Fibropromotion: Fibrin-assisted soft-tissue promotion technique for root coverage using advanced platelet-rich fibrin
Sharanya Bose1, Subhapriya Mandal1, B. S. Ravi Prakash1, Abhijit Chakraborty1, Vivek Raghavji Devani2
1Department of Periodontics, Guru Nanak Institute of Dental Sciences and Research, Kolkata, West Bengal, India, 2Department of Periodontics, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
Address for correspondence: Dr. Sharanya Bose, Department of Periodontics, Guru Nanak Institute of Dental Sciences and Research, Kolkata, West Bengal, India. E-mail: sharonbasu@gmail.com
Submitted: 09-Feb-2020
Revised: 12-Feb-2020
Accepted: 19-Feb-2020
Published: 28-Jul-2020
DOI: 10.4103/sidj.sidj_3_20
Saint Int Dent J 2020;4:60-62.
Copyright: © 2020 The Saint's International Dental Journal
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ABSTRACT
The periodontal plastic procedure aims to correct the soft-tissue deformities of the inadequate keratinized tissue or loss of attachment. The clinicians and researchers have tried various materials and techniques to maintain soft-tissue barrier. The literature supports the use of subepithelial connective tissue with satisfactory results. However, problems such as increased morbidity, safety concern, harvest quality, and insufficient procurement have impelled for better material. The third-generation autologous blood derivative: advanced platelet-rich fibrin (A-PRF) is an excellent alternative and fibropromotive material. The current case report discusses easy and reproducible fibrin-assisted soft-tissue promotion technique using A-PRF for root coverage of multiple defect.
Keywords: Advanced platelet-rich fibrin, fibrin-assisted soft-tissue promotion, fibropromotion, root coverage
Apical migration of the gingival margin is termed as gingival recession. It is the common clinical finding whose extent and prevalence increase with age. Etiology of which includes many factors such as trauma, periodontal disease, and genetics. Treating these deformities is important to avoid development of signs and symptoms such as dentinal hypersensitivity, progression of periodontal breakdown, root caries, or even esthetic concerns.[1] Cases with multiple recession among adjacent teeth are difficult to treat and are less predictable because of greater amount of avascular root surface that is exposed with reduced blood supply to the surgical site.[2] The primary goal of periodontal plastic procedures is to re-establish thicker keratinized and attached gingiva while restoring form, function, and esthetics.[3]
The traditional technique to achieve this goal involves either second surgical site (for procurement of soft tissue graft) or another donor origin (allograft/xenograft). These procedures often come with problems such as harvesting site morbidity, disease transmission risk, and high biomaterial cost.
Advanced platelet-rich fibrin (A-PRF), third-generation blood derivative, is a rich carrier of leukocytes, stem cells, and growth factors.[4] Various clinical trials using A-PRF with bone replacement material have provided promising results. It also has been used for root coverage procedure. The current case report discusses the fibropromotion, i.e., fibrin-assisted soft-tissue promotion (FASTP) technique, a conventional alternative for root coverage procedure using A-PRF.
CASE REPORT
A 48-year-old male patient presented with a chief complaint of sensitivity and receding gums in the upper right front region of the jaw. The clinical findings included Miller Class I gingival recession in 13, 14, and 15 with exposed root sensitivity [Figure 1a]. The prognosis was determined to be good for root coverage procedure for the choice of autologous graft.
Figure 1: (a) Preoperative clinical picture showing gingival recession in 13, 14, and 15, (b) placement of incision, (c) elevating flap up to the mucogingival junction to facilitate its coronal advancement
Local anesthesia was achieved and the surgical procedure was performed under complete aseptic condition. A number 15 blade was used to elevate split-thickness flap involving 13, 14, and 15 [Figure 1b]. The flap was raised till mucogingival junction [Figures 1c and 2a] to coronally advance up to cementoenamel junction of the above-mentioned teeth. Root biomodification was bypassed. Instead, good root planning on exposed root surface was performed to remove the smear layer [Figure 2b]. The A-PRF obtained was placed over the defect [Figure 2c]. Membrane was established and maintained on overexposed root surface [Figure 2d] and independent sling suture was given [Figure 3a]. Appropriate postoperative instructions were given. Sutures were removed after 21 days [Figure 3b].
Figure 2: (a) Tissue reflection, (b) root planning of the exposed root surface, (c) advanced platelet-rich fibrin obtained placed in platelet-rich fibrin box, (d) placement of advanced platelet-rich fibrin membrane on the defect
Figure 3: (a) Suture placement, (b) 21 days postoperative clinical picture before suture removal, 13 and (c) 4 months postoperative picture
For the preparation of A-PRF membrane, 10 ml blood was drawn and centrifuged at 1300 rpm for 8 min. The fibrin clot obtained was isolated from red corpuscles and formed into membrane using PRF box (Process Ltd.).
The patient was recalled after 4 months for postoperative surgical evaluation [Figure 3c]. Root coverage along with relief in sensitivity was recorded. Maintaining patient value helped with good patient compliance during the entire observational period.
The comparative evaluation of preoperative and postoperative clinical picture [Figure 4a and b] shows satisfactory results.
Figure 4: (a and b) Comparative evaluation of preoperative and postoperative picture
DISCUSSION
There is a paradigm shift with the introduction of FASTP in periodontal plastic procedures. The various advantages are discussed below. It reduces patient morbidity (pain and discomfort), is cost-effective, and helps avoid adverse reaction. Oates et al.[5] concluded the best predictable results with use of connective tissue graft. However, insufficient amount of connective tissue, patient’s refusal to have a second surgical site, and morbidity have impelled the clinicians and researchers for newer biomaterial.[6]
The clinical efficacy of PRF in comparison with connective tissue graft cannot be questioned. Various studies comparing connective tissue graft with PRF have shown statistically nonsignificant results,[7,8] thus proving to be good alternative to conventional procedure.
The mechanism of action of FASTP is explained through fibropromotion (biotensegrity[9] and volume). The failure to satisfy either of them will reduce the efficacy of its regenerative potential. Single A-PRF membrane was used in the current case instead of backpacking of two or more membrane. However, the results of preoperative and postoperative picture show satisfactory result [Figure 4a and b].
The obtained A-PRF is rich bio-scaffold naturally impregnated with leukocytes, stem cells, and growth factors for release up to 10 days.[4] It is an excellent choice for multiple defect management where graft procurement, insufficient graft, and volume are not to be worried about.
Mariotti[10] in his systematic review concluded that no statistical or clinical significance is observed with root bio-modification. In the current case report, root conditioning was bypassed and thorough manual debridement of exposed root surface was done. The result observed in the current case report is satisfactory with good patient compliance.
However, more randomized clinical studies with larger sample size and observational period for FASTP are recommended.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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