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Clinical Evaluation of Autologous Platelet-Rich Fibrin in the Treatment of Multiple Adjacent Gingival Recession Defects: A 12-Month Study Mustafa Tunalı, DDS, PhD1 Hakan Özdemir, DDS, PhD2 Taner Arabacı, DDS, PhD3/Bahadır Gürbüzer, DDS, PhD4 M. Levent Pikdöken, DDS, PhD5/Erhan Fıratlı, DDS, PhD6
Leukocyte- and platelet-rich fibrin (L-PRF) belongs to a new generation of platelet concentrates. There are limited numbers of studies focused on the use of L-PRF in gingival recession defects. This study evaluated the safety and effectiveness of using L-PRF membranes as a substitute for free connective tissue grafts (CTGs) as a treatment method for gingival recession defects. A total of 44 Miller Class I/II gingival recessions that were bilateral, adjacent, and greater than 3 mm in size were selected. Each recession site was randomly assigned to the test group (L-PRF) or the control group (CTG). After 12 months, root coverage was 76.63% and 77.36% in the L-PRF and CTG groups, respectively. It is suggested that L-PRF membrane may be an alternative graft material for treating multiple adjacent recessions greater than 3 mm in size without a requirement for additional surgery. (Int J Periodontics Restorative Dent 2015;35:105–114. doi: 10.11607/prd.1826)
Associate Professor, Department of Periodontology, Gulhane Military Medical Academy, Istanbul, Turkey. 2Assistant Professor, Department of Periodontology, School of Dentistry, Cumhuriyet University, Sivas, Turkey. 3Associate Professor, Department of Periodontology, School of Dentistry, Atatürk University, Erzurum, Turkey. 4Professor, Department of Oral Surgery, Gulhane Military Medical Academy, Istanbul, Turkey. 5Associate Professor, Department of Periodontology, Gulhane Military Medical Academy, Istanbul, Turkey. 6Professor, Department of Periodontology, School of Dentistry, Istanbul University, Istanbul, Turkey. 1
Correspondence to: Dr Mustafa Tunalı, Department of Periodontology, Haydarpasa Training Hospital, Gulhane Military Medical Academy, Üsküdar, 34168 Istanbul, Turkey; email: [email protected]. ©2015 by Quintessence Publishing Co Inc.
The main goal of plastic periodontal surgical procedures is to achieve an optimal esthetic appearance with complete root coverage. A coronally advanced flap (CAF) with a connective tissue graft (CTG) is a predictable surgical procedure for the coverage of gingival recession and is considered to be the gold standard. For the CTG technique, the reported mean percentage of root coverage ranges between 65% and 98%. CTG continues to hold the most promise for root coverage.1 However, when the amount and thickness of the donor tissue is not sufficient, the application of the technique is limited to multiple adjacent gingival recessions and requires a second surgical procedure to achieve better esthetic results. Leukocyte- and platelet-rich fibrin (L-PRF) can be defined as an autologous biomaterial.2 Unlike other platelet-rich products, this material does not require an anticoagulant or bovine thrombin.3–7 It is simply centrifuged blood without any additives, which makes it possible to avoid all of the legal restrictions related to the reimplantation
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106 of blood-derived products. L-PRF is composed of a fibrin matrix polymerized in a tetramolecular structure and is involved in the joining of platelets, leukocytes, cytokines, and circulating stem cells. Slow fibrin polymerization during the processing of L-PRF leads to the intrinsic incorporation of platelet cytokines and glycan chains into the fibrin meshes. This result implies that, unlike other platelet concentrates, L-PRF may be able to progressively release cytokines during remodeling of the fibrin matrix. Such a mechanism might explain the clinically observed healing properties of L-PRF.6 L-PRF has also been shown to organize as a dense fibrin scaffold with a high number of leukocytes concentrated in one part of the clot and a particularly slow release of growth factors and glycoproteins over 7 days.6 Previous studies have demonstrated that viable platelets in L-PRF release growth factors such as platelet-derived growth factor AB, transforming growth factor β-1, and vascular endothelial growth factor. The benefits of L-PRF have been examined in various studies.7–16 The purpose of this clinical study was to evaluate the safety and effectiveness of L-PRF membranes combined with coronally repositioned flap surgery and to compare this procedure with free connective tissue grafts in combination with coronally repositioned flap surgery in the treatment of multiple adjacent Miller Class I/II gingival recession defects greater than 3 mm in size.
Method and materials Patient and site selection
The study protocol was submitted to the Institutional Ethics Committee and Review Board of Gulhane Military Medical Academy Haydarpasa Training Hospital, Istanbul, Turkey (1491-369-08/1539). The study was conducted between June 2009 and August 2011. All patients were provided detailed information about the surgical procedure, and written consent was obtained. Following patient examination, complete mouth scaling and polishing were performed, and oral hygiene instructions were given. At the end of the initial treatment phase, the patients displayed full-mouth plaque scores17 above 15%. Ten systemically healthy patients, each with multiple adjacent Miller Class I/II buccal gingival recession defects greater than 3 mm in size, were included in this study. The inclusion criteria were as follows: (1) presence of multiple bilateral defects with recession depths greater than 3 mm when measured from the cementoenamel junction (CEJ) of the anterior teeth or premolars; (2) having Miller Class I or Class II recession defects with similar contralateral lesions; (3) having selected teeth that were vital, free of restorations, and did not bleed upon probing; and (4) having had no prior surgical treatment in the area to be covered. The exclusion criteria were as follows: smoking, any uncontrolled local or systemic disease that might be a contraindication for periodontal surgery,
pregnancy or lactation, severe immune deficiency, coagulation defect, or current anticoagulation treatment. Ten patients, six women and four men ranging in age between 25 and 52 years (mean age: 34.2 years), with a total of 44 affected teeth (22 treated with L-PRF and 22 treated with CTG) completed the study.
Clinical measurements
All clinical measurements were performed by one of the investigators (HO), who was blinded to the type of surgical procedure. The investigator was unaware of group assignments and demonstrated an acceptable level of intraexaminer agreement for all measurements. Repeat measurements were performed 30 minutes after the initial measurements. The investigator was required to demonstrate reproducibility within 1 mm on ≥ 95% and ≥ 90% of measurements for gingival recession (GR) and probing depth (PD), respectively. The following measurements were taken at baseline and 6 months and 12 months after surgery using a Michigan O periodontal probe: GR, distance from CEJ to the gingival margin; PD, distance from the gingival margin to the base of the gingival crevice; clinical attachment level (CAL), distance from CEJ to the base of the gingival crevice; and keratinized tissue width (KTW), distance from the gingival margin to the mucogingival junction (MGJ). The measurements were taken on the midbuccal aspects and rounded to the nearest 0.5 mm. The first site was selected for one of the two
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107 Fig 1 Leukocyte- and platelet-rich fibrin (L-PRF) procedure. (a) L-PRF clot tube. (b) L-PRF clot. (c) L-PRF membrane.
a
experimental groups incidentally, and the second site was consecutively added to the opposite group by one of the authors (BG). The percentages of root coverage (RC) and attachment gain (AG) were calculated according to the following formulas: RC = ([preoperative vertical recession – postoperative vertical recession] / preoperative vertical recession) × 100; AG = ([preoperative attachment level – postoperative attachment level] / preoperative attachment level) × 100.
