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 Table of Contents  
Year : 2021  |  Volume : 10  |  Issue : 17  |  Page : 58-61

Two-year follow-up of platelet-rich fibrin-reinforced and modified coronally advanced flap: Pinnacle of the regeneration milieu: Case series

1 Professor, Department of Periodontics, Institute of Dental Studies and Technologies, UP, India
2 Faces n Braces Dental Research Centre, New Delhi, Reader, Department of Prosthodontics and Crown & Bridge, Ex- Dr. BR Ambedkar Institute of Dental Sciences & Hospital, Patna, Bihar, India
3 Professor, Department of Periodontics, Bapuji Dental College and Hospital, Davangere, India

Date of Submission22-Jun-2020
Date of Decision11-Sep-2020
Date of Acceptance06-Oct-2020
Date of Web Publication24-Apr-2021

Correspondence Address:
Dr. Sumit Munjal
C-125, Golf View Apartments, Saket, New Delhi - 110 017
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/nnjcr.nnjcr_23_20

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Root coverage (RC) is a sine qua non for the restoration of periodontal vigor altered by the gingival recession (GR). The objective of this study was to clinically evaluate platelet-rich fibrin + coronally advanced flap (P-CAF) and novel platelet-rich fibrin + laterally slided coronally advanced flap (PLSCAF) procedures. RC is done using an assortment of biomaterials, even though they are overpriced and technique sensitive. The success of any autograft depends upon the survival of the same, which is determined by conducive healing. PRF has an edge for being autogenous, angiogenic, immunogenic, inexpensive, easily available, and lacks donor-site morbidity. This study was conducted on three middle-aged systemically healthy patients, one female and two males who had sufficient width, length, and thickness of keratinized tissue adjacent to isolated Miller's I or II GR. A significant improvement in recession width, depth, and gingival thickness was clearly delineated at the second year follow-up. We evinced expected positive outcome on all patients, besides a 100% RC with PLSCAF prowess. Within the limitation of this case series, P-CAF and PLSCAF demonstrated to be promising techniques when treating Miller's I or II GR. Nonetheless, embracing a four-pronged strategy for rapid healing is veritably demonstrated here.

Keywords: Platelet-rich fibrin + coronally advanced flap, platelet-rich fibrin + laterally slided coronally advanced flap, root coverage

How to cite this article:
Munjal S, Munjal S, Mehta DS. Two-year follow-up of platelet-rich fibrin-reinforced and modified coronally advanced flap: Pinnacle of the regeneration milieu: Case series. N Niger J Clin Res 2021;10:58-61

How to cite this URL:
Munjal S, Munjal S, Mehta DS. Two-year follow-up of platelet-rich fibrin-reinforced and modified coronally advanced flap: Pinnacle of the regeneration milieu: Case series. N Niger J Clin Res [serial online] 2021 [cited 2024 Mar 4];10:58-61. Available from: https://www.mdcan-uath.org/text.asp?2021/10/17/58/314598

  Introduction Top

Root coverage (RC) is a sine qua non for the restoration of periodontal vigor altered by the gingival recession (GR), distinguished by apical migration of gingival margin. If left untreated, the condition may lead to other problems including deficient esthetics, dentine hypersensitivity, and a higher risk of dental caries.[1] The lateral pedicle flap-revised technique[2] appeared as the recourse, howbeit soon followed up by coronally positioned pedicle graft which showed 95% complete RC.[3]

With the growth factor-dominated regeneration looming, the platelet-rich fibrin (PRF) emerged as a lucrative adjunct for periodontal plastic surgery. PRF is an autogenous biomaterial, rich in platelets, leukocytes, and lymphocytes and obtained through rapid centrifugation from patient's whole blood, without including anticoagulants.[4] The gathered clot is stable, resilient, strong, adhesive, and malleable[4] and hence can be used as a membrane. Above all, easy manipulation flanked by inexpensiveness has been, as plain as a pikestaff. The PRF + laterally slided CAF (PLSCAF) and PRF + CAF (P-CAF) maneuvers were attempted on patients with Miller's I and II GR sites, along with sufficient width, length, and thickness of keratinized tissue adjacent to it. The study is the attempt to evaluate the above-said RC situations for two years postoperatively.

