Advantage of Platelet-rich Fibrin and Lateral Position Pedicle Flap Technique for the Treatment of Gingival Recession

INTRODUCTION

Gingival recession is the apical migration of marginal gingiva that displaced from cementoenamel junction.¹ It may affect all surfaces of the tooth in localized area due to behavioral habits that may swell the gingival connective tissues which results in shrinkage and recession of the gingival tissues.² This shrinkage may lead to root hypersensitivity and root caries.³ In mid of 20th century, this disease was treated by free autogenous grafts, pedicle grafts including rotational flaps, coronally advanced flaps (CAFs), and semilunar flaps methods. Later, combination of autogenous or allograft as well as guided tissue regeneration membranes techniques were invented to cure such disease.⁴ Dentists have found numerous clinical challenges in treatment of gingival recession by laterally sliding flap technique which is the commonly used technique to cover isolated, denuded roots at vestibular depth.⁵ Laterally positioned pedicle flap-revised technique introduced by Ruben et al.⁶ have been found more suitable than laterally sliding flap technique that was described by Harvey⁷ due to undesirable results on the donor teeth. This method is quite useful in connective tissue–cementum fixation of the flap that prohibits the postoperative complication of bone resorption by preserving the periosteal protection and blood supply to the septum.⁸ Nowadays, second-generation platelet concentrate with autologous platelet-rich fibrin gel (PRF) along with growth factors that have cicatricle properties is being used for exposed root in dentistry.⁹ The main aim of the study is to analyze the adequacy of PRF and lateral position pedicle flap method over laterally sliding flap technique to cure gingival recession.

CASE DESCRIPTION

A patient with the problem of receding gums and sensitivity of lower gums came to Department of Dentistry, Anugrah Narayan Magadh Medical College and Hospital, Gaya. Clinical diagnosis reflects Miller class-I recession defect at 31. Buccal aspect of the tooth shows a loss of 6 mm that reflects the distance between the cementoenamel junction and gingival margin of 4 mm and the distance between the gingival margin and the base of the pocket of 2 mm above mucogingival junction (Fig. 1).

RESULTS

After 6 months of treatment, the patient showed almost 80% improvements at treated site with 5-mm increase in CAL, 4-mm decrease in recession, and 1-mm lessening in probing depth with admirable contour and color. No inflammation was observed on final evaluation in the gingival tissues of both the donor and recipient site.

DISCUSSION

Numerous surgical methods have been described to treat gingival recession and one of the successful methods is root coverage in periodontics. Laterally positioned pedicle flap revised technique introduced by Ruben et al.⁶ have been found more suitable than laterally sliding flap technique that was described by Harvey⁷ due to undesirable results on the donor teeth. This method is quite useful in connective tissue–cementum fixation of the flap that prohibits the postoperative complication of bone resorption by preserving the periosteal protection and blood supply to the septum.⁸ These lesions endow with osteogenic, fibrogenic, vascular proliferation, cementogenic, and neural trophic activity that exhibits significant role in healing of the periodontal surgical wound, which may avoid the exposure of the bone at the donor site.⁹ Root coverage procedures are quite useful in healing junctional epithelium as well as regeneration along apical portion of the lesion.¹⁰ Polypeptide growth factors and platelet-rich plasma (PRP) have been used for periodontal regeneration. PRP is kept in anticoagulant that may inhibit platelet activation and degranulation. After centrifugation, PRP is mixed with bovine thrombin and calcium chloride at the time of application.¹¹ However, platelet-rich fibrin has a number of advantages over PRP that remove the jeopardy associated with the use of bovine thrombin although both have different protocols.¹² It also provides a significant postoperative protection of the surgical site.¹³ In PRF preparation, care should be taken in collection of blood and centrifugation in the absence of anticoagulant because blood starts getting coagulated as soon as in contact with glass surface. Large sample size is required to emphasize PRF’s impact on soft-tissue reconstruction in periodontal therapy along with laterally positioned pedicle flap-revised technique.

CONCLUSION

It may be concluded that the adequacy of platelet-rich fibrin and lateral position pedicle flap method over laterally sliding flap technique to cure gingival recession defects is quite useful when compared to restore the functional properties of labial gingiva of teeth.

REFERENCES

1. Jan LW, Giovanni Z. Increased gingival dimensions. A significant factor for successful outcome of root coverage procedures?: a 2-year prospective clinical study. J Clin Periodontol 1996;23(8):770–777. DOI: 10.1111/j.1600-051X.1996.tb00608.x.

2. Allen E, Irwin C, Ziada H, et al. Periodontics: The management of gingival recession. Dent Update 2007;34(9):534–536.DOI: 10.12968/denu.2007.34.9.534, 538-40, 542.

3. Moawia MK, Robert EC. The etiology and prevalence of gingival recession. J Am Dent Assoc 2003;134(2):220–225. DOI: 10.14219/jada.archive.2003.0137.

4. Anilkumar K, Geetha A, Umasudhakar, et al. Platelet-rich-fibrin: a novel root coverage approach. J Indian Soc Periodontol 2009;13(1):50–54. DOI: 10.4103/0972-124X.51897.

5. Carranza S. in Clinical Periodontology ed. MG, Newman HH, Takei PR, Klokkevold et al. ed.ST. Louis, Missouri: Saunders Publication; 2006. p. 1016.

6. Ruben MP, Goldmon HM, Janson W. in Biological considerations fundamental to successful employment of laterally repositioned pedicle flaps and free autogenous gingival grafts in periodontal therapy ed. S, Stahl ed., ch. 9 Periodontal Surgery.Springfield: Illinois; 1976.

7. Harvey PM. Surgical reconstruction of the gingiva. Part II. Procedures. N Z Dent J 1970;66(303):42–52.

8. De waal H, Kon S, Ruben MP. The laterally positioned flap. Dent Clin North Am 1988;32(2):267–285.

9. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin (PRF): a second generation platelet concentrate. Part I: technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101(3):e37–e44. DOI: 10.1016/j.tripleo.2005.07.008.

10. Grupe HE, Warren RE. JR repair of gingival defects by a sliding flap operation. J Periodontol 1956;27(2):92–95. DOI: 10.1902/jop.1956.27.2.92.

11. Aroca S, Keglevich T, Barbieri B, et al. 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(2):244–251. DOI: 10.1902/jop.2009.080253.

12. Toffler M, Toscano M, Holtzclaw D, et al. Introducing Choukroun’s platelet rich fibrin (PRF) to the reconstructive surgery milieu. JIACD 2009;1:21–32.

13. Choukroun J, Diss A, Simonpieri A, 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 Endod 2006;101(3):299–303. DOI: 10.1016/j.tripleo.2005.07.012.