CASE REPORT

Platelet-Rich Fibrin in the Treatment of Bilateral Gingival Recessions

Glnihal Eren* and Gl Atilla*

Introduction: Subepithelial connective tissue graft (SCTG) coronally advanced flap (CAF) has been suggested as the most predictable technique for treatment of recession defects. However, the SCTG technique necessitates a second surgical site and increases the risk of morbidity linked with harvesting the autogenous palatal donor mucosa. Platelet-rich fibrin (PRF) has been shown to accelerate soft-tissue healing. The use of PRF in treatment of gingival recessions eliminates the requirement of a donor site. The aim of this case report is to evaluate the clinical effectiveness of the CAFPRF combined technique and CAFSCTG in the treatment of bilateral gingival recessions. Case Presentation: The surgical treatment of a 23-year-old female patient with bilateral gingival recessions in maxillary cuspids is discussed in this case report. Sites were randomly assigned to CAFPRF (test) or CAFSCTG (control) sites. Clinical periodontal parameters were recorded and clinical photographs were taken at baseline; 1, 3, and 6 months; and 1 year. The recession area was analyzed with a digital image analysis program. In addition, gingival thickness was evaluated at baseline and at 1 year. Conclusions: Root coverage amount, gingival thickness, and keratinized tissue width were improved in both sites. The outcomes remained stable for 1 year. CAFPRF presents an alternative to CAFSCTG in the treatment of gingival recessions. The PRF method is practical and simple to perform. Additionally, PRF seems to be superior to SCTG since it eliminates the requirement of a donor site. Clin Adv Periodontics 2012;2:154-160.
Key Words: Blood platelets; connective tissue; fibrin; gingival recession; wound healing.

Background
Gingival recession is the apical migration of the gingival margin beyond the cemento-enamel junction (CEJ). The recession of the gingiva results in attachment loss and root surface exposure, which causes esthetic concerns and root hypersensitivity. Also, gingival recession increases the risk of root caries and cervical abrasion.1 Several surgical procedures have been suggested to treat gingival recessions. These include laterally positioned flap,2 free gingival graft,3 the coronally advanced flap
_ * Department of Periodontology, Ege University, School of Dentistry, Izmir, Turkey.
Submitted July 28, 2011; accepted for publication September 9, 2011 doi: 10.1902/cap.2012.110074

(CAF),4 subepithelial connective tissue graft (SCTG)5 and guided tissue regeneration with membranes,6 enamel matrix derivative (EMD)7 or the application of an acellular dermal matrix (ADM),8 platelet-rich plasma (PRP),9 and platelet-rich fibrin (PRF)10 in combination with CAF. Among these treatment options, the CAFSCTG was accepted as the gold standard to alternative techniques. However, this technique necessitates another surgical site in the palatal area to harvest donor tissue and increases the risk of morbidity. Discomfort and post-surgical bleeding may be seen in the palatal area. Also, if the patient has thin palatal tissues, it is difficult to harvest sufficient donor tissue from a single site. An additional donor site may be required when multiple defects are present, leading to multiple surgeries. With the use of alternative materials, potential morbidity associated with root coverage techniques could be reduced.

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FIGURE 1 Buccal view of the recession defect on the test site (1a) and the
control site (1b). Scale bar 4 mm.

FIGURE 3 Surgical incisions performed on test (3a) and control (3b) sites.

FIGURE 2 Glass-coated plastic tube after PRF centrifugation (2a) and the
obtained PRF clot after centrifugation (2b).

CAFEMD, CAFADM, and CAFPRP have been compared to CAFSCTG in treatmeant of gingival recessions.11,12 None of them matched the effectiveness of CAFSCTG regarding clinical measurements. PRF is defined as an autologous leukocyte and PRF biomaterial.13 The advantages of PRF technique over the betterknown PRP include ease of preparation and lack of requiring anticoagulant and bovine thrombin.14 Slowly composed dense fibrin matrix makes PRF a manipulative material; hence, it can be trimmed, adapted, and sutured easily. PRF
Eren, Atilla

FIGURE 4 Placing and suturing the PRF membrane to the recipient bed.

was used in periodontal procedures, including furcation defects,15 sinus floor augmentation,16 and intrabony defects.17 PRF was also used as a membrane to treat multiple gingival recessions.10 The natural fibrin architecture of PRF seems responsible for releasing high amounts of growth factors (transforming growth factor-b, platelet-derived growth factor, and vascular endothelial growth factor) and other matrix
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FIGURE 6 Preoperative view (6a) of recession on the test site and 1 year
after surgery (6b). Scale bar 4 mm.