L-PRF procedure
The L-PRF was prepared according to the protocol developed by Choukroun et al in 2001 (Process Protocol).2 Immediately prior to surgery, 10 mL of blood was drawn from each patient by venipuncture of the antecubital vein and collected in a sterile glass test tube without any anticoagulant. The blood was quickly collected, and the tubes were immediately centrifuged at 2,700 rpm for 12 minutes5 using a Hettich Universal 320 table centrifuge (Hettich Instruments) at room
b
temperature. Because of differential densities, centrifugation resulted in separation of the following three basic fractions: red blood cells at the bottom, acellular plasma on the surface, and an L-PRF clot formed in the middle part of the tube (Fig 1a). After centrifugation, the L-PRF clots were removed from the tubes using sterile tweezers (Fig 1b) and placed on sterile woven gauze. Clots were emptied from their serum by compressing them between two pieces of woven gauze. L-PRF membranes were prepared by compressing clots between two pieces of woven gauze (Fig 1c).
Donor site
The CTG was harvested from the patient’s palate.18 The first incision on the palate was made parallel to the long axis of the teeth, approximately 4 mm apical to the gingival margin. The second incision was made parallel to the surface of the palate, 1 to 2 mm apical to the first incision. A small periosteal elevator was used to raise a tissue graft. The donor tissue was removed as
c
atraumatically as possible. Utilizing 5-0 silk sutures, a continuous suture with a locking technique was used to approximate the wound on the palate. After harvesting the graft, a 1- to 2-mm band of epithelium at the coronal aspect of the donor tissue, and abundant fatty parts, were removed. The graft was trimmed to a thickness of 1.5 mm.
Surgical procedures
Each patient received L-PRF and CTG surgeries on bilateral defects. The surgical procedures in both study groups were performed by one surgeon (MT). The sides for L-PRF and CTG were randomly determined by a coin toss. After local anesthesia (Ultracain D-S Forte, Hoechst Marion Roussel) was administered to donor and recipient sites, root planing of exposed root surfaces was carried out to reduce convexity and thus decrease the avascular surface area under the graft. The area was irrigated with sterile saline. The initial horizontal right-angle incision was beveled into the adjacent interdental papillae at or slightly coronal to the CEJ
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108 of the tooth with an exposed root surface. A full-thickness flap was reflected beyond the MGJ and at least 5 mm apical to the most apical margin of the bony dehiscence. The flap was further released by sharp dissection. The mesiodistal length of the incision was extended to the nearest distal line angle of the most mesial and distal teeth involved. A mesial vertical releasing incision was made during each procedure. A measurement of the approximate width necessary for the graft was obtained with a periodontal probe. All papillae were deepithelialized to create a connective tissue bed. At the test sites, the previously prepared fibrin clot was positioned over the recession defects, directly below the CEJ. The grafts were placed over the exposed roots and stabilized using a 5-0 bioabsorbable sling suture (Ethicon). The flaps were then coronally positioned to completely cover the graft and sutured directly over the graft with 4-0 silk sutures. Donor tissue was covered with the overlying flap as much as possible to provide more blood supply to the graft. Vertical incisions were also closed with 4-0 silk sutures. Mild pressure was applied for 5 minutes using gauze soaked in saline.
Postoperative care
A dry piece of foil was applied to the recipient area in both groups. Then, a noneugenol periodontal dressing (Voco Pac) was placed over the dry foil to stabilize and protect the donor tissue for 14 days postoperatively. The patients were given a cold
compress extraorally to minimize swelling and bleeding during the postoperative period. All patients were given appropriate antibiotics and analgesics (amoxicillin 1,000 mg twice a day for 5 days and naproxen sodium 550 mg twice a day). The patients used a 0.12% chlorhexidine gluconate mouthrinse (Klorhex, Drogsan) and were instructed to gently rinse twice daily for 1 minute for a total of 2 weeks. The patients were advised not to brush their teeth in the surgical areas. Two weeks after surgical treatment, the surgical wounds were gently cleansed with a 0.12% chlorhexidine digluconate solution. Afterwards, gentle brushing with a surgical toothbrush was recommended.
Statistical analysis
The statistical analysis was performed using a commercially available software program (SPSS version 16.0, SPSS). The results were averaged (mean ± SD) for all clinical parameters at baseline and 6 months and 12 months after treatment. After evaluation of normality with the KolmogorovSmirnov test, data were analyzed with the Mann-Whitney U test following the Kruskal-Wallis test (intergroup comparison) and the Wilcoxon signed-rank test (intragroup comparison). Differences of P < .05 were considered statistically significant. An a priori statistical power analysis using a software program (PC-Size, G.E. Dallal) was performed considering that the test and control groups were not
independent, under the hypothesis of normality for the variables examined. An alpha of .05 was selected for calculation. The required sample size was 22 in groups with a statistical power of 80%.19
Results There were no statistically significant differences between the recession-type defects in the two groups at baseline. All patients completed the study, and they did not show any altered wound healing. The statistical analyses for the clinical parameters at baseline and 6 months and 12 months posttreatment for both groups are presented in Table 1. Mean gingival recessions of 4.45 ± 0.18 mm and 4.02 ± 0.12 mm were determined for cases treated with the L-PRF (Table 2) and the CTG (Table 3) techniques, respectively. Six months after surgery, a significant decrease in recession depth was noted in both groups, and the mean remaining recession values were 1.14 ± 0.06 mm (P < .001) and 1.14 ± 0.04 mm (P < .001) in the L-PRF and CTG groups, respectively. At 12 months, the mean residual recession values were 1.05 ± 0.04 mm (P < .001) and 0.98 ± 0.05 mm (P < .001) in the L-PRF and CTG groups, respectively. In both groups, PDs significantly decreased after treatment (P < .001). The PD values were 1.33 ± 0.59 mm and 1.49 ± 0.50 mm at baseline, 1.24 ± 0.37 mm and 1.13 ± 0.35 mm at 6 months and 1.18 ± 0.33 mm and 1.18 ± 0.35 mm at 12 months in the L-PRF
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Table 1 Clinical parameters (mean ± SD) of the treated sites at baseline and 6 and 12 months postoperatively
Parameter PD (mm) CAL (mm) KTW (mm)
Group
Recessions Baseline (n) (mean ± SD)
L-PRF CTG L-PRF CTG L-PRF CTG
22 22 22 22 22 22
1.33 ± 0.59 1.49 ± 0.50 5.03 ± 1.94 5.20 ± 1.49 2.33 ± 0.56 2.43 ± 0.52
6 mo (mean ± SD)
12 mo (mean ± SD)
1.24 ± 0.37 1.13 ± 0.35 2.27 ± 0.92 2.24 ± 0.82 2.93 ± 0.70 2.93 ± 0.71
1.18 ± 0.33 1.18 ± 0.35 2.33 ± 0.90 2.16 ± 0.79 2.86 ± 0.69 3.03 ± 0.74
Baseline to 12 mo
Baseline to 6 mo z score
P
z score
P
–0.57 –2.02 –3.19 –3.44 –2.99 –2.99
.57 .04* .00* .00* .00* .00*
–0.78 –1.85 –3.19 –3.44 –2.44 –2.85
.44 .06 .00* .00* .02* .00*
PD = probing depth; CAL = clinical attachment level; KTW = keratinized tissue width; L-PRF = leukocyte- and platelet-rich fibrin; CTG = connective tissue graft. *Statistically significant difference (P < .05).
