells. Zone II together with Zone I is called cambium layer. Zone III consists of numerous fibroblasts with collagen fibers in scarce extracellular matrix. The blood vessels are scarce, mostly capillaries. This zone is easily perceivable because of the high amount of collagen fibers. This zone is called "fibrous layer" of periosteum. 
The osteogenic capacity  and the presence of adjacent to gingival recession defects in sufficient amounts make periosteum suitable for a graft.  Only few limited studies are available in literatures that have mentioned the use of periosteum for the treatment of gingival recession defects successfully. PPG for the treatment of gingival recession was used by Mahajan,  Harshavardhana et al.,  and Shah et al.  Singh and Kiran reported the periosteum eversion technique for the successful coverage of denuded root surface.  The periosteum eversion technique utilized marginal periosteum for the coverage of denuded root surface.
Platelets are a natural source of growth factors. Growth factors, stored within platelet α-granules, include platelet-derived growth factor, insulin-like growth factor, vascular endothelial growth factor, platelet-derived angiogenic factor, and transforming growth factor beta. Growth factors are involved in the key stages of wound healing and regenerative processes including chemotaxis, proliferation, differentiation, and angiogenesis.  As PRF is an autologous preparation from patients' own blood, it decreases the cost of the regeneration therapy and eliminates any chances of immune reaction. Placement of PRF does not require a skill, and it is less technique-sensitive than guided tissue regeneration and bone graft placement for the periodontal therapy.
As like in any study, this study of case report of the PRF-reinforced PPG with VISTA technique has certain limitations. This technique requires surgical expertness or mastering skills of surgery for PPG preparation and tunnel preparation, as there may be chances of tear or perforation of gingiva.
| Conclusion|| |
We conclude that within the limits of this case study, this PRF-reinforced PPG with VISTA technique might be potentially useful in achieving the predictable root coverage. Clearly, long-term follow-up with clinical and histological studies will be required to obtain more information about the PRF-reinforced PPG with VISTA technique for the coverage of exposed root surface.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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.
Raetzke PB. Covering localized areas of root exposure employing the "envelope" technique. J Periodontol 1985;56:397-402.
Tözüm TF, Dini FM. Treatment of adjacent gingival recessions with subepithelial connective tissue grafts and the modified tunnel technique. Quintessence Int 2003;34:7-13.
Ribeiro FS, Zandim DL, Pontes AE, Mantovani RV, Sampaio JE, Marcantonio E. Tunnel technique with a surgical maneuver to increase the graft extension: Case report with a 3-year follow-up. J Periodontol 2008;79:753-8.
Zadeh HH. Minimally invasive treatment of maxillary anterior gingival recession defects by vestibular incision subperiosteal tunnel access and platelet-derived growth factor BB. Int J Periodontics Restorative Dent 2011;31:653-60.
Cetiner D, Bodur A, Uraz A. Expanded mesh connective tissue graft for the treatment of multiple gingival recessions. J Periodontol 2004;75:1167-72.
Steiner GG, Kallet MP, Steiner DM, Roulet DN. The inverted periosteal graft. Compend Contin Educ Dent 2007;28:154-61.
Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part V: Histologic evaluations of PRF effects on bone allograft maturation in sinus lift. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:299-303.
O'Leary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol 1972;43:38.
Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J 1975;25:229-35.
Anilkumar K, Geetha A, Sudhakar U, Ramakrishnan T, Vijayalakshmi R, Pameela E. Platelet-rich-fibrin: A novel root coverage approach. J Indian Soc Periodontol 2009;13:50-4.
Shah MP, Patel AP, Shah KM. Periosteal pedicle graft: A novel root coverage approach. J Indian Soc Periodontol 2015;19:99-102.
Chatterjee A, Sharma E, Gundanavar G, Subbaiah SK. Treatment of multiple gingival recessions with VISTA technique: A case series. J Indian Soc Periodontol 2015;19:232-5.
Miller PD Jr. Root coverage grafting for regeneration and aesthetics. Periodontol 2000 1993;1:118-27.
Miller PD Jr. Root coverage using the free soft tissue autograft following citric acid application. III. A successful and predictable procedure in areas of deep-wide recession. Int J Periodontics Restorative Dent 1985;5:14-37.
Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13.
Squier CA, Ghoneim S, Kremenak CR. Ultrastructure of the periosteum from membrane bone. J Anat 1990;171:233-9.
Augustin G, Anabak A, Davila S. Retracted: The periosteum. Injury 2007;38:1115-8.
Ishida H, Tamai S, Yajima H, Inoue K, Ohgushi H, Dohi Y. Histologic and biochemical analysis of osteogenic capacity of vascularized periosteum. Plast Reconstr Surg 1996;97:512-8.
Mahajan A. Periosteal pedicle graft for the treatment of gingival recession defects: A novel technique. Aust Dent J 2009;54:250-4.
Harshavardhana B, Rath SK, Mukherjee M. Periosteal pedicle graft - A new modality for coverage of multiple gingival recession defects. Indian J Dent Adv 2013;5:1139-42.
Singh AK, Kiran P. The periosteum eversion technique for coverage of denuded root surface. J Indian Soc Periodontol 2015;19:458-61.
Wang HL, Avila G. Platelet rich plasma: Myth or reality? Eur J Dent 2007;1:192-4.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13]