FIGURE 5 The flaps were coronally positioned to completely cover the

grafts. 5a Test site. 5b Control site.

glycoproteins (thrombospondin-1) for 7 days.18 These biochemical components of PRF are involved in wound healing and postulated as promoters of tissue regeneration.18 Additionally, PRF has been reported to act as an appropriate scaffold for breeding human periosteal cells in vitro.19 PRF also induces proliferation of different cells in vitro, with strongest induction effect on osteoblasts.18 Considering that PRF may enhance the healing potential of soft tissues as well as bone, we hypothesized that it can be a potential grafting material for the treatment of gingival recessions. Its placement under CAF in recession defects could be as effective as the CAFSCTG technique. The following case report illustrates treatment of bilateral gingival recessions with CAFPRF versus CAFSCTG and the clinical outcomes of a 1-year period in one patient.

Clinical Presentation
A 23-year-old female patient with bilateral gingival recessions on maxillary cuspids was referred to the Department of Periodontology at Ege University School of Dentistry in
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April 2010 and provided written informed consent to participate in this study. Study protocol was approved by the Ethics Committee of the Ege University School of Medicine (2010; no:10-9/5). The patient was a non-smoker and had non-contributory medical history, but complained about dentin hypersensitivity and esthetic concerns. An intraoral examination revealed that maxillary cuspids were more prominent in the dental arch. According to the Miller classification,20 there was a 3.9-mm Class I facial recession defect on the maxillary right cuspid and a 3.8-mm Class I facial recession defect on the maxillary left cuspid (Fig. 1). The preoperative OLeary plaque score21 in this patient was 15%. The measurements were taken by one investigator (GE). With the use of a 4-mm-long wire, standardized photographs were taken. Clinical periodontal parameters, including recession depth, recession width, recession area, and keratinized tissue width, were analyzed with a digital image analysis program at baseline; 1, 3, and 6 months; and 1 year. Probing depth (PD) measurements were performed using a manual probe. Gingival thickness was assessed at

ImageJ for Windows, National Institutes of Health, Bethesda, MD. Williams probe, Hu-Friedy, Chicago, IL.

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layer consisted of acellular plasma, and the bottom-most layer consisted of red blood cells (Fig. 2). The fibrin clot was removed from the tube and separated by microsurgical scissors as described previously.22 PRF was squeezed in a special metal box that produces membranes at a constant thickness of 1 mm. Then the membrane was doubled by placing one part onto the other.

Surgical Intervention
The recession sites were prepared similar to the technique described by Langer and Langer.5 After achieving local anesthesia using 2% lidocaine, epinephrine at 1:100,000, sulcular incisions were made on the recipient teeth and joined to horizontal incisions extending into the adjacent interdental areas slightly coronal to the CEJ. The horizontal incisions were connected to two vertical incisions that began at the line angles of the adjacent teeth. A trapezoidalshaped, partial-thickness flap was elevated, providing a vascular connective tissue bed for placement of the selected graft material. Recession defects were thoroughly scaled using curets.k With microsurgical instruments and 2.5 loupes,{ incisions were made with a 15-C blade# on each recipient tooth (Fig. 3). A connective tissue graft was obtained from the palate with a scalpel with parallel blades (1.5 mm apart)** as described previously.23 The epithelial border was trimmed and discarded. The palatal donor site was sutured. At each site, both grafts extended apically beyond the apical base of the recession defect by 3 mm. At the test site, PRF membrane (2-mm thick) and at the control site harvested donor tissue (1.5-mm thick) were placed over the dehiscence (Fig. 4). Both grafts were secured to the interdental papillae and adjacent soft tissue at the apical part with horizontal mattress sutures. Each partial-thickness flap was further released and positioned over the graft to cover the CEJ and sutured with polypropylene sutures (Fig. 5). Gentle pressure was applied for 3 minutes to minimize the thickness of clot between flap and grafted tissue. The patient was given a 400 mg non-steroidal anti-inflammatory drug as needed for pain and advised not to brush the operated teeth but to clean them with a cotton pellet. Sutures were removed 10 days later and plaque control was reinforced. The patient was instructed in mechanical tooth cleaning in the operative areas using a soft-bristle brush. At each postoperative visit, supragingival plaque was removed using an ultrasonic device.

FIGURE 7 Preoperative view (7a) of recession on the control site and 1

year after surgery (7b). Scale bar 4 mm.

a mid-buccal location 1 mm apically to the bottom of the sulcus using a #15 endodontic reamer with a silicone disk stop. The mucosal surface was pierced at a 908 angle with slight pressure until hard tissue was reached. The silicone stop on the reamer was slid until it was in close contact with the gingiva. After removal of the reamer, the distance between the tip of the reamer and the inner border of the silicone stop was measured to the nearest 0.1 mm with calipers. Gingival thickness was evaluated at baseline and 1 year.