Table 2 Individual recession and root coverage results of the leukocyte- and platelet-rich fibrin sites
Patient 1 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 10 Mean
Tooth*
Miller Class
13 12 11 45 44 44 43 23 24 22 23 23 24 13 14 44 45 24 25 43 44 45
I II I II II I I I II I I II II II II II I I I I II II
Initial recession Recession (mm) (mm) 5.0 7.0 5.0 4.0 3.5 4.0 3.0 3.0 4.0 3.0 5.0 6.0 4.0 5.0 5.0 5.0 4.0 3.0 3.5 6.0 5.0 5.0 4.45
0.0 2.0 0.5 1.5 1.0 2.5 0.5 0.0 0.5 0.5 0.5 3.0 1.5 2.0 2.0 1.5 1.0 0.0 0.0 2.0 1.5 1.0 1.14
6 mo Coverage (mm) 5.0 5.0 4.5 2.5 2.5 1.5 2.5 3.0 3.5 2.5 4.5 3.0 2.5 3.0 3.0 3.5 3.0 3.0 3.5 4.0 3.5 4.0 3.32
12 mo Coverage (%) 100 72 90 63 72 38 83 100 88 84 90 50 63 60 60 70 75 100 100 67 70 80 74.61
Recession (mm) 0.0 2.0 0.5 1.0 1.0 1.5 0.5 0.5 0.5 0.5 1.0 2.5 1.5 2.0 2.0 1.0 1.0 0.0 0.0 2.0 1.5 0.5 1.05
Coverage (mm) 5.0 5.0 4.5 3.0 2.5 2.5 2.5 2.5 3.5 2.5 4.0 3.5 2.5 3.0 3.0 4.0 3.0 3.0 3.5 4.0 3.5 4.5 3.41
Coverage (%) 100 72 90 75 72 63 83 83 88 83 80 58 63 60 60 80 75 100 100 67 70 90 76.63
*FDI tooth-numbering system.
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Table 3 Individual recession and root coverage results of the connective tissue graft sites Initial recession Recession (mm) (mm)
6 mo
Tooth*
Miller Class
1
23
II
6.0
2.0
4.0
1
24
II
5.0
2.0
3.0
2
34
II
4.0
0.5
2
35
II
4.0
3
34
I
3.0
3
35
II
3.0
1.5
1.5
50
1.5
1.5
50
4
13
I
4.0
0.5
3.5
88
0.0
4.0
100
4
14
I
3.0
0.5
2.5
83
0.5
2.5
83
5
12
I
4.0
1.0
3.0
75
0.0
4.0
100
Patient
Coverage (mm)
12 mo Coverage (%)
Recession (mm)
Coverage (mm)
Coverage (%)
67
2.0
4.0
67
60
2.0
3.0
60
3.5
88
0.5
3.5
88
0.5
3.5
88
0.5
3.5
88
1.0
2.0
67
1.0
2.0
67
5
13
I
4.0
1.0
3.0
75
0.0
4.0
100
6
13
II
5.0
1.5
3.5
70
1.5
3.5
70
6
14
I
4.0
2.0
2.0
50
2.0
2.0
50
7
22
II
4.0
1.5
2.5
63
1.5
2.5
63
7
23
I
4.0
1.5
2.5
63
1.5
2.5
63
7
24
I
4.0
1.5
2.5
63
1.5
2.5
63
8
34
II
4.5
1.0
3.5
78
1.0
3.5
78
8
35
I
3.5
1.0
2.5
71
0.5
3.0
86
9
13
I
4.0
0.0
4.0
100
0.0
4.0
100
9
14
I
3.0
0.0
3.0
100
0.0
3.0
100
10
33
I
4.0
1.0
3.0
75
0.5
3.5
88
10
34
I
3.5
1.5
2.0
57
1.5
2.0
57
10
35
II
5.0
2.0
3.0
60
2.0
3.0
60
4.02
1.14
2.98
74.13
0.98
3.11
77.36
Mean *FDI tooth-numbering system.
and CTG groups, respectively. The L-PRF and CTG procedures resulted in a significant attachment gain at 6 months and 12 months (see Table 1). There were no significant differences in the CAL between the two groups. Both groups showed a significant increase in the KTW from baseline to 12 months; however, there were no statistically
significant differences in the KTW between the two groups at baseline or at 12 months (see Table 1). When compared with the untreated teeth, both treatments resulted in statistically significant improvements in the degree of root coverage at 6 and 12 months (Figs 2 and 3), which were 74.61% and 76.63% for the L-PRF group and 74.13%
and 77.36% for the CTG group, respectively. At 6 months, the mean root coverage values were 3.32 ± 0.12 mm and 2.98 ± 0.13 mm in the L-PRF and CTG groups, respectively. At 12 months, the mean root coverage values were 3.41 ± 0.10 mm and 3.11 ± 0.10 mm in the L-PRF and CTG groups, respectively (Table 4).
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111
a
b
c
d
e
f
Fig 2 Leukocyte- and platelet-rich fibrin (L-PRF) side. (a) Preoperative view of the recession defects in the maxillary left lateral incisor and canine region. (b) After L-PRF membrane application and suturing. (c) Three weeks after the surgical procedure, (d) at 8 weeks, (e) at 6 months, and (f) at 12 months after the surgical procedure. Fig 3 Connective tissue graft side of the same patient. (a) Preoperative view of the recession defects in the maxillary right lateral incisor and canine region. (b) Eight weeks after the surgical procedure, (c) at 6 months, and (d) at 12 months after the surgical procedure.