  Case Report Top

This institutional study was conducted on three healthy patients aged 25–40 years, one female and two males from May 2017 to May 2019. The GR location was treated either by PLSCAF or P-CAF operations. recession depth (RD), recession width (RW), and gingival thickness (GT) were recorded midbuccally, at cementoenamel junction (CEJ) and at the midfacial point, 3 mm below the gingival margin, respectively. Parameters were investigated using William's graduated probe (HuFriedyMfg co. LLC, Chicago, IL, USA)[Figure 3]a,[Figure 3]b, Vernier calipers, and magnifying loupes (EyeMag pro loupes, Carl Zeiss) [Table 1]. All those enrolled signed a consent upon an ethical committee clearance. The clinical trial was registered with CTRI/2017/04/008349. The preparation was done by relieving occlusal trauma, counseling for plaque control and roll brushing technique, scaling, and polishing. The surgeries alike the above-mentioned calibrations were performed by a single experienced periodontist.
Table 1: Comparison of clinical parameters baseline from 2 years postoperative*

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Platelet-rich fibrin preparation

Patients' blood was drawn from the median cubital vein in the test tube and centrifuged in an assemblage (ProcessTM, France) emulating a standard protocol[5] [Figure 1]b, [Figure 2]b and [Figure 3]e. The spin-off was perceived as three layers; plasma on top, PRF in the middle, and red corpuscle layer at the bottom [Figure 1]b. Each PRF clot procured in the end was pressed as a membrane inside a PRF box [Figure 1]d, [Figure 3]e and [Figure 3]f.
Figure 1: Case 1. (a) Preoperative. (b) Platelet rich fibrin preparation. (c) Laterally moved, coronally advanced flap technique. (d) Platelet rich fibrin stabilization. (e) Site closure. (f) Two-year postoperative

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Figure 2: Case 2. (a) Preoperative. (b) Platelet rich fibrin preparation and incision placement. (c) Platelet rich fibrin modified - laterally moved, coronally advanced flap. (d) Site closure. (e) First postoperative. (f) Two-year postoperative

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Figure 3: Case 3. (a) Preoperative. (b) Recession calibration. (c) Incision placement. (d) Coronally advanced flap reflection. (e) Centrifuge protocol. (f) Platelet rich fibrin gel and membrane application. (g) Site closure. (h) Periodontal pack placement. (i) Two-year postoperative

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Surgical procedure

First, the subjects were locally anesthetized using 2% lignocaine: 1:200,000 adrenaline. Surgery for the two patients commenced with a far and wide V-shaped cut about the denuded root using BP blade no. 15. A reverse bevel shaped incision was made along the soft-tissue margin of the recipient site in order to remove the epithelium around the root surface. Then, the donor site was prepared by giving a vertical incision from the gingival margin to outline the flap adjacent to the recipient site and a mixed thickness flap was warily elevated [Figure 1]c and [Figure 2]b.

Flap elevation for third patient's site initiated in mucoperiosteal fashion at sulcular margin followed up by two distinct divergent incisions to open up a trapezoidal-shaped flap. The same was extended to either side at the base and toward mucogingival junction apically [Figure 3]c. Finally, a split-thickness rise to alveolar mucosa along with de-epithelization of papillae was done [Figure 3]d. Fiber insertions were relieved to enable the tissue to be mobilized up to CEJ passively without stretching. The freshly prepared membrane was removed from PRF box and adapted completely over the meticulously planned root just apical to CEJ [Figure 1]d and [Figure 2]c An apparent dehiscence was observed in the course of action, so addressed by sticky bone[6] in one incidence [Figure 3]f. PRF was later stabilized by sling sutures and both stratagems consummated at primary closure uusing 40 interrupted knots[Figure 3]g, shielded with a periodontal dressing [Figure 3]h (Coe-pack, GC America, Alsip, IL, USA). A week-long Augmentin 500 and ibuprofen 400 dosage and 0.2% chlorhexidine rinse was prescribed until the next fortnightly recall.

