|Year : 2019 | Volume
| Issue : 4 | Page : 97-102
Evaluation of Platelet Rich Fibrin in the Management of Gingival Recession Type I/II by Miller: A Randomized Clinical Split Mouth Study
Mueataz Al-Qershi, Suleiman Dayoub
Department of Periodontology, Dental Faculty, Damascus University, Damascus, Syria
|Date of Submission||03-Sep-2019|
|Date of Decision||03-Nov-2019|
|Date of Acceptance||15-Nov-2019|
|Date of Web Publication||28-Jan-2020|
Department of Periodontology, Dental Faculty, Damascus University, Al-Mazzeh, Damascus
Source of Support: None, Conflict of Interest: None
Introduction: The ultimate goal of mucogingival plastic surgery is to obtain complete root coverage and an optimal appearance. The aim of this study was to evaluate the efficacy of platelet-rich fibrin (PRF) with coronally advanced flap (CAF) compared to connective tissue graft (CTG) with CAF in the treatment of gingival recession (GR). Material and Methods: A total of 20 patients were included in this randomized clinical study, presenting 40 GR Miller type I/II. The GR sides of patients were assigned randomly into test group (PRF + CAF) and control group (CTG + CAF). Clinical parameters, such as GR, probing depth (PD), clinical attachment level (CAL), and width of keratinized gingiva (WKG), were evaluated at baseline and 12 months later. Root coverage (RC %) and complete root coverage (CRC %) were assessed at 12 months post surgically. Statistical analysis was performed using paired, independent t-test and Mann–Whitney U test. Statistical significance was set at 0.05. Results: At 12 months the mean (SD) GR was 0.20 ± 0.50 mm for test group and 0.05 ± 0.15 mm for control group, whereas the mean RC% was 95.32 ± 11.92 for PRF + CAF and 98.61 ± 4.37 for CTG + CAF. CRC was obtained in CTG + CAF with 90% and with 80% in PRF + CAF. CAL gain was 2.80 ± 0.28 mm and 2.49 ± 0.55 mm in test and control sites, respectively. The gain of WKG was 1.31 ± 0.45 mm and 1.85 ± 0.25 mm in test and control sites, respectively. All the values were not significantly different (P ≥ 0.05). Conclusion: Using of PRF + CAF in the treatment of GR is a successful and effective treatment option and could serve as an alternative to CTGs.
Keywords: Gingiva, gingival recession, platelet-rich fibrin
|How to cite this article:|
Al-Qershi M, Dayoub S. Evaluation of Platelet Rich Fibrin in the Management of Gingival Recession Type I/II by Miller: A Randomized Clinical Split Mouth Study. Dent Hypotheses 2019;10:97-102
|How to cite this URL:|
Al-Qershi M, Dayoub S. Evaluation of Platelet Rich Fibrin in the Management of Gingival Recession Type I/II by Miller: A Randomized Clinical Split Mouth Study. Dent Hypotheses [serial online] 2019 [cited 2020 May 25];10:97-102. Available from: http://www.dentalhypotheses.com/text.asp?2019/10/4/97/277007
| Introduction|| |
Gingival recession (GR) defects have been treated by several techniques, some of those were by using repositioned periodontal flaps alone or combined with auto- or allo-grafts or membranes.,,, Till now, the predominant choice for treatment GR is by coronally advanced flap (CAF) with an autogenous connective tissue graft (CTG) obtained from the patient’s palate, but due to patient’s discomfort, avoiding the second surgery and reducing the surgical time, that prompted researchers to investigate alternative materials to CTG such as enamel matrix derivatives (EMD), Alloderm, or collagen matrix to match the effectiveness of CTG + CAF in obtaining complete root coverage.
Recently, plasma-rich derivatives were used for tissues regeneration in dental plastic surgery., Many studies demonstrated that growth factors in plasma could stimulate the repair and regeneration of soft and hard tissues and reduce inflammation and postoperative pain. Platelet-rich fibrin (PRF) is a fibrous membrane containing cytokines and growth factors that are released over time, it was used as an absorbable membrane. Choukroun et al , were the first who used PRF in the context of oral and maxillofacial surgery to enhance bone healing after dental implantation.