a
b
c
d
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Table 4 Mean recession and root coverage parameters 6 mo
12 mo
Initial recession (mm)
Recession (mm)
Coverage (mm)
Coverage (%)
Recession (mm)
Coverage (mm)
Coverage (%)
L-PRF
4.45
1.14
3.32
74.61
1.05
3.41
76.63
CTG
4.02
1.14
2.98
74.13
0.98
3.11
77.36
Treatment group
Discussion The results of the study demonstrate that both autogenous L-PRF and CTG are effective treatment methods for gingival recession defects, with significant root coverage (76.63% and 77.36%, respectively) and clinical attachment gain (2.90 mm and 3.04 mm, respectively) 12 months after surgery. All patients noticed highly successful esthetic results 12 months following surgery. The differences between the two techniques in terms of recession reduction and attachment gain are not statistically significant. The amount of keratinized gingival tissue in both groups was found to be increased by 0.6 mm. Previous studies10,20 evaluated the use of L-PRF for treatment of multiple gingival recessions with a CAF procedure and found significant improvement in the early periodontal healing phase. The results of the current study are consistent with the results of Del Corso et al.10 However, another study21 compared the L-PRF membrane and CAF methods and did not find any difference between the thickness of gingival tissue at baseline and after 6 months. Previous studies have re-
ported that the treatment degree of gingival defects differs based on site, type, and size of the defect.22–25 The Miller Class I and II defects included in the authors’ study are equal to or greater than 3 mm in size. The initial gingival recession was 4.45 mm in the L-PRF group and 4.02 mm in the group treated with connective tissue. In the study by Aroca et al21 that compared L-PRF membrane and coronally positioned flap methods, 43% of the defects in the L-PRF group were equal to or greater than 3 mm (average: 2.9 mm), and 33% of the defects in the CAF group were equal to or greater than 3 mm in size (average: 2.5 mm). Although Aroca et al21 only used CAFs in the test group, the current study included both CTGs and CAFs. In the current study, the closure amounts were measured as 3.41 mm (76.63%) for the L-PRF group and 3.11 mm (77.36%) for the CTG group. In the study by Aroca et al,21 these ratios were 2.3 mm (80.7%) for the L-PRF group and 2.3 mm (91.5%) for the CAF group. The percentage ratio is higher in the study by Aroca et al.21 However, the current study revealed a higher closure amount. Larger gingival recession defects
helped clarify the limitations of the treatment methods, which was critical for a more thorough evaluation. L-PRF, developed by Choukroun et al, was administered to the application site as soon as possible.3–7 The same method was used in the administration of the L-PRF clot and the L-PRF membrane. Aroca et al21 kept the L-PRF membrane stored at +4°C until surgery. The current authors believe that this practice is unfavorable for the platelets. It is known that storage at 4°C affects platelet morphology.26 Subsequent studies have demonstrated that exposure to cold temperatures results in platelet activation,26–29 seriously compromising the in vivo survival and hemostatic effectiveness of the platelets.29 In the current study, preparation of the implant site and L-PRF were performed simultaneously, and the L-PRF membrane was sutured to the recession site. In the recent 6-month randomized controlled clinical study by Jankovic et al,20 which compared L-PRF and CTG methods in the treatment of gingival recession, no difference could be found between procedures in gingival recession therapy, except for a greater gain
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113 in keratinized tissue width obtained in the CTG group and enhanced wound healing associated with the L-PRF group. Especially after CTG operations, the need for a second surgery negatively affects the comfort of the patient. Therefore, clinicians look for alternative techniques. Multiple clinical studies have also documented predictable and esthetic results with an acellular dermal graft, bioabsorbable membranes, and CTG with an enamel matrix derivative.1 When compared with the CTG, the L-PRF technique is a more atraumatic technique. As a result, when factors such as the success rate for gingival recession and patient comfort after surgery are considered, the L-PRF technique can be used as an alternative to the CTG. In the present study, surgical procedures have been performed in the same patient according to the splitmouth protocol. The limited number of patients can be considered to be the main limitation of this controlled clinical study. Studies with higher statistical power would contribute to the understanding of the efficiency of this platelet-rich product.
Conclusions Within the limitations of this study, the results demonstrated that the L-PRF membrane, in combination with a coronally repositioned flap procedure, is safe and effective for the treatment of Miller Class I and II gingival recession defects, without the significant morbidity or potential clinical difficulties associated with donor-site surgery.
Acknowledgments The authors would like to thank Dr Mustafa Gultepe for his kind help and assistance in all sections of the study. A part of this study was presented at the International Association for Dental Research General Session in San Diego, California, March 16–19, 2011. The authors reported no conflicts of interest related to this study.
References 1. Hofmänner P, Alessandri R, Laugisch O, et al. Predictability of surgical techniques used for coverage of multiple adjacent gingival recessions—A systematic review. Quintessence Int 2012;43:545–554. 2. Choukroun J, Adda F, Schoeffler C, Vervelle A. An opportunity in perioimplantology: The PRF [in French]. Implantodontie 2001;42:55–62. 3. Choukroun J, Diss A, Simonpieri A, et al. Platelet-rich fibrin (PRF): A secondgeneration platelet concentrate. Part IV: Clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:56–60. 4. 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 Radiol Endod 2006;101:299–303. 5. Dohan Ehrenfest 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;101:37–44. 6. Dohan Ehrenfest DM, Choukroun J, Diss A, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part II: Platelet-related biologic features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:45–50. 7. Dohan Ehrenfest DM, Choukroun J, Diss A, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part III: Leucocyte activation: A new feature for platelet concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:51–55.
8. O’Connell SM, Impeduglia T, Hessler K, Wang X-J, Carroll RJ, Dardik H. Autologous platelet-rich fibrin matrix as cell therapy in the healing of chronic lowerextremity ulcers. Wound Repair Regen 2008;16:749–756. 9. Braccini F, Tardivet L, Dohan Ehrenfest DM. The relevance of Choukroun’s Platelet-Rich Fibrin (PRF) during middle ear surgery: Preliminary results [in French]. Rev Laryngol Otol Rhinol (Bord) 2009; 130:175–180. 10. Del Corso M, Sammartino G, Dohan Ehrenfest DM. Re: “Clinical evaluation of a modified coronally advanced flap alone or in combination with a plateletrich fibrin membrane for the treatment of adjacent multiple gingival recessions: A 6-month study”. J Periodontol 2009; 80:1694–1697. 11. Mazor Z, Horowitz RA, Del Corso M, Prasad HS, Rohrer MD, Dohan Ehrenfest DM. Sinus floor augmentation with simultaneous implant placement using Choukroun’s platelet-rich fibrin as the sole grafting material: A radiologic and histologic study at 6 months. J Periodontol 2009;80:2056–2064. 12. Baeyens W, Glineur R, Evrard L. The use of platelet concentrates: Platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) in bone reconstruction prior to dental implant surgery. Rev Med Brux 2010;31: 521–527. 13. Gürbüzer B, Pikdöken L, Tunali M, Urhan M, Küçükodaci Z, Ercan F. Scintigraphic evaluation of osteoblastic activity in extraction sockets treated with platelet-rich fibrin. J Oral Maxillofac Surg 2010;68:980–989. 14. Sharma A, Pradeep AR. Autologous platelet-rich fibrin in the treatment of mandibular degree II furcation defects: A randomized clinical trial. J Periodontol 2011; 82:1396–1403. 15. Simonpieri A, Choukroun J, Del Corso M, Sammartino G, Dohan Ehrenfest DM. Simultaneous sinus-lift and implantation using microthreaded implants and leukocyte- and platelet-rich fibrin as sole grafting material: A six-year experience. Implant Dent 2011;20:2–12. 16. Carroll RC, Craft RM, Chavez JJ, Snider CC, Bresee SJ, Cohen EA. Thrombelastograph whole blood assay for clinical monitoring of NSAID-insensitive transcellular platelet activation by arachidonic acid. J Lab Clin Med 2005;146:30–35. 17. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8–13.
