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Table of Contents   
CASE REPORT  
Year : 2021  |  Volume : 32  |  Issue : 2  |  Page : 264-267
Management of marginal tissue recession using platelet-rich fibrin: A case report


Department of Periodontology, ADC (R&R), Dhaula Kuan, New Delhi, India

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Date of Submission08-Aug-2018
Date of Decision22-Sep-2019
Date of Acceptance21-Jan-2021
Date of Web Publication22-Nov-2021
 

   Abstract 


Background: Marginal tissue recession leads to exposure of root surfaces of teeth resulting in root sensitivity, caries, or an unsightly appearance. Its management is carried out both by eliminating contributing factors as well as using surgical techniques. Platelet-rich fibrin (PRF) is a seond-generation platelet concentrate first described by Choukroun et al. in 2001. This case report is of a Millers Class II recession in 41 regions managed using PRF with a double pedicle flap. Method: A 25-year-old patient presented with gingival recession height of 5 mm, measured from the cemento-enamel junction (CEJ) to gingival margin. The recession width was 3 mm at the CEJ and PD of 1 mm with respect to 41 region. There was no keratinized tissue apical to recession. However, adequate keratinized tissue was clinically present on either side of the recession defect wrt 41 region. A partial thickness double pedicle flap was raised wrt 41 region. PRF was prepared by centrifuging whole blood at 2,700 RPM for 12 min. The membrane was folded to create bulk and secured over the recession defect. Results: The patient was reviewed at regular intervals of 01, 06, months and 01 year postoperatively. Significant coverage of denuded root was achieved with good color match and relief from sensitivity. Results were stable one year postoperatively. Conclusion: Cases that present with a deep and wide recession are challenging to address owing to the extensive loss of keratinized tissue. In such cases, double pedicle flap can be carried out to augment gingiva by utilizing keratinized tissue adjacent to the defect site. Platelet concentrates like PRF contain platelet-derived growth factors that exhibit chemotactic and mitogenic properties that promote and modulate cellular functions involved in tissue healing, regeneration, and cell proliferation. PRF is an autologous biomaterial which may be used in root coverage procedures. Long-term studies with a larger sample size are required to establish PRF as a predictable method of gingival recession coverage.

Keywords: Marginal tissue recession, platelet rich fibrin, sensitivity

How to cite this article:
Prakash P. Management of marginal tissue recession using platelet-rich fibrin: A case report. Indian J Dent Res 2021;32:264-7

How to cite this URL:
Prakash P. Management of marginal tissue recession using platelet-rich fibrin: A case report. Indian J Dent Res [serial online] 2021 [cited 2021 Dec 8];32:264-7. Available from: https://www.ijdr.in/text.asp?2021/32/2/264/330858



   Introduction Top


Marginal tissue recession is the migration of the gingival margin apical to the cemento-enamel junction. This leads to exposure of root surfaces of teeth and often results in root sensitivity, caries, or an unsightly appearance.[1] Management of denuded roots often requires elimination of predisposing factors as well as surgical correction. Numerous surgical procedures exist for marginal tissue recession coverage with varying rates of success.[2] Subepithelial connective tissue graft (SCTG) based procedures provide the best outcomes in terms of percentage of mean and complete root coverage, as well as significant increase of keratinized tissue. It results in 84% to 96% predictability in recession defects ≥3 mm.[3],[4] Despite high rates of success of the SCTG techniques it has certain limitations in terms of the amount graft that can be harvested, need for a 2nd surgery to harvest the graft, intra-operative time involved and cost which may contribute to patient discomfort.[5]

Platelet-rich fibrin (PRF) is a second-generation platelet concentrate first described by Choukroun et al. in 2001.[6] It consists of autologous fibrin in which there are a large quantity of embedded platelets and leukocytes. The fibrin bandage helps accelerate healing of wound edges, apart from releasing various growth factors and proteins like fibronectin and vitronectin.[7]

Double pedicle flap is a procedure performed in areas with specific indications like the presence of an intact interdental papilla and keratinized tissue adjacent the area of recession defect. It is performed in areas where there is no more predictable technique or to overcome the need for two-stage procedures. The surgical procedure involves elevation of flaps from sites adjacent to the defect to form two pedicles which is sutured medially over the exposed root.[8] This case report is of a Millers Class II recession in 41 regions managed using PRF in combination with a double pedicle flap.