Case Management
Treatment procedure of test and control sites was determined by tossing a coin. The test site was treated with the CAFPRF, whereas the control site received CAFSCTG.

PRF Preparation
Before surgery in the test side, intravenous blood was collected in a 10-mL glass-coated plastic tube without any anticoagulant and centrifuged immediately using a table centrifugex for 12 minutes at z400 g.13 The PRF clot and membrane were prepared as described by Choukroun et al.22 The coagulation cascade led to the formation of a natural fibrin clot in the middle of the tube. The top-most
Eren, Atilla
x

NF200, Nve, Ankara, Turkey. Gracey curets, Hu-Friedy. { Binocular loupes, Heine, Herrsching, Germany. # Swann-Morton, Sheffield, UK. ** Harris Double Blade Graft Knife, H & H Company, Ontario, CA. san Surgical Sutures, Istanbul, Turkey. Dog Etodolac, Etol Fort, Nobel, Istanbul, Turkey.
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TABLE 1 Clinical Parameters at Baseline; 1, 3, and 6 Months; and 1 Year Baseline Parameters Test Control 1 Month Test Control 3 Months Test Control 6 Months Test Control Test 1 Year Control

Recession depth (mm) Recession width (mm) Recession area (mm2) Keratinized tissue width (mm) PD (mm) Gingival thickness (mm)
d not recorded.

3.88 3.67 7.57 0.80 1.0 0.94

3.78 3.42 6.45 2.10 1.0 0.90

0.3 1.9 0.71 1.74 d d

0.28 0.9 0.37 2.60 d d

0.3 1.9 0.71 2.0 1.0 d

0 0 0 3.20 2.0 d

0.3 1.9 0.71 2.0 1.0 d

0 0 0 3.20 2.0 d

0 0 0 2.0 1.0 1.10

0 0 0 3.20 2.0 1.27

Clinical Outcomes
Healing was uneventful at both sites (Figs. 6 and 7). Pre- and post-surgical clinical periodontal measurements are shown in Table 1. Complete root coverage was accomplished in both treatment modalities, and the outcomes remained stable for 1 year.

Discussion
The objectives of this case report are to demonstrate 1-year outcomes of the CAFPRF and CAFSCTG techniques and to investigate the efficiency of PRF as a substitute material to palatal donor tissue in root coverage treatments. To the best of our knowledge, this is the first case report to test whether CAFPRF could be an alternative to the gold-standard procedure CAFSCTG. Our result show that gingival recessions can be treated with the patients own autologous material without the need for complicated techniques or expensive materials. Platelet concentrates have been suggested for use in periodontal surgery for many years.24 PRP is primarily referred as an adjunctive autogenous material, but not an alternative to SCTG.25 However, in one study, Cheung and Griffin12 compared the effectiveness of platelet concentrate graft versus SCTG and found that both techniques can effectively

treat shallow recessions. PRF is a second-generation platelet concentrate, and there are few references that provide information about the clinical effectiveness of PRF in the treatment of gingival recessions.10,26 Aroca et al.10 showed that CAF surgery alone or CAF in combination with PRF is an effective procedure in the treatment of multiple gingival recessions. However, to our knowledge, there are no studies that evaluate clinical outcomes of CAFPRF versus CAFSCTG in bilateral gingival recessions. According to the results of this present case report, complete root coverage is achieved, and gingival thickness and keratinized tissue width increased with both procedures. Within the limits of this case report, PRF appears to act like SCTG and provides a living-tissue scaffold that can be suggested to treat gingival recessions without the morbidity of graft harvest. Although there are still many areas currently unknown about the histologic and long-term clinical performance of PRF, this technique is less invasive and promising and should be investigated with additional clinical case-control studies. The present case report demonstrates that gingival recessions can be successfully treated with the patients own autologous blood-derived material, without an additional donor site. This can be accepted as a guide for soft-tissue grafting procedures. n

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Summary
Why is this case new information?
j

Clinical reports showing effectiveness of PRF in the treatment of gingival recessions are very limited. To the best of our knowledge, this is the first case report that assesses the clinical outcomes of CAFPRF versus CAFSCTG in the treatment of gingival recessions. Important requirements include: atraumatic microsurgical approach; a systemically healthy, non-smoker patient; PRF derivation with appropriate technique; and good oral hygiene.

What are the keys to successful management of this case?

What are the primary limitations to success in this case?

