Bilateral multiple recession coverage with platelet-rich fibrin in comparison with amniotic membrane.

Various plastic procedures are done to enhance esthetics, relieve hypersensitivity or even prevent root caries. The most predictable plastic procedure is the coronally advanced flap procedure, with subepithelial connective tissue. Owing to the second surgical donor site and difficulty in procuring a sufficient graft in multiple recessions, various alternative additive membranes are used. This is a case report, the first of its kind, wherein a bilaterally occurring multiple Millers class I recession was managed by using Platelet-rich Fibrin (PrF) and amniotic membrane, in a 40-year-old male, who presented to the Department of Periodontics. He complained of hypersensitivity in relation to the upper right and left back region, a bilateral Millers class I recession in relation to 15, 16, and 25, 26 of 3 mm each. Both the recessions were planned for root coverage with coronally advanced flap and additive membrane. The sites were randomly assigned for the use of platelet-rich fibrin and an aminotic membrane. The clinical outcome of the surgical procedure accounted for 100% root coverage, an enhanced gingival biotype, with both the membranes. Furthermore, the results were stable even after seven months in the amniotic membrane-treated site. Hence, the use of amniotic membrane as a novel approach to root coverage is more advantageous than PrF owing to the laboratory preparation of the autologous biomaterial.

RCT Entities:   Population Interventions Outcomes

INTRODUCTION

Periodontal reconstructive surgery consists of various mucogingival procedures. The primary goal of these procedures is to benefit periodontal health through the reconstruction of lost hard and soft tissues, or by preventing its additional loss, and also enhancing the esthetic appearance.

There are two types of gingival recessions, one due to periodontitis and the other primarily related to the mechanical factors, especially brushing of teeth.[1] In general, complete coverage of facial recession defects can be achieved when there is no loss of interproximal bone. Other factors that can predispose to gingival recession include tooth malpositioning, bone dehiscence, thin marginal soft tissue, high frenulum attachment, inflammation, inflammatory viral eruption, and dental restorative, orthodontic, or periodontal treatments.[23456]

The various plastic procedures performed to enhance esthetics or relieve hypersensitivity due to exposed root surfaces are, the Laterally Positioned Flap Technique, Free Gingival Graft Technique, Connective Tissue Graft Techniques, Free Gingival Graft/Coronally Positioned Flap Technique, Guided Tissue Regeneration Technique, and the Acellular Dermal Matrix Technique. Recent reviews that have been systematic, evidence-based, or meta-analytical have demonstrated that connective tissue grafting is an effective means of root coverage.[78] However, the disadvantages of using subepithelial connective tissue are the second donor site and difficulty in procuring sufficient tissue for multiple recessions. Hence, various other additive materials are available like the acellular dermal matrix, PrF as a membrane or aminiotic membranes.

This case report presents bilateral multiple adjacent gingival recessions treated with a combined coronally advanced flap (CAF) PrF and CAF amniotic membrane, a novel technique.

CASE REPORT

A 40 year-old male patient reported to the Department of Periodontology with a complaint of hypersensitivity to chilled drinks, in relation to the upper left and right back teeth region. He had no significant medical history. The patient gives a two-year prior orthodontic history. On clinical examination, multiple adjacent recessions were identified on the right and left posterior maxillary teeth. The bilateral recession defects, Miller Class I, were measured by calculating the distance between the cementoenamel junction (CEJ) and the gingival margin. It was recorded as the second premolar of 3 mm and first molar of 3 mm. A hard tissue abrasion defect was also present on these teeth and was measured to be less than 0.5 mm in dimension. Phase 1 therapy was completed with oral hygiene instruction reinforced. The surgical procedure was explained to the patient and informed consent was obtained. The use of an additive membrane was assigned by toss of a coin.