   Case Report Top


A 25-year-old female patient reported with a chief complaint of receding gum, sensitivity, and tenderness on touching gums in lower front tooth region. She had no significant medical and dental history. On clinical examination, she had crowding of maxillary and mandibular anterior teeth with a fair oral hygiene, except in 41 regions where she had abundance of calculus accumulation, erythematous, and inflamed gingiva. She had tenderness on palpating the gingiva on buccal aspect and keratinized tissue was found inadequate wrt 41 region [Figure 1]. Radiograph revealed no pathology or loss of bone interproximally. Based on the clinical and radiographic evaluation, it was diagnosed as a case of Millers Class II gingival recession. Clinical parameters were assessed pre-treatment and after 06 weeks following phase I therapy wrt 41 region. These included gingival recession height (GRH) of 5 mm, measured from the CEJ to gingival margin midbuccally, recession width of 3 mm measured at the CEJ and probing depth (PD) of 1 mm measured using a UNC-15 Probe [Figure 2]. The clinical attachment loss was 6 mm wrt 41. The width of keratinized tissue was assessed using the roll technique. There was no keratinized tissue present apical to recession defect.
Figure 1: Marginal tissue recession with respect to 41

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Figure 2: Pre-treatment Marginal Tissue Recession of 5 mm

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Presurgery

The presurgical management included an orthodontic consultation and the patient was unwilling to undergo correction of malocclusion. Phase I therapy included thorough oral prophylaxis, oral hygiene instructions, and motivation. The patient was re-evaluated after 06 weeks and assessed for oral hygiene maintenance before taking up for surgical correction. The surgical procedure was explained to the patient and a written informed consent obtained.

Surgical management

The procedure was done under LA (2% Lignocaine with 1:80,000 adrenalin). After thorough root planning, an intrasulcular incision was made to remove the epithelial lining with No 15 surgical blade at the labial gingival aspect of the involved tooth. Two horizontal incisions were made at the level of the CEJ preserving the gingival margin of the adjacent teeth by at least 0.5 mm. This was followed by vertical incisions made on either side of the recession defect connecting the two horizontal incisions made obliquely so as to keep the base wider directed apical to the mucogingival junction (MGJ). Butt joints were created by making incisions perpendicular to the gingival surface. The keratinized tissue on the right side of the recession defect was wider and hence the pedicle on the right was kept wider [Figure 3].
Figure 3: Incision outline

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Preparation of PRF

10 mL of whole blood was drawn in a sterile test tube without anticoagulant. This was immediately centrifuged at 2,700 RPM for 12 min. The PRF clot was separated from the layers of platelet poor plasma on top and red corpuscles below it. The excess serum was pressed out to make PRF membrane of length of approx. 8 mm and width of 11 mm.

The PRF membrane was folded to create thickness, placed over the recipient bed and recession defect at a level coronal to the CEJ and secured to the recipient site using interrupted sutures at the coronal and apical extents using 5-0 Vicryl [Figure 4]. The partial thickness double pedicle flaps were sutured medially over the previously secured PRF over recession defect using interrupted suturing using 4-0 Black Braided Silk Suture. Periodontal pack was placed to protect the surgical site.
Figure 4: PRF membrane secured over recession defect

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Postoperative instructions

The postoperative instructions given to the patient include not biting on food using anterior teeth, to avoid brushing near the surgical site, and to avoid excessive movement of lower lip. The patient was called for suture removal 8 days postoperatively. Patient was asked to rinse with 10 ml of 0.2% Chlorhexidine mouth wash after 24 h post-surgery for 2 weeks. The clinical parameters including PD, GRH were evaluated mid labially. Also the recession width and width of keratinized tissue were evaluated postoperatively. The patient was kept on a follow-up of 01 months, 06 months, and 01 year.