Additional clinical case-control studies are needed to evaluate the effectiveness of PRF. j In addition, studies are needed to demonstrate the histologic findings that can clearly explain the wound-healing process after PRF application.
j

Acknowledgment
The authors report no conflicts of interest related to this case report.

CORRESPONDENCE: Dr. Glnihal Eren, Ege University, School of Dentistry, Department of Periodontology, Bornova 35100, I_zmir, Turkey. E-mail: gulnihal_karasu@ hotmail.com.

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References
1. Wennstrom J, Pini Prato GP. Mucogingival therapy. In: Lindhe J, Karring T, Lang NP, eds. Clinical Periodontology and Implant Dentistry. Copenhagen: Munksgaard: 1997:569-591. 2. Grupe HE, Warren RF. Repair of gingival defects by a sliding flap operation. J Periodontol 1956;27:92-95. 3. Sullivan HC, Atkins JH. Free autogenous gingival grafts. 3. Utilization of grafts in the treatment of gingival recession. Periodontics 1968;6: 152-160. 4. Allen EP, Miller PD Jr. Coronal positioning of existing gingiva: Short term results in the treatment of shallow marginal tissue recession. J Periodontol 1989;60:316-319. 5. Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-720. 6. Tinti C, Vincenzi G, Cortellini P, Pini Prato G, Clauser C. Guided tissue regeneration in the treatment of human facial recession. A 12-case report. J Periodontol 1992;63:554-560. 7. Moses O, Artzi Z, Sculean A, et al. Comparative study of two root coverage procedures: A 24-month follow-up multicenter study. J Periodontol 2006;77:195-202. 8. Aichelmann-Reidy ME, Yukna RA, Evans GH, Nasr HF, Mayer ET. Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession. J Periodontol 2001;72:998-1005. 9. Shepherd N, Greenwell H, Hill M, Vidal R, Scheetz JP. Root coverage using acellular dermal matrix and comparing a coronally positioned tunnel with and without platelet-rich plasma: A pilot study in humans. J Periodontol 2009;80:397-404. 10. 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. 11. Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: A systematic review. J Clin Periodontol 2008;35(Suppl. 8):136-162. 12. Cheung WS, Griffin TJ. A comparative study of root coverage with connective tissue and platelet concentrate grafts: 8-month results. J Periodontol 2004;75:1678-1687. 13. Dohan 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:e37-e44.

14. Toffler M, Toscano N, Holtzclaw D, Del Corso M, Ehrenfest DD. Introducing Choukrouns platelet rich fibrin (PRF) to the reconstructive surgery milieu. J Implant Adv Clin Dent 2009;1:21-32. 15. 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. 16. Mazor Z, Horowitz RA, Del Corso M, Prasad HS, Rohrer MD, Dohan Ehrenfest DM. Sinus floor augmentation with simultaneous implant placement using Choukrouns platelet-rich fibrin as sole grafting material: A radiologic and histologic study at 6 months. J Periodontol 2009;80:2056-2064. 17. Sharma A, Pradeep AR. Treatment of 3-wall intrabony defects in patients with chronic periodontitis with autologous platelet-rich fibrin: A randomized controlled clinical trial. J Periodontol 2011: 82:1705-1712. 18. Dohan Ehrenfest DM, Diss A, Odin G, Doglioli P, Hippolyte MP, Charrier JB. In vitro effects of Choukrouns PRF (platelet-rich fibrin) on human gingival fibroblasts, dermal prekeratinocytes, preadipocytes, and maxillofacial osteoblasts in primary cultures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:341-352. il Y, Wiltfang J, Becker ST. 19. Gassling V, Douglas T, Warnke PH, Ac Platelet-rich fibrin membranes as scaffolds for periosteal tissue engineering. Clin Oral Implants Res 2010;21:543-549. 20. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5(2):8-13. 21. OLeary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol 1972;43:38. 22. Choukroun J, Ada F, Schoeffler C, Vervelle A. An opportunity in perioimplantology: The PRF (in French).Implantodontie 2001;42:55-62. 23. Harris RJ. The connective tissue and partial thickness double pedicle graft: A predictable method of obtaining root coverage. J Periodontol 1992;63:477-486.  A, Karabulut E. Use of platelet gel 24. Keceli HG, Sengun D, Berberoglu with connective tissue grafts for root coverage: A randomized-controlled trial. J Clin Periodontol 2008;35:255-262. 25. 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;76:17681777. 26. Anilkumar K, Geetha A, Umasudhakar, Ramakrishnan T, Vijayalakshmi R, Pameela E. Platelet-rich-fibrin: A novel root coverage approach. J Indian Soc Periodontol 2009;13:50-54.

indicates key references.

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