PRF has been used in the treatment of periodontal intrabony defects. Several studies proved its effective role in reducing the probing depth (PD) and improving clinical attachment level, whether it is used alone or in combination with other grafts., PRF was also used in the treatment of furcation defects and resulted in improving the clinical attachment level.
Currently, PRF is used in the treatment of GRs. Several studies have shown that the results obtained with PRF match the results of CTG., The aim of this study was to compare the PRF + CAF with CTG + CAF in the treatment of Miller type I and II GR defects and reject the null hypothesis H0 (the PRF has no effect in treating GRs in comparison to CTG).
| Material and methods|| |
This randomized clinical split mouth trail was registered in Iranian Registry of Clinical Trials with registration number: IRCT20190614043892N2. The study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2000, and was approved by the internal Ethical Committee of the Damascus University No. 827/SM. A written informed consent was obtained from all subjects who participated in the research study.
A total of 23 patients (10 males and 10 females) were enrolled in this study from those attending the department of periodontology at the faculty of dentistry in the period between December 2017 and December 2018. Patients must fulfill these criteria: 1) patient’s age ranges from 20 to 45 years with the ability to demonstrate a good oral hygiene; 2) subjects should be periodontally and systemically healthy; and 4) presence of GR in two sites. Just 20 patients (10 males and 10 females) were available for follow up after 12 months [Figure 1]. The exclusion criteria were: patients who were smokers (more than 20 cigarettes a day) or patients suffering from systemic diseases or periodontal diseases, or patients under orthodontic treatment, or patients who can’t maintain a good oral hygiene, or patients who had previous surgical treatments to cover the recession in the chosen area, or in case of pregnancy or lactating or presence of restorative materials in the chosen area.
Bilateral or contralateral GRs were assigned randomized to treatment sides or control sides by a computer-generated randomization list (SPSS v 22 for win, IBM Corp Armonk NY) after assessment of clinical parameters. A total of 20 GRs were treated by PRF with CAF (PRF + CAF) as test group and other 20 GRs were treated by CTG with CTF (CTG + CAF) as control group.
All enrolled subjects received a pre-periodontal treatment (scaling and root planning) before two weeks of surgery. On the day of surgery, patients were prepared with a pre-operative rinse of 0.2% chlorhexidine for 1 min. Both sites were treated in the same surgical session.
Intravenous blood samples were collected before the surgery in a 10-ml glass-coated plastic tube without adding any anticoagulant. Then they were centrifuged immediately at 2.700 rpm for 12 minutes with a table centrifuge (Hettich, Zentrifugrn D-7200 Tuttlingen, Germany). The fibrin clot, which formed in the middle part of the tube, was taken and transferred to the PRF box and compressed to create PRF membrane.
In control sites, a CTF was done by elevating a full thickness flap with an intra-cervical incision and two vertical incisions and freed from tension, a CTG was harvested from the subject’s palate and sutured to the recipient site using Vicryl 5-0 (Johnson & Johnson LLC, Piscataway, NJ, USA), the flap was coronally repositioned and sutured (Silk 0-4, ACUFIRM, Dreieich, Germany) [Figure 2]. In test sites, the PRF was sutured with vicryl 5-0 (Johnson & Johnson LLC, Piscataway, NJ, USA), then CAF were sutured coronally to the cemento-enamel junction (CEJ) using Silk 0-4 (ACUFIRM, Dreieich, Germany) [Figure 3].
|Figure 2 The figure represents control site. A) Gingival recession defect at base line, B) the connective tissue graft from the palate C) the connective tissue graft placed and sutured over the recession at D) 12 months follow up.|
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|Figure 3 The figure represents test site. A) Gingival recession defect at base line, B) the platelet-rich fibrin membrane, C) the platelet-rich fibrin placed and sutured over the recession at D) 12 months follow up.|
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After surgery, patients were given instruction on a written paper, included to rinse twice daily with chlorhexidine rinse 0.2% (ICPA Health Products Ltd. Mumbai, India) and to avoid tooth brushing for a month in the surgical area. Patients assumed antibiotic amoxicillin/clavulanate potassium (625 g three times daily for six days) and non-steroidal analgesic diclofenac potassium (50 mg, twice a day for six days). Patients were told to come two weeks after surgery to remove the sutures. All patients were followed up at 12 months.
