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C linical Report
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Jadhav Tanya Postgraduate student, Betsy S Thomas


Professor Department of Periodontology, Manipal
College of Dental Sciences, Manipal University, Manipal, Karnataka, India.
Correspondence : Betsy SThomas, Professor, Department of Periodontology, Manipal College of Dental Sciences, Manipal University,
Manipal-576104, Karnataka, India. Email address : betsythomas99@gmail.com
Received Aug 08, 2012; Revised Sep 14, 2012; Accepted Sep 28, 2012
PLATELET RICH FIBRIN MEMBRANE FOR RECESSION COVERAGE
ABSTRACT
Predictable esthetic root coverage has been the dream of any dentist. This paper reports the use of a PRF membrane
prepared by a novel technique for root coverage.
Keywords : Platelet-rich fibrin, recession coverage, autogenous membrane
INTRODUCTION
Marginal tissue recession is due to the
displacement of the gingival margin apical to the cemento-
enamel junction with exposure of the root surfaces to the
oral cavity. It may be a common cause of concern for the
patient for a number of reasons like esthetic considerations,
root hypersensitivity or root caries. Additionally, it may be
localised to a single tooth or may involve multiple adjacent
teeth.
In multiple adjacent recession defects, the surface
area of avascular root surface is far more extensive.
Furthermore some anatomical characteristics such as thin
gingival biotype, decreased keratinized tissue (KT) width,
root prominence and root proximity make the choice of
surgical treatment much more difficult as compared to
localized gingival recession defects.
Numerous periodontal plastic surgical procedures
have been proposed in gingival recession treatment with
varying predictability and success rates. One of the most
widely employed procedures to cover denuded roots is the
coronally advanced flap (CAF) procedure. The treatment
outcomes vary between 9-95%.
1
However, data also reveals unstable long term results using
CAF alone.
2
Another limitation is the limited gain in the
apico-coronal dimension of keratinized tissue, which is an
important parameter in preventing the recurrence of gingival
recession.
3
Therefore, it appears that CAF alone is a less than
optimal technique to achieve root coverage despite its
advantage of low morbidity. The predictability can be
increased by combining CAF with other regenerative
techniques such as a connective tissue graft, enamel- matrix
derivative, synthetic allograft, autologous platelet
concentrates including platelet-rich fibrin (PRF) etc.
Platelet- rich fibrin is a second generation platelet
concentrate and is defined as an autologous leukocyte and
platelet-rich fibrin biomaterial. It was first developed by
Choukroun et al. (2001).
4
It has been used extensively in
combination with bone graft materials for periodontal
regeneration, ridge augmentation, sinus lift procedures for
implant placement and for coverage of recession defects in
the form of a membrane. The PRF membrane can be prepared
using specially designed preparation box (PRF Box

Process, Nice, France). This membrane consists of a fibrin

3-D polymerized matrix in a specific structure, with the
incorporation of platelets, leukocytes, growth factors and
presence of circulating stem cells. The PRF clot exudates/
PRF releasate is frequently discarded. However, it has been
found to be rich in proteins; fibronectin and vitronectin
and thus, can be used as a part of regeneration therapy.
4
This report presents a case of multiple adjacent
gingival recessions treated by combined CAF-PRF novel
technique.
CASE REPORT
A 58 year old male patient reported to the
Department of Periodontology, Manipal College of Dental
Sciences, Manipal with the complaint of sensitivity to cold
water in the upper left back tooth region. No relevant
medical and dental history was reported.
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On clinical examination, multiple adjacent
recessions were identified on the right posterior maxillary
teeth (Figure 1). The recession defect, Millers Class I type,
were measured by calculating the distance between the
cementoenamel junction and the gingival margin. It was
recorded as follows :
1
st
premolar =3mm
2
nd
premolar =3mm
A hard tissue abrasion defect was also present on these
teeth and was measured to be less than 0.5 mm in dimension.
Presurgical therapy
Preparation of the patient included scaling and
root planing of the entire dentition and oral hygiene
instructions. The surgical procedure was explained to the
patient and the informed consent obtained.
Surgical procedure
The operative site was anaesthetized using 2%
xylocaine with adrenaline (1:200000). A coronally positioned
flap technique was performed at the surgical site. This site
was delineated by two oblique releasing incisions at the
mesial and distal aspects and sulcular incisions around the
affected teeth. A full thickness flap was elevated to expose
atleast 3 mm of marginal bone apical to the dehiscence area
(Figure 2). A horizontal releasing incision was made in the
periosteum at the base of the flap to facilitate tension free
coronal displacement. The exposed root surfaces were
scaled and root planed. Following this, the cervical step at
the CEJ was eliminated using a diamond bur.
Preparation of PRF membrane
After the recipient site preparation was completed,
the required quantity of blood was drawn in 10 ml test tubes
without an anticoagulant and centrifuged immediately. It
was centrifuged using a tabletop centrifuge (Remi R8C
Laboratory