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18. Bruno J. Connective tissue graft technique assuring wide root coverage. Int J Periodontics Restorative Dent 1994;14: 127–137. 19. Del Pizzo M, Zucchelli G, Modica F, Villa R, Debernardi C. Coronally advanced flap with or without enamel matrix derivative for root coverage: A 2-year study. J Clin Periodontol 2005;32:1181–1187. 20. Jankovic S, Aleksic Z, Klokkevold P, et al. Use of platelet-rich fibrin membrane following treatment of gingival recession: A randomized clinical trial. Int J Periodontics Restorative Dent 2012;32:e41–e50. 21. 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;80:244–252.
22. Nelson SW. The subepithelial connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987;58: 95–102. 23. Harris RJ. The connective tissue and partial thickness double pedicle graft: A predictable method for obtaining root coverage. J Periodontol 1992;63:477–486. 24. De Sanctis M, Zucchelli G. Bilaminar techniques. In: De Sanctis M, Zucchelli G (eds). Soft Tissue Plastic Surgery. 2nd ed. Bologna: Martina, 1997:132–192. 25. Tözüm TF, Keçeli HG, Güncü GN, Hatipog˘lu H, Sengün D. Treatment of gingival recession: Comparison of two techniques of subepithelial connective tissue graft. J Periodontol 2005;76:1842–1848.
26. Zucker MB, Borelli J. Reversible alterations in platelet morphology produced by anticoagulants and by cold. Blood 1954;9: 602–608. 27. Kattlove HE, Alexander B. The effect of cold on platelets. I. Cold-induced platelet aggregation. Blood 1971;38:39–48. 28. Filip DJ, Aster RH. Relative hemostatic effectiveness of human platelets stored at 4 degrees and 22 degrees C. J Lab Clin Med 1978;91:618–624. 29. Peerschke EI, Zucker MB. Fibrinogen receptor exposure and aggregation of human blood platelets produced by ADP and chilling. Blood 1981;57:663–670.
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Clinical Evaluation of Autologous Platelet-Rich Fibrin in the Treatment of Multiple Adjacent Gingival Recession Defects: A 12-Month Study Mustafa Tunalı, DDS, PhD1 Hakan Özdemir, DDS, PhD2 Taner Arabacı, DDS, PhD3/Bahadır Gürbüzer, DDS, PhD4 M. Levent Pikdöken, DDS, PhD5/Erhan Fıratlı, DDS, PhD6
Leukocyte- and platelet-rich fibrin (L-PRF) belongs to a new generation of platelet concentrates. There are limited numbers of studies focused on the use of L-PRF in gingival recession defects. This study evaluated the safety and effectiveness of using L-PRF membranes as a substitute for free connective tissue grafts (CTGs) as a treatment method for gingival recession defects. A total of 44 Miller Class I/II gingival recessions that were bilateral, adjacent, and greater than 3 mm in size were selected. Each recession site was randomly assigned to the test group (L-PRF) or the control group (CTG). After 12 months, root coverage was 76.63% and 77.36% in the L-PRF and CTG groups, respectively. It is suggested that L-PRF membrane may be an alternative graft material for treating multiple adjacent recessions greater than 3 mm in size without a requirement for additional surgery. (Int J Periodontics Restorative Dent 2015;35:105–114. doi: 10.11607/prd.1826)
Associate Professor, Department of Periodontology, Gulhane Military Medical Academy, Istanbul, Turkey. 2Assistant Professor, Department of Periodontology, School of Dentistry, Cumhuriyet University, Sivas, Turkey. 3Associate Professor, Department of Periodontology, School of Dentistry, Atatürk University, Erzurum, Turkey. 4Professor, Department of Oral Surgery, Gulhane Military Medical Academy, Istanbul, Turkey. 5Associate Professor, Department of Periodontology, Gulhane Military Medical Academy, Istanbul, Turkey. 6Professor, Department of Periodontology, School of Dentistry, Istanbul University, Istanbul, Turkey. 1
Correspondence to: Dr Mustafa Tunalı, Department of Periodontology, Haydarpasa Training Hospital, Gulhane Military Medical Academy, Üsküdar, 34168 Istanbul, Turkey; email: [email protected]. ©2015 by Quintessence Publishing Co Inc.
The main goal of plastic periodontal surgical procedures is to achieve an optimal esthetic appearance with complete root coverage. A coronally advanced flap (CAF) with a connective tissue graft (CTG) is a predictable surgical procedure for the coverage of gingival recession and is considered to be the gold standard. For the CTG technique, the reported mean percentage of root coverage ranges between 65% and 98%. CTG continues to hold the most promise for root coverage.1 However, when the amount and thickness of the donor tissue is not sufficient, the application of the technique is limited to multiple adjacent gingival recessions and requires a second surgical procedure to achieve better esthetic results. Leukocyte- and platelet-rich fibrin (L-PRF) can be defined as an autologous biomaterial.2 Unlike other platelet-rich products, this material does not require an anticoagulant or bovine thrombin.3–7 It is simply centrifuged blood without any additives, which makes it possible to avoid all of the legal restrictions related to the reimplantation
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106 of blood-derived products. L-PRF is composed of a fibrin matrix polymerized in a tetramolecular structure and is involved in the joining of platelets, leukocytes, cytokines, and circulating stem cells. Slow fibrin polymerization during the processing of L-PRF leads to the intrinsic incorporation of platelet cytokines and glycan chains into the fibrin meshes. This result implies that, unlike other platelet concentrates, L-PRF may be able to progressively release cytokines during remodeling of the fibrin matrix. Such a mechanism might explain the clinically observed healing properties of L-PRF.6 L-PRF has also been shown to organize as a dense fibrin scaffold with a high number of leukocytes concentrated in one part of the clot and a particularly slow release of growth factors and glycoproteins over 7 days.6 Previous studies have demonstrated that viable platelets in L-PRF release growth factors such as platelet-derived growth factor AB, transforming growth factor β-1, and vascular endothelial growth factor. The benefits of L-PRF have been examined in various studies.7–16 The purpose of this clinical study was to evaluate the safety and effectiveness of L-PRF membranes combined with coronally repositioned flap surgery and to compare this procedure with free connective tissue grafts in combination with coronally repositioned flap surgery in the treatment of multiple adjacent Miller Class I/II gingival recession defects greater than 3 mm in size.