The primary parameter was the GR depth for test group 3.05 ± 0.71 mm and for control 2.91 ± 0.70. Secondary parameters were clinical attachment level (CAL) for test group 3.95 ± 1.09 mm and for control 3.76 ± 0.89, PD for test group 0.95 ± 0.42 mm and for control 0.85 ± 0.36, and width of keratinized gingiva (WKG) for test group 2.23 ± 0.69 mm and for control 2.25 ± 0.70. These clinical parameters were recorded by using calibrated UNC-15 probes (PCP UNC-15, Hu Friedy, Chicago IL) which were made to the nearest 0.5 mm at baseline and 12 months post surgically. Also, we took in consideration other parameters: root coverage percentage (RC %) and complete root coverage (CRC%) were evaluated at 12 months post surgically.
The sample size was determined based on the null hypothesis, which states that the test group (PRF + CAF) and the control group (CTG + CAF) weren’t equal. The confidence level was determined by 95%, the desired sample power was 95%, then G power (version 3.1.2) was used, and the required sample size was 20 subjects. The selected study sample was increased by three persons, with the possibility of dispensing results of some subjects. The sample size was 23 persons.
Values were entered into a database and the SPSS statistical package v22.0 was used for analyzing data. For the descriptive analysis of quantitative variables, dispersion measures (mean, standard deviation) were used. For both test and control groups, data were analyzed using paired t-test at baseline and 12 months. Independent t-test was used for intergroup comparisons. Statistical significance was set at .05. The odds ratio (OR) with 95% confidence intervals was calculated.
| Results|| |
A total of 20 patients (10 male and 10 female) with mean ± SD age (30.5 ± 6.05 ‘years) were enrolled in this study. The OR was 2.25. The mean ± SD of GR at 12 months was 0.05 ± 0.15 in control group and 0.20 ± 0.50 in mm in test group. The mean ± SD CAL has changed in control from 3.76 ± 0.89 mm to 1.27 ± 0.34 mm and in test group from 3.95 ± 1.09 to 1.15 ± 0.81 mm [Table 1].
|Table 1 Preoperative and postoperative clinical parameters in control group (CTG + CAF) and test group (PRF + CAF)|
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The mean ± SD percentage of root coverage was 98.61 ± 4.37 for control group and 95.32± 11.92 for test group (P = 0.25, independent t-test) Complete root coverage was obtained in 80% and 90% in both test and control groups, respectively (P = 0.60, Mann–Whitney U)
| Discussion|| |
The main goal of mucogingival plastic surgery is to obtain complete, predictable, and aesthetic root coverage. To achieve this goal many procedures have been used. In this study, we evaluated the efficacy of the use of PRF with CAF for the treatment of GR compared to CTG + CAF with a 1 year follow up. Periodontal clinical parameters (GR, PD, CAL, WKG) were evaluated at baseline and 12-months later. Both surgical techniques PRF and CTG were effective in the treatment of GR with significant root coverage.
Aroca et al.,  conducted a study to compare the modified coronally advanced flap (MCAF) alone with PRF + MCAF in the treatment of multiple GRs The percent of root coverage was greater for the MCAF group when compared to PRF + MCAF group, and CRC was obtained in 74.6% in MCAF and 52.2% in PRF + MCAF. A randomized clinical trial was conducted by Jankovic et al. and compared using PRF + CAF and CTG + CAF in treating GR, at 6 months follow up, the outcomes of the measurements of Gr, CAL, WKG, RC% were similar with no statistical differences. This study demonstrated that using PRF advanced the tissue healing after the surgery. Eren and Atilla proved in their study that PRF could be suggested as an alternative treatment for localized GR, the results of their study showed no differences between PRF and subepithelial connective tissue graft (SCTG).
A systematic review and meta-analysis study were conducted  to evaluate the use of PRF in treating GRs. The review included six RCTs and one prospective clinical trial. Regarding percent of root coverage and clinical attachment level, the study reported that there weren’t significant differences between the groups. Regarding the width of keratinized gingiva, it was higher in the groups treated with CTG. This review resulted that using PRF did not improve the clinical parameters of GRs, which isn’t compatible to the results of our study, and that could be related to the small number of RCTs on the subject.
