Management of multiple recession defects in esthetic zone using platelet-rich fibrin membrane: A 36-month follow-up case report.

A patient undergoing orthodontic treatment presented with multiple recession defects in maxillary anterior region. After thorough clinical examination and assessment, measurements were recorded. Maxillary anterior teeth with recession defects of 3-4 mm were treated with coronally advanced flap and platelet-rich fibrin (PRF) membrane. Regular follow-up was maintained for the patient at 3, 6 , 12, 18, 24, 30, and 36 months. After 36 months, significant root coverage of 100 percent was observed in four defects and 50% coverage in one defect. This shows that PRF membrane along with coronally advanced provides a predictable and significant result for management of recession defects.

INTRODUCTION

Gingival recession is multifactorial and universally creates esthetic and functional problems for patients. Since the last century, 1902 to be precise,[1] researchers and clinicians have been searching for a treatment strategy to provide cure from gingival recession. However, advancements in treatment protocols prove that no technique is better than the other. In Cochrane-based systematic analysis by Chambrone et al.,[1] subepithelial connective tissue grafts (CTGs) are considered better for root coverage procedures. However, in another systematic analysis, according to Roccuzzo et al.,[2] coronally advanced flap (CAF) and its outcome, when combined with a CTG (bilaminar technique), is considered as the gold standard.[2] Nonetheless, long-term stability of the graft hugely depends on the anatomic placement of the tooth, stability of the graft, and blood supply.[3]

In recent times, platelet-rich fibrin (PRF) and its various forms such as liquid, membrane, and clot have gained tremendous importance for soft-tissue enhancement. It is a second-generation autologous platelet concentrate, developed by Dohan EDM, et al.[4] which helps in healing of the tissues by releasing an array of growth factors.[5] The main advantage of using PRF is its capability to neovascularize the injured site.[6] Moreover, when it comes to membrane, it consists of a fibrin three-dimensional polymerized matrix with incorporated platelets, leukocytes, growth factors, and presence of circulating stem cells.[6]

Anatomically, malpositioned teeth and teeth movement (orthodontic treatment) have been considered as the precipitating factors for recession.[7] Clinical studies have shown that tooth movement causes hard- and soft-tissue loss; however, the existing data are weak in terms of long-term effects of any root coverage treatment done in patients undergoing orthodontic treatment.[7] The aim of our report was to determine whether the addition of an autologous fibrin clot to CAF improved root coverage of multiple Miller Class I or II gingival recessions compared to CAF alone in patient undergoing orthodontic treatment who was followed up to 36 months.

CASE REPORT

A 22-year male patient reported to the dental office with a chief complaint of receding gums and sensitivity to hot and cold in relation to the upper anterior teeth. The patient was undergoing orthodontic treatment before the chief complaint, the treatment was discontinued due to personal reasons, and the patient again wanted to continue with the orthodontic treatment. Clinical examination revealed a Class I Miller's defect in relation to 11, 13, 21, 22, and 23 [Figures 1–5]. Cervical abrasion was presented in relation to 11 [Figure 5]. Root coverage procedure was planned for the management of gingival recession in relation to maxillary anterior teeth involved. Cervical abrasion was restored with Glass ionomer cement thereafter CAF along with PRF membrane was planned for the management of gingival recession in relation to 13, 11, 21, 22, and 23.

Figure 1

Preoperative view irt 13

Figure 5

Preoperative view 11

Preoperative view irt 22

Preoperative view irt 23

Preoperative view 21

Root coverage procedure was carried out in three stages.

In Stage I, recession defect in relation to 13 was treated with CAF with PRF membrane before orthodontic brackets were placed

In Stage II, after 3 weeks of Stage I, recession defect in relation to 22 and 23 was treated with CAF with PRF membrane before orthodontic brackets were placed. In Stage III, after 5 months of Stage II, recession defects in relation to 11 and 21 were treated with CAF with PRF membrane.

Presurgical therapy

The surgical procedure was explained to the patient, and a written informed consent was obtained. The patient was healthy, without any medical condition and nonallergic to the local anesthetic agent and other medications. Preparation of the patient included scaling and root planing of the entire dentition and oral hygiene instruction. Necessary clinical measurements were recorded using either Hu Friedy UNC-15 probe or Hu Friedy William's Probe with the help of arbitrary markings on the tooth [Table 1].

Table 1

Month-wise gain in attachment levels (mm)

Surgical therapy

After proper cleaning and isolation of the surgical field, the operative sites were anesthetized using 2% xylocaine hydrochloride with adrenaline (1:200,000).

Horizontal incision was given at the level of cementoenamel junction (CEJ) at the interdental area, and crevicular incision was made around the teeth with recession defects in continuation with horizontal incisions. Vertical releasing incisions up to mucogingival junction was given to raise a trapezoidal full thickness flap, vertical incisions were advanced beyond mucogingival junction to raise further a partial thickness flap to allow coronal repositioning of the flap without tension. Papillae were deepithelialized to create a connective tissue bed. Root planing was done after which PRF membrane was placed just below the CEJ [Figures 6–8]. The PRF membrane was stabilized with the help of sutures after which the flap was coronally repositioned cover the membrane and was held in that position with the help of interrupted sling sutures [Figures 9–11]. Vertical incisions are sutured with simple loop sutures. Periodontal dressing (COE pack) was placed.