Surgical procedure SITE 1: Coronally advanced flap with platelet-rich fibrin

The operative site, that is, 15 and 16 was anesthetized using 2% Xylocaine with adrenaline (1:200,000). A coronally positioned flap technique was performed at the surgical site in relation to 15 and 16 [Figure 1]. This was performed by making two horizontal incisions with respect to the distal and mesial interdental papillae of 16 and 15, followed by a crevicular incision, two vertical releasing incisions at the mesial and distal aspects of 16 and 15. A full thickness flap followed by a partial thickness one was reflected [Figure 2]. A horizontal releasing incision was made in the periosteum, at the base of the flap, to facilitate tension-free coronal displacement. The exposed root surfaces were scaled and root planed. Following this, the cervical step at the CEJ was eliminated using an aerator and a diamond bur.

Figure 1

Miller class 1 recession 15, 16

Figure 2

Full thickness mucoperiosteal flap reflected followed by a partial thickness one, to create a recipient bed

Preparation of platelet-rich fibrin membrane

After the recipient site preparation was completed, 5 ml of venous blood was drawn in test tubes without an anticoagulant, and centrifuged immediately. It was centrifuged for 12 minutes at 2700 rpm. The resultant product consisted of the following three layers: The topmost layer consisted of acellular Platelet-Poor Plasma (PPP), a PrF clot in the middle, and red blood cells (RBCs) at the bottom. After centrifugation, the PrF clot was obtained, separated from the RBC base using scissors, and placed in a sterile dappen dish. The PrF membrane was prepared by placing it into a petri dish. At the recipient site, the PRF clot was placed over the denuded root surfaces [Figure 3]. The flap was coronally advanced to cover the membrane as well as the defect and sutured [Figure 4]. A tin foil and periodontal dressing were placed over the surgical area.

Figure 3

PrF placed as the membrane

Figure 4

Flap advanced and sutured

Postoperative care

The patient was advised to use 0.2% chlorhexidine digluconate mouth rinse, twice daily. Systemic analgesics were prescribed and he was advised to follow the routine postoperative instructions. The dressing and sutures were removed 10 days after surgery.

Follow-up of seven months [Figure 5].

Figure 5

Seven months follow up

Surgical procedure SITE 2: Coronally advanced flap with amniotic membrane

A similar surgical procedure was followed for the receipt bed preparation along with reduction of the cervical step in relation to 25and 26, similar to that for the PrF membrane [Figures 6–8]. The commercially available amniotic membrane# was cut into the desired shape and length with scissors and placed onto the recession site [Figure 9]. The flap was coronally advanced and sutured [Figure 10]. A tin foil and periodontal dressing were placed over the surgical area.

Figure 6

Miller class 1 recession 25, 26

Figure 8

Full thickness mucoperiosteal flap reflected followed by a partial thickness one, to create a recipient bed

Figure 9

Amniotic membrane placement

Figure 10

Flap advanced and sutured

Horizontal followed by vertical releasing incision made

Similar postoperative instructions were advocated as those for CAF with PrF.

Follow-up of seven months [Figure 11].

Figure 11

Seven months follow up

Postoperative examination was done for one, three, six, and seven months. At the end of the seventh month, both the treatment procedures showed 100% root coverage and increased gingival biotype. However, the amniotic membrane-treated sites showed more stable results than the PrF-treated sites at the end of the seventh month.

DISCUSSION

Platelet-rich fibrin is a second generation platelet concentrate and is defined as an autologous leukocyte and platelet-rich fibrin biomaterial. It was first developed by Choukroun et al.[9] It has been used extensively in combination with bone graft materials for periodontal regeneration, ridge augmentation, sinus lift procedures for implant placement and for coverage of recession defects in the form of a membrane. This membrane consists of a fibrin 3-D polymerized matrix in a specific structure, with the incorporation of platelets, leukocytes, growth factors, and the presence of circulating stem cells.

The amniotic membrane is a composite membrane consisting of a pluripotent cellular element embedded in a semipermeable membranous structure.[10] It has been shown that the amniotic membrane is an immunotolerant structure. Meanwhile, the existence of pluripotent stem cells possessing the ability of transdifferentiation to other cellular elements of the periodontium makes it a suitable candidate for guided tissue regeneration (GTR). Excellent revascularization of the amniotic membrane is another favorable property of this natural structure. The clinical application of the amniotic membrane for GTR, while fulfilling the current mechanical concept of GTR, amends it with the modern concept of biological GTR. The biomechanical GTR proposed herein, using the amniotic membrane, not only maintains the structural and anatomical configuration of the regenerated tissues, but also contributes to the enhancement of healing through reduction of postoperative scarring and subsequent loss of function, and also provides a rich source of stem cells. It has been demonstrated that the amniotic membrane enhances the gingival wound healing properties and reduces scarring.

