Comparative evaluation of the platelet-rich fibrin bandage versus gelatin sponge-assisted palatal wound healing of free gingival graft donor site: A case series.

Periodontal plastic surgery often involves palatal donor site, thereby creating an open wound that is prone to postoperative complications such as bleeding, pain, and slow healing process. To prevent the same, platelet-rich fibrin (PRF) and gelatin sponge (GS) were utilized equally at the donor site in six patients. Patients were monitored at the 1st, 2nd, 3rd, and 4th weeks after surgery for postoperative discomfort (D), consumption of analgesics during first postoperative week, alteration of sensitivity (AS), change in feeding habits (CFH), complete wound epithelialization (CWE), and healing index (Landry et al. 1998). Two patients in the GS group showed significantly early CWE, higher healing index score, and less D, AS, and CFH postoperatively in comparison to the PRF group. It was suggested that GS can also be considered as an effective, economical, and biocompatible dressing material of choice to enhance wound healing and to minimize postoperative complications associated with the donor site. Copyright:

INTRODUCTION

Compromised width of attached gingiva is the most common mucogingival problem which is often associated with gingival recession and or lack of adequate vestibular depth. Different periodontal surgical procedures are recommended for the management of the same, but subepithelial connective tissue and free gingival grafting (FGG) yield excellent outcome in terms of the increased width of attached gingiva but are associated with postoperative complications at the donor site. Various hemostatic agents have been recommended for the management of donor sites, but each one has its own disadvantages.[123] Till date, most of the reports studied the efficacy of platelet-rich fibrin (PRF)/collagen/oxidized regenerated cellulose, etc., in comparison to control. The present case series was the second of its own kind to the best of our knowledge, comparatively evaluated the efficiency of PRF membrane and gelatin sponge (GS) as a dressing material at the palatal donor site.

CASE REPORT

Six patients were randomly selected of 13 patients from the institutional outpatient department after fulfillment of inclusion criterion (patients ≥18 years of age with at least one site of Miller Class I or Class II recessions [≥3 mm of depth] in mandibular anterior teeth) and exclusion criterion (patients with systemic diseases, coagulation disorders, pregnancy, and recession defects associated with caries or restoration, smokers, and those with the past history of periodontal surgery on the involved site). All the patients submitted the written signed consent after listen about the study protocol with their pros and cons. The present pilot study was conducted as per the Helsinki Declaration revised in 2013 and was approved by the institutional ethical committee. To avoid bias, sequentially numbered, opaque, sealed envelopes method was used for randomization.

Methodology

Phase I periodontal therapy was performed. Routine blood investigations advised were reported to be within the normal limits. Under the aseptic surgical protocol, local anesthesia was administered. After root planning, gingival de-epithelization was carried out first, followed by mucogingival incision for the preparation of FGG recipient surgical site. FGG harvested from the palatal site was further trimmed to 1.5–2 mm thickness using the conventional scalpel technique and was secured at recipient sites, utilizing 4-0 vicryl suture. All the donor sites were equally covered by GS and Choukroun's PRF membrane bandage and secured by 4-0 vicryl sutures. Oral hygiene instructions for 7 days and analgesic SOS were advised with clear instructions to record the number of analgesics consumed, intensity, nature, and duration of pain.

Postoperative discomfort (D) was evaluated utilizing the Numerical Rating Scale (NRS) till the 1st week postoperatively, whereas complete wound epithelialization (CWE) was assessed by utilizing hydrogen peroxide (3%) test [Figures 1 and 2], and change in feeding habits (CFH) and alteration of sensitivity (AS) were recorded using the NRS with healing index at each interval till the 4th week postoperatively.

Figure 1

(Alphabets A, B, C, D, E, and downward arrow ↓ represent immediate after dressing, 1st, 2nd, 3rd, and 4th week postoperative healing in patients [P1, P2, and P3] in both the groups) P1, P3 (C), and P2 (D) – Absence of bubbles indicating complete epithelialization at 2nd and 3rd weeks postoperatively, P1, P2, and P3 (E) – Perfect tissue color blending at 4th week postoperatively

Figure 2

(Alphabets A, B, C, D, E, and downward arrow ↓ represent immediate after dressing, 1st, 2nd, 3rd, and 4th week post-operative healing in patients (P1, P2, and P3) in both the groups) P1, P2, and P3 (D) – Absence of bubbles indicating complete epithelialization at the 3rd week post-operatively, P1 (E) – showed only perfect tissue color blending, whereas P2 and P3 (E) – complete healing but the persistence of slight redness at 4th week post-operatively

RESULTS

GS group patients reported with less D in terms of duration of pain, the number of analgesic consumed, and CFH and AS with better CWE in two patients and in the third patient at 2nd-and 3rd-week postoperatively in comparison to PRF group where CWE occurred at the 3rd week [Table 1].