Culhaoglu et al. evaluated the outcomes of multiple layers of PRF membranes in the treatment of GRs. It was classified in three groups in this study: test group 1 (two layers of PRF + CAF), test group 2 (four layers of PRF + CAF), and control group (CTG + CAF). Clinical parameters were assessed at baseline and 6 months later. The RC% was in test group 1 (56.34%), test group 2 (69.65%), and (80.13%) in control group. The keratinized tissue height was greater in test group 1 with 4.86 mm than in test group 2 (4.15 mm). The results of this study were significant and even better when using more layers of PRF in the treatment. PRF was also used by Oncu to treat multiple GRs: the defects were treated by PTF + MCAF (test group) and CTG + MCAF (control group). After 6 months the RC% was 84% in the control group and 77% in the test one. CRC was obtained in test and control sites 50% and 60%, respectively. In other study, Mufti et al. compared the PRF and CTG in treating GRs. In test group, GR changes from 2.19 mm to 1.12 mm, and in control group the change was from 2.13 mm to 1.38 mm. t\The mean height of keratinized tissue was 4.44 mm in test group and 4.63 mm in control group. Another study was conducted by Dixit et al  to assess effect of PRF + CAF compared with CAF alone in treating GRs. The study included 12 patients. After 6 months the mean of GR was 0.85 mm in CAF group and 0.82 mm in PRF + CAF group.
The findings of this study GR, RC%, CRC% indicated that both techniques PRF + CAF and CTG + CAF were similar in treating GRs, the higher percentage of CRC demonstrated the recovery from hypersensitivity and other esthetic factors associated with recessions. These results are compared to other studies ,,,,, in which CRC was achieved in both techniques and was indicated that PRF matches the CTG in the management of GR. Our results outperformed the results obtained by Aroca  and Oncu  that could be related to the various presurgical deeps of GR and to different surgical techniques, in which they used MCAF.This study demonstrated that there were no statistically significant differences in PD parameter between groups, the PD has increased in both the control and test sites, which is in agreement with other studies. On the other hand, there was a significant decrease in CAL for both study groups at the end of the study and these results were similar to those reported by Jankovic et al. The main gain of CAL in test group was 2.83 mm and 2.48 mm in control group, and that could be related to the new formed attachment to the root. According to that, PRF + CAF seems to be a safe and predictable alternative to CTG in the management of GRs.
For WKG, the gain of WKG at 12 months was higher in CTG + CAF group with 1.85 mm versus 1.31 mm in PRF+CAF group, and no statistical differences were observed. These findings are in consistence to other studies,,,,,, where the gain in WKG was higher in both groups. The increase in CTG group correlated to the ability of the connective tissue to induce keratinization of the epithelium , and the gain in PRF group could be explained by the biology of PRF that contains growth factors and cytokines influencing proliferation and manifestation of the tissue.
In PRF group no complications were observed, while in CTG group postoperative complications such as pain, swelling, and bleeding were observed in the donor site. The clinicians should take into consideration these points when preparing for mucogingival surgery.
This study has some positive points, as it was designed as an experimental split-mouth study to exclude the influence of individual characteristics of subjects and to obtain a more robust treatment estimate with a small sample size. However, this study has some limitations. A histological study was not conducted to evaluate the regeneration role of PRF in forming a new attachment. The authors recommend doing a histological study to evaluate the capacity of PRF in periodontal surgery. It is also recommendable to evaluate the role of PRF in treating multiple GR, due to its capacity in healing and regeneration.
| Conclusion|| |
Using PRF with CAF represents a clinical and esthetical treatment of GR defects. The percentage of root coverage and the gain in width of keratinized gingiva and clinical attachment level at 12 months follow up were closed to the outcomes obtained from CTG + CAF technique. PRF + CAF is an effective treatment option and could serve as an alternative to CTGs in the management of GRs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Patel A, Chapple I. Periodontal aspects of esthetic dentistry − managing recession defects. In: Wilson N, Millar B. (eds) Principles and Practice of Esthetic Dentistry. London, UK: Elsevier, 2015, pp 137-163 .
Zucchelli G, Mounssif I. Periodontal plastic surgery. Periodontal 2000. 2015;68:333-68.
Jepsen K, Stefanini M, Sanz M, Zucchelli G, Jepsen S. Long-term stability of root coverage by coronally advanced flap procedures. J Periodontol 2017;88:626-633.
Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: a systematic review. J Clin Periodontol 2008;35:136-62.