  Results Top

A staunch criterion was decided for clinicoradiographic selection from the outpatient periodontics department. Only an isolated Miller's I or II GR with depth and width ≥3 mm, sufficient vestibular depth along with adequate width of attached gingival were included. But current or former smokers, poor hygiene maintainers, generalized or aggressive periodontitis patients and those with uncontrolled systemic conditions or during pregnancy and lactation were excluded.

The upshot of study [Table 1] at 2nd year recall was summed up as a significant recession width gain and depth curtailment for both the PLSCAF and PCAF manipulations [Figure 1]f, [Figure 2]e, [Figure 2]f, [Figure 3]i, more pronounced for the former [Table 2], besides evincing 100% RC with PLSCAF. There was also tangible increase in gingival thickness, a corroboration of previous findings,[7] moreover, patients are followed up further.
Table 2: Case 2 (PLCAF) comparison of clinical parameters baseline from 2 years postoperative*

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  Discussion Top

GR per se is a complex phenomenon thus poses therapeutic challenges for RC. Although a simple technique, some unfavorable local anatomic conditions may render the CAF contraindicated.[8] Reinforcement of CAF with PRF has provided enough scientific validation so was used in one case. The laterally repositioned, coronally advanced flap,[2] however, formed the basis of PLSCAF used in other two cases. Marked improvement in RD combined with clinical attachment level in these sites may be attributed to the formation of the long junctional epithelium. In the present study, however, the exact nature of reattachment could not be known as histological evaluation of new attachment apparatus was not done. Despite the fact that the PRF membrane was left exposed in the inceptive postsuturing phase, [Figure 1]e and [Figure 2]d patients reported with no postoperative morbidity or immunogenic response. It is established that growth factors are sustainably released for at least 1 week up to 28 days,[9] thus allowing PRF to stimulate the oral environment for a prolonged time. This view, however, is irreconcilable with the results of a GTR meta-analysis inferring infection and negative effect of early membrane exposure.[10]

All patients complied with regular periodic visits and maintenance of stable gingival margin was noted for all on the annual checkup. This was in agreement with the study of Jancovic et al.,[11] who stated that the satisfactory improvement in a gingival recession may be attributed to the high percentage of undamaged platelets, contained within a fibrin matrix. This may suggest that platelet concentrates promote more rapid attachment to the tooth with the stable result. Furthermore, the same finding was seen even after two years by dint of the glue properties of fibrin matrix in PRF, which maintains the flap in a constant position, and reduces necrosis.

Noteworthily, the uncompromised blood supply, by virtue of PRF having neo-antigenic characteristics,[4],[5] is the genesis of a Four pronged approach to [Figure 4] in healing. The positive desired results in terms of recession width, depth, and thickness are presented as a chronicle to available evidence.[7] Contrary to this claim, PRF/CAF approach was taken to compare with conventional therapy yet an inferior RC was achieved.[12] The imminent failures resulted from attempting for heavy smokers and PRF storage until use, unlike in our study, wherein the fresh product was delivered immediately. Owing to the variability in centrifuge protocols, the limitations remain debated.
Figure 4: Four -pronged approachto wound healing in periodontal regeneration

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The presented techniques show predictability by means of a substantial restoration of tissue quantity and quality with RC. Most histomorphometric[13] and randomized controlled trials[14] are by enlarge supportive. Nonetheless, a concatenation of more well-designed and properly controlled studies will be necessary to sustain the clinical findings.