Table 1

Evaluation of D, AS, CFH through NRS (Scale of 1–10) score, Consumption of Analgesic, delayed bleeding, CWE, Healing Index and Wound dimension observations in Group I (PRF Bandage group) and Group II (GS group)

					Group number (n)
					Group 1 [PRF]				Group 2 [GS]
					P1	P2	P3	Mean	P1	P2	P3	Mean
The postoperative discomfort (D)
Intensity					6	5	7	6	7	6	5	6
Duration					2	2	4	-	2	1	1	-
Min					-	-	-	-	-	-	-	-
Hours					•	-	•	-	•	•	•	-
Whole day					-	•	-	-	-	-	-	-
Nature
Intermittent					-	-	-	-	-	-	-	-
Continuous					•	•	•	•	•	•	•	•
AS (week)
1st					7	7	7	7	8	6	7	7
2nd					5	6	5	5.3	5	4	5	4.6
3rd					0	2	2	1.3	0	0	0	0
4th					0	0	0	0	0	0	0	0
CFH (week)
1st					7	7	7	7	8	6	7	7
2nd					4	4	4	4	4	3	4	3.6
3rd					0	2	2	1.3	0	0	0	0
4th					0	0	0	0	0	0	0	0
Consumption of analgesic
Amount of tablet					4	4	8	-	2	2	2	-
Time (days)					2	2	4	-	1	1	1	-
Delayed bleeding during 1st week					No	No	No	-	No	No	No	-
Complete wound epithelialization (CWE)					3rd week	3rd week	3rd week	-	2nd week	3rd week	2nd week	-
Group 1					Group 2
HI (visit)	P1	P2	P3	Mean	P1	P2	P3	Mean
1st	1	2	1	-	2	1	1	-
2nd	2	2	2	-	3	4	4	-
3rd	4	3	3	-	4	5	4	-
4th	4	5	5	-	5	5	5	-
Wound dimension
Width	15	15	12	14	12	15	10	12.33
Height	10	9	8	9	10	10	8	9.3

AS – Alteration of sensitivity; CFH – Change in feeding habits; CWE – Complete wound epithelialization, HI – Healing index; P – Patient; • – Duration of pain reported for few hours/whole day in both groups and its continuous nature

DISCUSSION

FGG is utilized for gingival recession coverage, to increase the width of attached gingiva alone or in combination. It is most commonly procured from the palate but leaving the donor site that needs a long time to heal by secondary intention and also causes postoperative discomfort to the patient.[4] Therefore, PRF and GS bandage were utilized at the FGG donor site in the present report to evaluate its effect on the healing of donor site and to overcome/reduce the different complications associated with it on the basis of different parameters described above.

D and amount of analgesics consumed were reported to be less in the GS group than PRF group, which was in contrary to the report of Femminella et al.[5] Overall AS level was found to be greater in the PRF group than GS group, which was first observed in our study, but the intensity of sensitivity seems to decrease at subsequent visits in both the groups, which was in accordance with the results of Femminella et al.[5]

The trend in CFH was similar till the 1st week in both the groups, which was in accordance to the report of Femminella et al.,[5] but GS group showed CFH till the 2nd week which was contrary to the report of Femminella et al.[5] The reason for the least degree of D, AS, and CFH observed in the GS group may be because the thickness of the remaining soft tissue covering the palatal bone after FGG harvested will be approximately ≥ 2 mm in GS group.[6]

Studies on the donor site of FGG have shown that palatal wound requires 2–4 weeks to heal with secondary intention.[7] In the present series, PRF was used as a palatal bandage for CWE that was reported to occur at the 3rd week, which was similar to the results observed by Femminella et al.[5] The possible reason may be because PRF is a three-dimensional (3D) fibrin network and represents a combination of cytokines, structural glycoproteins, and glycanic chains that play a synergetic role in healing and stimulating angiogenesis, immunity, and epithelialization.[8] However, in the GS group, two patients showed CWE at the 2nd and at 3rd weeks respectively. The possible reason for this may be because GS may act in support of clotting by the formation of a mechanical matrix,[9] which mimics natural extracellular matrix by providing 3D space for cell growth and proliferation; in addition, gelatin has good hydrophilicity, biodegradability, and low antigenicity,[10] which was partially in accordance to the report of Rossmann and Rees[9] where complete wound healing in 80% occurred by the end of 3rd week. GS group showed comparatively better donor site healing than PRF group. Overall early CWE was observed in GS group may be because the rate of wound healing is strongly associated with wound size[9] as it was observed in our report that the wound size of GS group (volume of graft) was less than PRF group.

CONCLUSION

Although it is very difficult to reach the final conclusion on the basis of few cases; it was observed that GS dressing is comparatively better in term of minimizing the post-operative discomfort and to enhance the wound healing of FGG donor site than PRF bandage. Therefore, it can also be considered as economical, effective and biocompatible alternative material of choice for the management of same.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.