   Results Top


The patient had an uneventful healing period. The 6 months and 1 year postoperative evaluation revealed stability of marginal tissue recession coverage. The amount of coverage achieved was of 4 mm. There was a residual GRH of 1 mm, PD of 0.5 mm [Figure 5]. There was a gain in attachment of 3.5 mm wrt 41 region and keratinized tissue formation [Table 1]. The patient was relieved of all the symptoms like tenderness of gums and sensitivity. She was able to maintain good oral hygiene and satisfied with the outcome.
Figure 5: Postoperative 01 year

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Table 1: Clinical parameters evaluated preoperatively at baseline and postoperative 01 month, 06 months & 01 Year

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   Discussion Top


The ultimate aim of root coverage procedures is to have a technique that can predictably cover the denuded roots, relieve the patient of symptoms like sensitivity, create a site easily maintainable by the patient, enhance esthetics and most importantly be performed with minimal discomfort to the patient. The marginal tissue recession was a Millers Class II which was deep and narrow in nature. The double pedicle flap was performed in this case because of the location and nature of the recession defect. The recession defect was shallow narrow with no keratinized mucosa apical to the defect and presence of intact papilla adjacent to recession. The PRF was used in the form of a membrane along with the double pedicle flap to enhance healing, avoid 2nd operative site, reducing intraoperative time and thus enhancing patient comfort. Literature shows encouraging results with the use of PRF in esthetic gingival recession coverage. Results from a 06 month randomized controlled clinical study comparing use of CTG and PRF in gingival recession coverage showed enhanced wound healing with the use of PRF, decreased in patient discomfort and comparable root coverage was between the two groups. However, there was a greater gain in the keratinized tissue in the CTG group.[9]

Double pedicle flap alone was considered to a flap with limited usefulness by the World Workshop in Clinical Periodontics, 1989 because of predictability and the technical skill required in performing the procedure successfully.[10] In the present case report, the use of PRF with double pedicle flap required surgical dexterity, produced extremely aesthetic results, and when combined with PRF resulted in enhanced healing. Marginal tissue recession coverage was obtained with a gain in attachment and keratinized tissue formation. The percentage of root coverage obtained was 80%. Based on the following formula:



The esthetic outcome was satisfactory, patient was relieved of sensitivity and there was lesser intraoperative time which contributed to patient comfort.


   Conclusion Top


The use of PRF as a membrane in marginal tissue recession coverage has many advantages like it avoids the need for a 2nd operative site to obtain the graft, patient comfort in the post-surgical healing and relief from root sensitivity. Also satisfactory coverage of denuded roots was achieved with increase in the width of keratinized tissue. The clinical result from this case report warrants further studies with larger sample size. There is a requirement for histological analysis of the nature of attachment formation with the use of PRF for root coverage.

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.



 
   References Top

1.
Erpenstein H, Borchard R. Criteria for selection of root coverage procedures. Part-1: Intention, indication, methods. Periodontal Pract Today 2006;3:139-52.  Back to cited text no. 1
    
2.
Rasperini G, Acunzo R, Limiroli E. Decision making in gingival recession treatment: Scientific evidence and clinical experience. Clin Adv Periodontics 2011;1:41-52.  Back to cited text no. 2
    
3.
Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: A systematic review from the AAP regeneration workshop. J Periodontol 2015;86 (2 Suppl):S8-51.  Back to cited text no. 3
    
4.
Randall HJ. Connective tissue graft combined with double pedicle grafts or coronally positioned pedicle grafts: Results of 266 consecutively treated defects in 200 patients. Int J Periodontics Restorative Dent 2002;22:463-71.  Back to cited text no. 4
    
5.
Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc 2003;134:220-5.  Back to cited text no. 5
    
6.
Toffler M, Toscano N, Holtzclaw D, Corso MD, Ehrenfest DD. Introducing Choukroun's platelet rich fibrin (PRF) to the reconstructive surgery milieu. J Implant Adv Clin Dent 2009;1:21-32.  Back to cited text no. 6
    
7.
Su CY, Kuo YP, Tseng YH, Su CH, Burnouf T. In vitro release of growth factors from platelet-rich fibrin (PRF): A proposal to optimize the clinical applications of PRF. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:56-61.  Back to cited text no. 7
    
8.
Cohen DW, Ross SE. The double papilla repositioned flap in periodontal therapy. J Periodontol 1968;39:65-70.  Back to cited text no. 8
    
9.
Jankovik S, Aleksic Z, Klokkevold P, Lekovik 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.  Back to cited text no. 9
    
10.
American Academy of Periodontology. Proceedings of the World Workshop in Periodontics. Chicago, IL: American Academy of Periodontology; 1989. p. VII-1--21.  Back to cited text no. 10
    

Top
Correspondence Address:
Dr. Priyanka Prakash
Classified Specialist Periodontology, Department of Periodontology, Army Dental Centre (R&R), Dhaula Kuan, New Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_619_18

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