The human amniotic membrane (HAM) has been used in the field of oral and maxillofacial surgery from 1969 onwards, because of its immunological preference and its pain-reducing, antimicrobial, mechanical, and side-dependent adhesive or anti-adhesive properties. The effects of HAM on dermal and mucosal re-epithelialization have been highlighted. Typically, HAM is applied after being banked in a glycerol-preserved, DMSO-preserved or freeze-dried and irradiated state. Even as the use of HAM in flap surgery and in intraoral and extraoral lining is reported frequently, novel HAM applications in posttraumatic orbital surgery and temporomandibular joint surgery have been added since 2010. Tissue engineering with HAM is a fast-expanding field with a high variety of future options.[11]

The other indications for the use of amniotic membrane in the field of oral surgery, wherein the membrane transplantation shows rapid epithelialization in both granulation tissue and collagen formation, but which suppresses inflammation, suggesting that amniotic membrane transplantation may promote rapid gingival wound healing compared to secondary healing, has been seen in rabbits.[12]

Moreover, when used in vestibuloplasty, these grafts of the amniotic membrane are viable and reliable for covering of the raw surface, as they prevent secondary contraction after vestibuloplasty and maintain the postoperative vestibular depth.[13] An average gain of 4-6 mm in the depth of the labial vestibule has been noted, proving that the amniotic membrane can be a favorable graft material for vestibuloplasty, promoting healing and preventing relapse. It is easily available and preserved and is a cost-effective material.[14]

The hyperdry amniotic membrane, a novel preservable material derived from the human amnion, has been introduced clinically in ophthalmology and other fields. This membrane is available as a wound dressing material for surgical wounds of the tongue and buccal mucosa, but has not been used on wounds of the alveolar mucosa. This article has reported two cases in which intraoral alveolar wounds with bone exposure have been successfully treated with the use of hyperdry amniotic membrane. The cases are of a 74-year-old woman with gingival leukoplakia of the edentulous mandible and a 43-year-old man, who underwent vestibuloplasty of the reconstructed mandible. The results indicate that the hyperdry amniotic membrane is a useful dressing material not only for soft tissue wounds, but also for exposed bone in the oral cavity.[15]

Oronasal fistulas, are a frequent complication after cleft palate surgery. Use of the amniotic membrane has been successful for oronasal fistula repair and use of the multilayer technique and protective plate utilization prevent membrane ruptures.[16]

A recent six-month study evaluated the use of PrF in the treatment of multiple gingival recessions with coronally advanced flap procedure and found significant improvement during the early periodontal healing phase, with a thick and stable final remodeled gingiva.

However, another randomized clinical trial in the same year reported an inferior root coverage of about 80.7% at the test site (CAF + PRF) as compared to about 91.5% achieved at the control site (CAF), but it was an additional gain in gingival/mucosal thickness compared to conventional therapy.[17] An increase in thickness of the keratinized tissues, reported in both studies, might contribute to a long-term stable clinical outcome, with reduced probability of the recurrence of recession.[18]

CONCLUSION

Root coverage is a successful and predictable procedure in periodontics, employing a variety of techniques. This is an area of rapid change and new techniques are constantly being reported. Connective tissue graft procedures are the most extensively documented procedures. Newer techniques allow root coverage without the use of a palatal donor tissue. This facilitates treating a larger number of sites in one surgical appointment.

Within the limitation of the study, use of the amniotic membrane as an additive material alternate to subepithelial connective tissue SECT in reducing the need for a second surgical site and alternate to PrF in reducing the need for preparation of the autologous biomaterial, is advocated. However, further testing is needed to confirm their long-term stability.