  Conclusion Top

The explicated methodology is considerably feasible in dental clinic setup for the ease of applying PRF, besides yielding high esthetic outcomes.

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


Conflicts of interest

There are no conflicts of interest.

  References Top

Cortellini P, Pini Prato G. Coronally advanced flap and combination therapy for root coverage. Clinical strategies based on scientific evidence and clinical experience. Periodontol 2000 2012;59:158-84.  Back to cited text no. 1
Ruben MP, Goldman HM, Janson W. Biological considerations fundamental to successful employment of laterally repositioned pedicle flaps and free autogenous gingival grafts in periodontal therapy. In: Stahl S, editor. Periodontal Surgery. Illinois: Springfield; 1976.  Back to cited text no. 2
Harris RJ, Harris AW. The coronally positioned pedicle graft with inlaid margins: A predictable method of obtaining root coverage of shallow defects. Int J Periodontics Restorative Dent 1994;14:228-41.  Back to cited text no. 3
Zumarán CC, Parra MV, Olate SA, Fernández EG, Muñoz FT, Haidar ZS. The 3 R's for Platelet-Rich Fibrin: A “Super” Tri-Dimensional Biomaterial for Contemporary Naturally-Guided Oro-Maxillo-Facial Soft and Hard Tissue Repair, Reconstruction and Regeneration. Materials (Basel) 2018;11:1293.  Back to cited text no. 4
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, 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 2006;101:37-44.  Back to cited text no. 5
Soni R, Priya A, Yadav H, Mishra N, Kumar L. Bone augmentation with sticky bone and platelet-rich fibrin by ridge-split technique and nasal floor engagement for immediate loading of dental implant after extracting impacted canine. Natl J Maxillofac Surg 2019;10:98-101.  Back to cited text no. 6
[PUBMED]  [Full text]  
Dixit N, Lamba AK, Faraz F, Tandon S, Aggarwal K, Ahad A. Root coverage by modified coronally advanced flap with and without platelet-rich fibrin: A clinical study. Indian J Dent Res 2018;29:600-4.  Back to cited text no. 7
Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: A systematic review. J Clin Periodontol 2008;35:136-62.  Back to cited text no. 8
He L, Lin Y, Hu X, Zhang Y, Wu H. A comparative study of platelet-rich fibrin (PRF) and platelet-rich plasma (PRP) on the effect of proliferation and differentiation of rat osteoblasts in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:707-13.  Back to cited text no. 9
Machtei EE. The effect of membrane exposure on the outcome of regenerative procedures in humans: A meta-analysis. J Periodontol 2001;72:512-6.  Back to cited text no. 10
Jankovic S, Aleksic Z, Milinkovic I, Dimitrijevic B. The coronally advanced flap in combination with plateletrich fibrin (PRF) and enamel matrix derivative in the treatment of gingival recession: A comparative study. Eur J Esthet Dent 2010;5:260-73.  Back to cited text no. 11
Aroca S, Keglevich T, Barbieri B, Gera I, Etienne D. Clinical evaluation of a modified coronally advanced flap alone or in combination with a platelet-rich fibrin membrane for the treatment of adjacent multiple gingival recessions: A 6-month study. J Periodontol 2009;80:244-52.  Back to cited text no. 12
Zhang Y, Tangl S, Huber CD, Lin Y, Qiu L, Rausch-Fan X. Effects of Choukroun's platelet-rich fibrin on bone regeneration in combination with deproteinized bovine bone mineral in maxillary sinus augmentation: A histological and histomorphometric study. J CraniomaxillofacSurg 2012;40:321-28.  Back to cited text no. 13
Al-Qershi M, Dayoub S. Evaluation of platelet rich fibrin in the management of gingival recession Type I/II by Miller: A randomized clinical split mouth study. Dent Hypotheses 2019;10:97-102.  Back to cited text no. 14
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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