) for 10 minutes at 3,000 rpm. The resultant

product consists of the following three layers:
Top most layer consisting of acellular PPP
PRF clot in the middle
RBCs at the bottom
After centrifugation, the PRF clot was removed
from the tube using sterile tweezers, separated from the
RBC base using scissors, and placed in a sterile metal cup.
At the recipient site, the PRF clot was placed over
the denuded root surfaces (Figure 3). A sterile tin foil was
adapted over the clot (Figure 3) and the flap was pulled
over it. This area was then compressed using digital pressure
in order to obtain a PRF membrane (Figure 4). With this
technique we ensured that the protein rich- PRF clot
releasate is contained at the recipient site.
After removal of the tin foil, the flap was coronally
advanced and sutured. The periodontal dressing was placed
over the surgical area.
Post operative care
The patient was advised to use 0.2% chlorhexidine
digluconate mouthrinse (0.2% Clohex
TM
). Systemic
antibiotics were prescribed and advised to follow routine
post-operative periodontal mucogingival instructions. The
dressing and sutures were removed 10 days after surgery.
DISCUSSION
The scientific rationale behind the use of platelet
preparations lies in the fact that the platelet - granules are
a reservoir of many growth factors that are known to play a
crucial role in hard and soft tissue repair mechanism.
6, 7
These include platelet-derived growth factors (PDGFs),
transforming growth factor beta (TGF-), vascular
endothelial growth factor (VEGF), and epidermal growth
factor (EGF), insulin like growth factor-1 (IGF-1). Platelet
growth factors exhibit chemotactic and mitogenic properties
that promote and modulate cellular functions involved in
tissue healing and regeneration, and cell proliferation.
8
It appears that the release of these growth factors
is affected by a number of factors related to the preparation,
handling and storage of the platelet preparation.
Currently, the standard operating procedure
promoted by Choukroun group
4
indicates that PRF clots
should be squeezed between sheets of cotton gauze to
obtain a fibrin membrane. Alternatively, the PRF Box

can
also be used to obtain compressed membranes. When
preparing membranes with compresses, the initial release
of PDGF-AB (and of TGF also, when considering the
very first hours) seemed to be lost, even if the membrane
remained very rich in growth factors and able to produce
large amounts for several days. This observation also raised
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the question of the adequate way to conserve the PRF
membrane when prepared, because keeping the membranes
on compresses (even wet compresses) for too long would
increase an untimely release of growth factors and the
shrinkage of the fibrin network and could also dehydrate
and damage the leukocyte content.
Once the PRF membranes are prepared, the
resulting fluid (PRF releasate) is usually discarded or may
be mixed with bone graft materials. This initial exudate
contains 3.1 g fibronectin per clot, and 1 membrane
released a mean 3.5 g after 20 minutes, 5.3 g after 1 hour,
and 48.4 g of fibronectin after 7 days.
9
The platelet-poor plasma has been known to
contain growth,
10
has biologic sealant activity and adhesive
potential
11, 12
and the ability to induce differentiation of the
periodontal ligament cells and osteoblasts that are critical
for periodontal and bone regeneration.
13
Consequently, the
potential of this GF-rich physiological medium should be
utilized. In our case, this was done by compression of the
PRF clot on the recipient site in order to prevent the loss of
valuable growth factors and proteins in order to optimize
the PRF procedure.
The effect of time lapse between PRF preparation
and its subsequent growth factor and cytokine profile
release has also been extensively evaluated. If the PRF is
used within the first hour, it was reported there would be
continuous release of the growth factors during the initial
healing period after application of the membrane on the
surgical site. The results of a study conducted by Su et
al.
14
supported preparing the PRF immediately before using
it to allow for continuous release of growth factors over
the subsequent 300 minutes. To save time, it would thus be
ideal to expose the surgical site just before the formation of
the PRF membrane. It was advised to use the PRF membrane
immediately after formation to maximize release of growth
factors to the surgical site. A similar protocol was followed
in our case in which there was minimal delay between
preparation and placement of the PRF clot at the surgical
site. Additionally, the preparation of the PRF membrane
within the recipient site seems to be advantageous.
Moreover, the fibrin matrix itself shows mechanical adhesive
properties and biologic functions like fibrin glues: it
maintains the flap in a high and stable position, enhances
neoangiogenesis, reduces necrosis and shrinkage of the
flap, and, thus, guarantees maximal root covering.
15
As
interposition material, the PRF layer avoids the early
invagination of the gingival epithelium, hence may also
serve as a barrier to epithelial migration.
There are many advantages of using PRF, a
second-generation platelet concentrate. PRF does not use
bovine thrombin or other exogenous activators in the
preparation process. It forms a gel-like matrix that contains
high concentrations of non-activated, functional, intact
platelets, contained within a fibrin matrix, that release, a
relatively constant concentration of growth factors over a
period of 7 days.
16
In the form of a membrane, it can be used
as fibrin bandage serving as a matrix to accelerate the healing
of wound edges.
17, 18
Being autologous in nature, it is
relatively inexpensive as no additional cost for synthetic
membranes is incurred to the patients. Furthermore, the
chair side preparation of PRF is quite easy and processing
is fast and simple.
19
A recent 6-month study evaluated the use of PRF
in the treatment of multiple gingival recessions with
coronally advanced flap procedure and found the
significant improvement during the early periodontal
healing phase with a thick and stable final remodelled
gingiva.
20
However, another randomised clinical trial in the
same year reported inferior root coverage of about 80.7%
at the test site (CAF+PRF) as compared to about 91.5%
achieved at control site (CAF), but an additional gain in
gingival/ mucosal thickness compared to conventional
therapy.
21
An increase in thickness of the keratinised tissues
reported in both studies may contribute to a long term stable
clinical outcome with reduced probability of recurrence of
recession.
CONCLUSION
The use of autologous platelet preparations like
PRF allows the clinician to optimize tissue remodelling,
wound healing and angiogenesis by the local delivery of
growth factors and proteins. This case report reflects the
success of this biomaterial for coverage of multiple
recession defects and the ability to increase the thickness
of the keratinised gingival tissue. The novel technique
described enables the clinician to gainfully harvest the full
regenerative capacity of this autologous biologic material.
Platelet rich fibrin membrane for recession coverage
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Betsy S Thomas et al
Figure 1: Pre-operative view
Figure 2: Full thickness mucoperiosteal flap at recipient
site
Figure 3: Adaptation of PRF clot and foil and at recipient
site
Figure 4: PRF membrane prepared at recipient site
Figure 5: 3 Months post operative view
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