Nunn ME, Miyamoto T. Coronally advanced flaps (CAF) plus connective tissue graft (CTG) is the gold standard for treatment of Miller class I and II gingival defects. J Evid Based Dent Pract 2013;13:157-9.
Amine K, El Amrani Y, Chemlali S, Kissa J. Alternatives to connective tissue graft in the treatment of localized gingival recessions: A systematic review. J Stomatol Oral Maxillofac Surg 2018;119:25-32.
Petrungaro PS Using platelet-rich plasma to accelerate soft tissue maturation in esthetic periodontal surgery. Compend Contin Educ Dent 2001;22:729-32, 734, 736.
Huang LH, Neiva RE, Soehren SE, Giannobile WV, Wang HL. The effect of platelet-rich plasma on the coronally advanced flap root coverage procedure: a pilot human trial. J Periodontol 2005;76:1768-77.
Alissa R, Esposito M, Horner K, Oliver R. The influence of platelet-rich plasma on the healing of extractionsockets: an explorative randomised clinical trial. Eur J Oral Implantol 2010;3:121-34.
Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL et al.
Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part IV: clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e56-60.
Choukroun J, Adda F, Schoeffler C, Vervelle A. Une opportunité en paro-implantologie. Le PRF. Implantodontie 2001;42:55-62.
Agarwal A, Gupta ND, Jain A. Platelet rich fibrin combined with decalcified freeze-dried bone allograft for the treatment of human intrabony periodontal defects: a randomized split mouth clinical trail. Acta Odontol Scand 2016;74:36-43.
Shah M, Patel J, Dave D, Shah S. Comparative evaluation of platelet-rich fibrin with demineralized freeze-dried bone allograft in periodontal infrabony defects: A randomized controlled clinical study. J Indian Soc Periodontol 2015;19:56-60.
] [Full text]
Sharma A, Pradeep AR. Autologous platelet-rich fibrin in the treatment of mandibular degree II furcation defects: a randomized clinical trial. J Periodontol 2011;82:1396-403.
Aroca S, Keglevich T, Barbieri B, Gera I, Etienne D. 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;80:244-52.
Jankovic S, Aleksic Z, Klokkevold P, Lekovic V, Dimitrijevic B, Kenney EB, Camargo P. Use of platelet-rich fibrin membrane following treatment of gingival recession: a randomized clinical trial. Int J Periodontics Restorative Dent 2012;32:e41-50.
Sunitha Raja V, Munirathnam Naidu E. Platelet-rich fibrin: evolution of a second-generation platelet concentrate. Indian J Dent Res 2008;19:42-6.
Eren G, Atilla G. Platelet-rich fibrin in the treatment of localized gingival recessions: a split-mouth randomized clinical trial. Clin Oral Investig 2014;18:1941-48.
Moraschini V, Barboza Edos S. Use of platelet-rich fibrin membrane in the treatment of gingival recession: a systematic review and meta-analysis. J Periodontol 2016;87:281-90.
Culhaoglu R, Taner L, Guler B. Evaluation of the effect of dose-dependent platelet-rich fibrin membrane on treatment of gingival recession: a randomized, controlled clinical trial. J Appl Oral Sci 2018;26:e20170278.
Öncü E. The use of platelet-rich fibrin versus subepithelial connective tissue graft in treatment of multiple gingival recessions: a randomized clinical trial. Int J Periodontics Restorative Dent 2017;37:265-71.
Mufti S, Dadawala SM, Patel P, Shah M, Dave DH. Comparative evaluation of platelet-rich fibrin with connective tissue grafts in the treatment of Miller’s Class I gingival recessions. Contemp Clin Dent 2017;8:531-7.
] [Full text]
Dixit N, Lamba AK, Faraz F, Tandon S, Aggarwal K, Ahad A. Root coverage by modified coronally advanced flap with and without platelet-rich fibrin: a clinical study. Indian J Dent Res 2018;29:600-4.
Edel A, Faccini JM. Histologic changes following the grafting of connective tissue into human gingiva. Oral Surg Oral Med Oral Pathol 1977;43:190-5.
Eren G, Kantarci A, Sculean A, Atilla G. Vascularization after treatment of gingival recession defects with platelet-rich fibrin or connective tissue graft. Clin Oral Investig 2016;20:2045-2053.
[Figure 1], [Figure 2], [Figure 3]