Method and materials Patient and site selection
The study protocol was submitted to the Institutional Ethics Committee and Review Board of Gulhane Military Medical Academy Haydarpasa Training Hospital, Istanbul, Turkey (1491-369-08/1539). The study was conducted between June 2009 and August 2011. All patients were provided detailed information about the surgical procedure, and written consent was obtained. Following patient examination, complete mouth scaling and polishing were performed, and oral hygiene instructions were given. At the end of the initial treatment phase, the patients displayed full-mouth plaque scores17 above 15%. Ten systemically healthy patients, each with multiple adjacent Miller Class I/II buccal gingival recession defects greater than 3 mm in size, were included in this study. The inclusion criteria were as follows: (1) presence of multiple bilateral defects with recession depths greater than 3 mm when measured from the cementoenamel junction (CEJ) of the anterior teeth or premolars; (2) having Miller Class I or Class II recession defects with similar contralateral lesions; (3) having selected teeth that were vital, free of restorations, and did not bleed upon probing; and (4) having had no prior surgical treatment in the area to be covered. The exclusion criteria were as follows: smoking, any uncontrolled local or systemic disease that might be a contraindication for periodontal surgery,
pregnancy or lactation, severe immune deficiency, coagulation defect, or current anticoagulation treatment. Ten patients, six women and four men ranging in age between 25 and 52 years (mean age: 34.2 years), with a total of 44 affected teeth (22 treated with L-PRF and 22 treated with CTG) completed the study.
Clinical measurements
All clinical measurements were performed by one of the investigators (HO), who was blinded to the type of surgical procedure. The investigator was unaware of group assignments and demonstrated an acceptable level of intraexaminer agreement for all measurements. Repeat measurements were performed 30 minutes after the initial measurements. The investigator was required to demonstrate reproducibility within 1 mm on ≥ 95% and ≥ 90% of measurements for gingival recession (GR) and probing depth (PD), respectively. The following measurements were taken at baseline and 6 months and 12 months after surgery using a Michigan O periodontal probe: GR, distance from CEJ to the gingival margin; PD, distance from the gingival margin to the base of the gingival crevice; clinical attachment level (CAL), distance from CEJ to the base of the gingival crevice; and keratinized tissue width (KTW), distance from the gingival margin to the mucogingival junction (MGJ). The measurements were taken on the midbuccal aspects and rounded to the nearest 0.5 mm. The first site was selected for one of the two
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107 Fig 1 Leukocyte- and platelet-rich fibrin (L-PRF) procedure. (a) L-PRF clot tube. (b) L-PRF clot. (c) L-PRF membrane.
a
experimental groups incidentally, and the second site was consecutively added to the opposite group by one of the authors (BG). The percentages of root coverage (RC) and attachment gain (AG) were calculated according to the following formulas: RC = ([preoperative vertical recession – postoperative vertical recession] / preoperative vertical recession) × 100; AG = ([preoperative attachment level – postoperative attachment level] / preoperative attachment level) × 100.
L-PRF procedure
The L-PRF was prepared according to the protocol developed by Choukroun et al in 2001 (Process Protocol).2 Immediately prior to surgery, 10 mL of blood was drawn from each patient by venipuncture of the antecubital vein and collected in a sterile glass test tube without any anticoagulant. The blood was quickly collected, and the tubes were immediately centrifuged at 2,700 rpm for 12 minutes5 using a Hettich Universal 320 table centrifuge (Hettich Instruments) at room
b
temperature. Because of differential densities, centrifugation resulted in separation of the following three basic fractions: red blood cells at the bottom, acellular plasma on the surface, and an L-PRF clot formed in the middle part of the tube (Fig 1a). After centrifugation, the L-PRF clots were removed from the tubes using sterile tweezers (Fig 1b) and placed on sterile woven gauze. Clots were emptied from their serum by compressing them between two pieces of woven gauze. L-PRF membranes were prepared by compressing clots between two pieces of woven gauze (Fig 1c).
Donor site
The CTG was harvested from the patient’s palate.18 The first incision on the palate was made parallel to the long axis of the teeth, approximately 4 mm apical to the gingival margin. The second incision was made parallel to the surface of the palate, 1 to 2 mm apical to the first incision. A small periosteal elevator was used to raise a tissue graft. The donor tissue was removed as
c
atraumatically as possible. Utilizing 5-0 silk sutures, a continuous suture with a locking technique was used to approximate the wound on the palate. After harvesting the graft, a 1- to 2-mm band of epithelium at the coronal aspect of the donor tissue, and abundant fatty parts, were removed. The graft was trimmed to a thickness of 1.5 mm.
Surgical procedures
Each patient received L-PRF and CTG surgeries on bilateral defects. The surgical procedures in both study groups were performed by one surgeon (MT). The sides for L-PRF and CTG were randomly determined by a coin toss. After local anesthesia (Ultracain D-S Forte, Hoechst Marion Roussel) was administered to donor and recipient sites, root planing of exposed root surfaces was carried out to reduce convexity and thus decrease the avascular surface area under the graft. The area was irrigated with sterile saline. The initial horizontal right-angle incision was beveled into the adjacent interdental papillae at or slightly coronal to the CEJ
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108 of the tooth with an exposed root surface. A full-thickness flap was reflected beyond the MGJ and at least 5 mm apical to the most apical margin of the bony dehiscence. The flap was further released by sharp dissection. The mesiodistal length of the incision was extended to the nearest distal line angle of the most mesial and distal teeth involved. A mesial vertical releasing incision was made during each procedure. A measurement of the approximate width necessary for the graft was obtained with a periodontal probe. All papillae were deepithelialized to create a connective tissue bed. At the test sites, the previously prepared fibrin clot was positioned over the recession defects, directly below the CEJ. The grafts were placed over the exposed roots and stabilized using a 5-0 bioabsorbable sling suture (Ethicon). The flaps were then coronally positioned to completely cover the graft and sutured directly over the graft with 4-0 silk sutures. Donor tissue was covered with the overlying flap as much as possible to provide more blood supply to the graft. Vertical incisions were also closed with 4-0 silk sutures. Mild pressure was applied for 5 minutes using gauze soaked in saline.
Postoperative care
A dry piece of foil was applied to the recipient area in both groups. Then, a noneugenol periodontal dressing (Voco Pac) was placed over the dry foil to stabilize and protect the donor tissue for 14 days postoperatively. The patients were given a cold
compress extraorally to minimize swelling and bleeding during the postoperative period. All patients were given appropriate antibiotics and analgesics (amoxicillin 1,000 mg twice a day for 5 days and naproxen sodium 550 mg twice a day). The patients used a 0.12% chlorhexidine gluconate mouthrinse (Klorhex, Drogsan) and were instructed to gently rinse twice daily for 1 minute for a total of 2 weeks. The patients were advised not to brush their teeth in the surgical areas. Two weeks after surgical treatment, the surgical wounds were gently cleansed with a 0.12% chlorhexidine digluconate solution. Afterwards, gentle brushing with a surgical toothbrush was recommended.