Figure 6

Flap reflection and placement of platelet-rich fibrin membrane irt 13

Figure 8

Flap reflection and placement of platelet-rich fibrin membrane irt 11, 21

Figure 9

Suturing irt 13

Figure 11

Suturing irt 11, 21

Flap reflection and placement of platelet-rich fibrin membrane irt 22, 23

Suturing irt 22, 23

Postoperatively, patients were prescribed 0.12% chlorhexidine gluconate mouthwash for 4 weeks, systemic antibiotics, i.e., augmentin 625 BD for 3 days and analgesic ibuprofen 400 mg + paracetamol 325 mg and cold therapy if required. Postoperative instructions were given. Both dressings and sutures were removed 10 days after surgery to ensure proper adaptation and stabilization of the flap and membrane. The rest of the two surgical procedures were commenced in the same manner along with same postoperative care.

Healing was uneventful with no postoperative complications in all the surgical phases. Postoperative examination was done after 1, 3, 6, 9, 12, 18, 24, 30, and 36 months.

Platelet-rich fibrin preparation

A volume of 10 ml of blood was drawn in 10 ml vacutainer tubes without an anticoagulant and centrifuged immediately using a tabletop centrifuge (REMY laboratories) for 10 min at 3000 rpm.[8]

The resultant product consisted of the following three layers [Figure 12]:

Figure 12

Platelet-rich fibrin clot

Topmost layer consisting of acellular plasma (PPP)

PRF clot in the middle [Figure 13]

Figure 13

Platelet-rich fibrin clot, ready to be converted into membrane

Red blood cells at the bottom.

PRF membrane can be obtained by squeezing out the fibrin clot.[8]

RESULTS

After follow-up of 36 months, 100% root coverage was achieved in relation to 13, 21, 22, and 23 [Figures 14–16] and 50% coverage in relation to 11 [Figure 16 and Table 1]. It was observed that patient was maintaining good oral hygiene and partial root coverage in relation 11 cannot be attributed to oral hygiene.

Figure 14

Postoperative 36 months irt 13

Figure 16

Postoperative 36 months irt 11, 21

Postoperative 36 months irt 22, 23

DISCUSSION

Gingival recession is multifactorial and its treatment becomes challenging when it comes to restoring tissues, providing as esthetic and functional comfort to the patient with minimal probing depth.[9] As mentioned previously, there are various techniques available along with their modifications to treat gingival recessions, but these have been shown to heal with long junctional epithelium.[10] Existing literature also shows that bilaminar technique using subepithelial CTGs has best results, histological studies show unpredictable healing,[10] putting clinicians yet again in dilemma of a technique with predictable results.

During root coverage procedures, behavior of periodontal cells, especially fibroblasts, is critical for repair, thus providing right amount growth factors become paramount in shaping their activity and influencing the treatment outcomes.[11] As a result, PRF in the form of membrane has gained popularity where it maintains all the properties of PRF clot and is restorable as layers to provide a continuous supply of growth factors such as platelet-derived growth factors, transforming growth factor beta, vascular endothelial growth factor, epidermal growth factor, and insulin-like growth factor-1[5] which enhances fibroblast proliferation.[11] Platelet growth factors also exhibit mitogenic and chemotactic properties promoting and modulating cellular functions involved in tissue healing and regeneration and cell proliferation.[12] Since it is prepared from patients, own blood, it is nontoxic and nonimmunoreactive as it also eliminates the risk associated with the use of bovine thrombin.[13]

In a 6-month long study by Del Corso et al.[14] stated significant improvement during the early periodontal healing phase when multiple recession defects were treated with PRF along with CAF However, another randomized clinical trial by Aroca et al.[15] reported inferior root coverage of 80.7% at the test site (CAF + PRF) as compared to 91.5% at control site (CAF), but an additional gain in gingival/mucosal thickness compared to conventional therapy. In a study conducted by Santamaria et al.[16] to evaluate the treatment of gingival recession, associated with noncarious cervical lesions by a CTG alone, or in combination with a resin-modified glass ionomer restoration (CTG + R), it was stated that resin cements did not affect the treatment outcome. Whereas Martins et al.,[17] in another animal study concluded that, though restorative materials exhibit biocompatibility, but they also interfere in the development of bone and connective tissue attachment process.

Keeping the aforementioned advantages of PRF (as a membrane) in recession defects, root coverage procedure was carried out where PRF was placed 1 mm coronal to CEJ, meaning it was left exposed in the oral cavity. The healing was uneventful and did not show any signs of infection. Surgical Stage III was carried out after 5 months of Stage II so complete healing can take place for the previous surgery as the flap design was trapezoidal. Furthermore, staged treatment was protocol was adopted as the recent guidelines suggest root coverage before orthodontic treatment, thus the root coverage was done before the start of the orthodontic treatment and part after the placement of the brackets but no active tooth movement.[18]

Results of our treatment procedure were in accordance with the results of studies conducted by Pazmiño et al.[19] and Gupta et al.[20] and promoted the coverage of the recession irt 11, 13, 21, 22, and 23 with PRF membrane. The results of this study are also in accordance with Agarwal et al.,[21] who reported successful mandibular root coverage. However, in a comparative study by Shetty and Chatterjee[22] between amniotic membrane and PRF membrane, amniotic membrane had better results of root coverage. In authors's view, the advantage of this technique is that additional surgical site is not required for root coverage and is less expensive and less time-consuming, providing patient satisfaction. However, further such studies are required along with histological evaluation to comment upon the clinical stability, and long-term results of PRF-assisted root coverage procedures.

CONCLUSION

The use of autologous platelet concentrates, such as PRF in any form, helps in the regeneration of the lost tissue by the local delivery of growth factors enhancing wound healing primarily by angiogenesis. This case report reflects the success of PRF for coverage of multiple recession defects. However, long-term clinical and histological findings are required to state the nature of the attachment formed and success of the treatment outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.