Statistical analysis
The statistical analysis was performed using a commercially available software program (SPSS version 16.0, SPSS). The results were averaged (mean ± SD) for all clinical parameters at baseline and 6 months and 12 months after treatment. After evaluation of normality with the KolmogorovSmirnov test, data were analyzed with the Mann-Whitney U test following the Kruskal-Wallis test (intergroup comparison) and the Wilcoxon signed-rank test (intragroup comparison). Differences of P < .05 were considered statistically significant. An a priori statistical power analysis using a software program (PC-Size, G.E. Dallal) was performed considering that the test and control groups were not
independent, under the hypothesis of normality for the variables examined. An alpha of .05 was selected for calculation. The required sample size was 22 in groups with a statistical power of 80%.19
Results There were no statistically significant differences between the recession-type defects in the two groups at baseline. All patients completed the study, and they did not show any altered wound healing. The statistical analyses for the clinical parameters at baseline and 6 months and 12 months posttreatment for both groups are presented in Table 1. Mean gingival recessions of 4.45 ± 0.18 mm and 4.02 ± 0.12 mm were determined for cases treated with the L-PRF (Table 2) and the CTG (Table 3) techniques, respectively. Six months after surgery, a significant decrease in recession depth was noted in both groups, and the mean remaining recession values were 1.14 ± 0.06 mm (P < .001) and 1.14 ± 0.04 mm (P < .001) in the L-PRF and CTG groups, respectively. At 12 months, the mean residual recession values were 1.05 ± 0.04 mm (P < .001) and 0.98 ± 0.05 mm (P < .001) in the L-PRF and CTG groups, respectively. In both groups, PDs significantly decreased after treatment (P < .001). The PD values were 1.33 ± 0.59 mm and 1.49 ± 0.50 mm at baseline, 1.24 ± 0.37 mm and 1.13 ± 0.35 mm at 6 months and 1.18 ± 0.33 mm and 1.18 ± 0.35 mm at 12 months in the L-PRF
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Table 1 Clinical parameters (mean ± SD) of the treated sites at baseline and 6 and 12 months postoperatively
Parameter PD (mm) CAL (mm) KTW (mm)
Group
Recessions Baseline (n) (mean ± SD)
L-PRF CTG L-PRF CTG L-PRF CTG
22 22 22 22 22 22
1.33 ± 0.59 1.49 ± 0.50 5.03 ± 1.94 5.20 ± 1.49 2.33 ± 0.56 2.43 ± 0.52
6 mo (mean ± SD)
12 mo (mean ± SD)
1.24 ± 0.37 1.13 ± 0.35 2.27 ± 0.92 2.24 ± 0.82 2.93 ± 0.70 2.93 ± 0.71
1.18 ± 0.33 1.18 ± 0.35 2.33 ± 0.90 2.16 ± 0.79 2.86 ± 0.69 3.03 ± 0.74
Baseline to 12 mo
Baseline to 6 mo z score
P
z score
P
–0.57 –2.02 –3.19 –3.44 –2.99 –2.99
.57 .04* .00* .00* .00* .00*
–0.78 –1.85 –3.19 –3.44 –2.44 –2.85
.44 .06 .00* .00* .02* .00*
PD = probing depth; CAL = clinical attachment level; KTW = keratinized tissue width; L-PRF = leukocyte- and platelet-rich fibrin; CTG = connective tissue graft. *Statistically significant difference (P < .05).
Table 2 Individual recession and root coverage results of the leukocyte- and platelet-rich fibrin sites
Patient 1 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 10 Mean
Tooth*
Miller Class
13 12 11 45 44 44 43 23 24 22 23 23 24 13 14 44 45 24 25 43 44 45
I II I II II I I I II I I II II II II II I I I I II II
Initial recession Recession (mm) (mm) 5.0 7.0 5.0 4.0 3.5 4.0 3.0 3.0 4.0 3.0 5.0 6.0 4.0 5.0 5.0 5.0 4.0 3.0 3.5 6.0 5.0 5.0 4.45
0.0 2.0 0.5 1.5 1.0 2.5 0.5 0.0 0.5 0.5 0.5 3.0 1.5 2.0 2.0 1.5 1.0 0.0 0.0 2.0 1.5 1.0 1.14
6 mo Coverage (mm) 5.0 5.0 4.5 2.5 2.5 1.5 2.5 3.0 3.5 2.5 4.5 3.0 2.5 3.0 3.0 3.5 3.0 3.0 3.5 4.0 3.5 4.0 3.32
12 mo Coverage (%) 100 72 90 63 72 38 83 100 88 84 90 50 63 60 60 70 75 100 100 67 70 80 74.61
Recession (mm) 0.0 2.0 0.5 1.0 1.0 1.5 0.5 0.5 0.5 0.5 1.0 2.5 1.5 2.0 2.0 1.0 1.0 0.0 0.0 2.0 1.5 0.5 1.05
Coverage (mm) 5.0 5.0 4.5 3.0 2.5 2.5 2.5 2.5 3.5 2.5 4.0 3.5 2.5 3.0 3.0 4.0 3.0 3.0 3.5 4.0 3.5 4.5 3.41
Coverage (%) 100 72 90 75 72 63 83 83 88 83 80 58 63 60 60 80 75 100 100 67 70 90 76.63
*FDI tooth-numbering system.
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Table 3 Individual recession and root coverage results of the connective tissue graft sites Initial recession Recession (mm) (mm)
6 mo
Tooth*
Miller Class
1
23
II
6.0
2.0
4.0
1
24
II
5.0
2.0
3.0
2
34
II
4.0
0.5
2
35
II
4.0
3
34
I
3.0
3
35
II
3.0
1.5
1.5
50
1.5
1.5
50
4
13
I
4.0
0.5
3.5
88
0.0
4.0
100
4
14
I
3.0
0.5
2.5
83
0.5
2.5
83
5
12
I
4.0
1.0
3.0
75
0.0
4.0
100
Patient
Coverage (mm)
12 mo Coverage (%)
Recession (mm)
Coverage (mm)
Coverage (%)
67
2.0
4.0
67
60
2.0
3.0
60
3.5
88
0.5
3.5
88
0.5
3.5
88
0.5
3.5
88
1.0
2.0
67
1.0
2.0
67
5
13
I
4.0
1.0
3.0
75
0.0
4.0
100
6
13
II
5.0
1.5
3.5
70
1.5
3.5
70
6
14
I
4.0
2.0
2.0
50
2.0
2.0
50
7
22
II
4.0
1.5
2.5
63
1.5
2.5
63
7
23
I
4.0
1.5
2.5
63
1.5
2.5
63
7
24
I
4.0
1.5
2.5
63
1.5
2.5
63
8
34
II
4.5
1.0
3.5
78
1.0
3.5
78
8
35
I
3.5
1.0
2.5
71
0.5
3.0
86
9
13
I
4.0
0.0
4.0
100
0.0
4.0
100
9
14
I
3.0
0.0
3.0
100
0.0
3.0
100
10
33
I
4.0
1.0
3.0
75
0.5
3.5
88
10
34
I
3.5
1.5
2.0
57
1.5
2.0
57
10
35
II
5.0
2.0
3.0
60
2.0
3.0
60
4.02
1.14
2.98
74.13
0.98
3.11
77.36
Mean *FDI tooth-numbering system.
and CTG groups, respectively. The L-PRF and CTG procedures resulted in a significant attachment gain at 6 months and 12 months (see Table 1). There were no significant differences in the CAL between the two groups. Both groups showed a significant increase in the KTW from baseline to 12 months; however, there were no statistically
significant differences in the KTW between the two groups at baseline or at 12 months (see Table 1). When compared with the untreated teeth, both treatments resulted in statistically significant improvements in the degree of root coverage at 6 and 12 months (Figs 2 and 3), which were 74.61% and 76.63% for the L-PRF group and 74.13%
and 77.36% for the CTG group, respectively. At 6 months, the mean root coverage values were 3.32 ± 0.12 mm and 2.98 ± 0.13 mm in the L-PRF and CTG groups, respectively. At 12 months, the mean root coverage values were 3.41 ± 0.10 mm and 3.11 ± 0.10 mm in the L-PRF and CTG groups, respectively (Table 4).
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a
b
c
d
e
f
Fig 2 Leukocyte- and platelet-rich fibrin (L-PRF) side. (a) Preoperative view of the recession defects in the maxillary left lateral incisor and canine region. (b) After L-PRF membrane application and suturing. (c) Three weeks after the surgical procedure, (d) at 8 weeks, (e) at 6 months, and (f) at 12 months after the surgical procedure. Fig 3 Connective tissue graft side of the same patient. (a) Preoperative view of the recession defects in the maxillary right lateral incisor and canine region. (b) Eight weeks after the surgical procedure, (c) at 6 months, and (d) at 12 months after the surgical procedure.
a
b
c
d
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Table 4 Mean recession and root coverage parameters 6 mo
12 mo
Initial recession (mm)
Recession (mm)
Coverage (mm)
Coverage (%)
Recession (mm)
Coverage (mm)
Coverage (%)
L-PRF
4.45
1.14
3.32
74.61
1.05
3.41
76.63
CTG
4.02
1.14
2.98
74.13
0.98
3.11
77.36
Treatment group
Discussion The results of the study demonstrate that both autogenous L-PRF and CTG are effective treatment methods for gingival recession defects, with significant root coverage (76.63% and 77.36%, respectively) and clinical attachment gain (2.90 mm and 3.04 mm, respectively) 12 months after surgery. All patients noticed highly successful esthetic results 12 months following surgery. The differences between the two techniques in terms of recession reduction and attachment gain are not statistically significant. The amount of keratinized gingival tissue in both groups was found to be increased by 0.6 mm. Previous studies10,20 evaluated the use of L-PRF for treatment of multiple gingival recessions with a CAF procedure and found significant improvement in the early periodontal healing phase. The results of the current study are consistent with the results of Del Corso et al.10 However, another study21 compared the L-PRF membrane and CAF methods and did not find any difference between the thickness of gingival tissue at baseline and after 6 months. Previous studies have re-
ported that the treatment degree of gingival defects differs based on site, type, and size of the defect.22–25 The Miller Class I and II defects included in the authors’ study are equal to or greater than 3 mm in size. The initial gingival recession was 4.45 mm in the L-PRF group and 4.02 mm in the group treated with connective tissue. In the study by Aroca et al21 that compared L-PRF membrane and coronally positioned flap methods, 43% of the defects in the L-PRF group were equal to or greater than 3 mm (average: 2.9 mm), and 33% of the defects in the CAF group were equal to or greater than 3 mm in size (average: 2.5 mm). Although Aroca et al21 only used CAFs in the test group, the current study included both CTGs and CAFs. In the current study, the closure amounts were measured as 3.41 mm (76.63%) for the L-PRF group and 3.11 mm (77.36%) for the CTG group. In the study by Aroca et al,21 these ratios were 2.3 mm (80.7%) for the L-PRF group and 2.3 mm (91.5%) for the CAF group. The percentage ratio is higher in the study by Aroca et al.21 However, the current study revealed a higher closure amount. Larger gingival recession defects
helped clarify the limitations of the treatment methods, which was critical for a more thorough evaluation. L-PRF, developed by Choukroun et al, was administered to the application site as soon as possible.3–7 The same method was used in the administration of the L-PRF clot and the L-PRF membrane. Aroca et al21 kept the L-PRF membrane stored at +4°C until surgery. The current authors believe that this practice is unfavorable for the platelets. It is known that storage at 4°C affects platelet morphology.26 Subsequent studies have demonstrated that exposure to cold temperatures results in platelet activation,26–29 seriously compromising the in vivo survival and hemostatic effectiveness of the platelets.29 In the current study, preparation of the implant site and L-PRF were performed simultaneously, and the L-PRF membrane was sutured to the recession site. In the recent 6-month randomized controlled clinical study by Jankovic et al,20 which compared L-PRF and CTG methods in the treatment of gingival recession, no difference could be found between procedures in gingival recession therapy, except for a greater gain
The International Journal of Periodontics & Restorative Dentistry © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
113 in keratinized tissue width obtained in the CTG group and enhanced wound healing associated with the L-PRF group. Especially after CTG operations, the need for a second surgery negatively affects the comfort of the patient. Therefore, clinicians look for alternative techniques. Multiple clinical studies have also documented predictable and esthetic results with an acellular dermal graft, bioabsorbable membranes, and CTG with an enamel matrix derivative.1 When compared with the CTG, the L-PRF technique is a more atraumatic technique. As a result, when factors such as the success rate for gingival recession and patient comfort after surgery are considered, the L-PRF technique can be used as an alternative to the CTG. In the present study, surgical procedures have been performed in the same patient according to the splitmouth protocol. The limited number of patients can be considered to be the main limitation of this controlled clinical study. Studies with higher statistical power would contribute to the understanding of the efficiency of this platelet-rich product.
Conclusions Within the limitations of this study, the results demonstrated that the L-PRF membrane, in combination with a coronally repositioned flap procedure, is safe and effective for the treatment of Miller Class I and II gingival recession defects, without the significant morbidity or potential clinical difficulties associated with donor-site surgery.
Acknowledgments The authors would like to thank Dr Mustafa Gultepe for his kind help and assistance in all sections of the study. A part of this study was presented at the International Association for Dental Research General Session in San Diego, California, March 16–19, 2011. The authors reported no conflicts of interest related to this study.
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