Clinical Advances in Periodontics

Advanced platelet rich fibrin in periosteal inversion

technique for root coverage - A case report

Journal: Clinical Advances in Periodontics

Manuscript ID CAP-19-0083.R2

Manuscript Type: Case Report

Date Submitted by the

22-Jul-2020
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Author:

Complete List of Authors: Burnice, Nalina; Meenakshi Academy of Higher Education and Research,
Faculty of Dentistry, Department of Periodontology
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Ganesh, Balaji; Saveetha Institute of Medical and Technical Sciences,

Saveetha Dental College and Hospital, Department of Periodontology
VIJAYALAKSHMI, RAJARAM; Meenakshi Academy of Higher Education
and Research, Faculty of Dentistry, Department of Periodontology
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Introduction: The management of gingival recession associated with

aesthetic concerns and root hypersensitivity is challenging and its
sequelae is based on the assessment of etiological factors and the
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degree of tissue involvement. Procedures using pedicle flaps, free soft

tissue grafts, combination of pedicle flaps with grafts, barrier membranes
and the use of platelet concentrates are all effective for this purpose.
The use of the third generation platelet concentrate, Advanced platelet
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rich fibrin (A-PRF) has evolved as a promising regenerative material

wherein it acts as a scaffold and also accelerates wound healing due to
its dense fibrin meshwork.
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Case presentation: This case report, discusses treating an isolated

Abstract: maxillary Miller Class I recession in a 25 year old male patient by a
periosteal inversion method along with the A-PRF membrane. A partial
thickness flap was reflected; periosteum was inverted and; a A-PRF
membrane was placed over the denuded root surface which aided in
enhanced regeneration. 100% root coverage was obtained as seen in
followup visits.
Conclusion: The periosteal inversion technique along with a A-PRF
membrane seems to be a novel approach in managing an isolated Millers
Class I maxillary gingival recession.
Key Words – Gingival recession, periodontal regeneration, plastic
periodontal surgery,
biomaterials

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Page 1 of 21 Clinical Advances in Periodontics

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3 Title - Advanced platelet rich fibrin in periosteal inversion technique for root coverage –
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6 A Case Report
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8 List of Authors
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10 Chellathurai Burnice Nalina Kumari,* Balaji Ganesh,† Rajaram Vijayalakshmi*
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Institutional Affiliation
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*Assistant Professor, Department of Periodontics, Faculty of Dentistry, Meenakshi Academy
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17 of Higher Education and Research, Chennai - 600 095, India.
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19 †Senior Lecturer, Department of Periodontics, Saveetha Dental College and Hospitals,
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22 Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai - 600 077,
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24 India.
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29 Address for correspondence

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31 *Dr. Chellathurai Burnice Nalina Kumari M.D.S,
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33 Assistant Professor, Department of Periodontics,
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Faculty of Dentistry, Meenakshi Academy of Higher Education and Research,
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38 Alapakkam main road, Maduravoyal, Chennai- 600095, India
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40 Email ID: dr_burnice@yahoo.co.in
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Contact No: 9790944335
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45 Word count - 1043
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47 Number of figures - 11
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49 Number of references - 16
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52 Running title - Periosteal inversion technique with A-PRF for root coverage.
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54 Summary - The present case report is the first of its kind in the literature for the treatment of
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56 gingival recession by the periosteal inversion method with advanced platelet rich fibrin.
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 Clinical Advances in Periodontics Page 2 of 21

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3 Author contributions:
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6 Study concept and design: Chellathurai Burnice Nalina Kumari and Balaji Ganesh. Drafting
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9 the article: Balaji Ganesh. Critical revision of the manuscript for important intellectual content:
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11 Chellathurai Burnice Nalina Kumari; Balaji Ganesh and Rajaram Vijayalakshmi.
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Page 3 of 21 Clinical Advances in Periodontics

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9 Abstract
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12 Introduction: The management of gingival recession associated with aesthetic concerns and
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root hypersensitivity is challenging and its sequelae is based on the assessment of etiological
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17 factors and the degree of tissue involvement. Procedures using pedicle flaps, free soft tissue
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19 grafts, combination of pedicle flaps with grafts, barrier membranes and the use of platelet
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concentrates are all effective for this purpose. The use of the third generation platelet
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24 concentrate, Advanced platelet rich fibrin (A-PRF) has evolved as a promising regenerative
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26 material wherein it acts as a scaffold and also accelerates wound healing due to its dense fibrin
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29 meshwork.
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32 Case presentation: This case report, discusses treating an isolated maxillary Miller Class I
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34 recession in a 25 year old male patient by a periosteal inversion method along with the A-PRF
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37 membrane. A partial thickness flap was reflected; periosteum was inverted and; a A-PRF
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39 membrane was placed over the denuded root surface which aided in enhanced regeneration.
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41 100% root coverage was obtained as seen in followup visits.
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44 Conclusion: The periosteal inversion technique along with a A-PRF membrane seems to be a
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novel approach in managing an isolated Millers Class I maxillary gingival recession.
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Key Words – Gingival recession, periodontal regeneration, plastic periodontal surgery,
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52 biomaterials
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6 BACKGROUND
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9 Gingival recession is a matter of concern for both patients and dental professionals, especially
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12 when exposure of the root surface is linked to deterioration of esthetic appearance and an
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14 increase in dental hypersensitivity.1 Gingival anatomic factors, chronic trauma, periodontitis,
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16 and tooth alignment are the main conditions leading to the development of these defects.2
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Traditionally, the primary goals of periodontal therapy are to eliminate any etiologic agents
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21 associated with inflammatory disease and to improve clinical attachment level. Successful
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23 treatment of recession type defects is based on the use of clinically predictable root coverage
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25 procedures. Among the soft tissue grafting techniques, the sub-epithelial connective tissue graft
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28 is the gold standard and the most predictable technique, but it requires a second surgical site.3
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30 Platelet concentrates are known to release several growth factors which stimulate tissue
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32 regeneration and can be used as alternative to traditional barrier membrane for acceleration of
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35 tissue regeneration.4 Advanced PRF(A-PRF) is a third generation platelet concentrate.5 The
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37 present case report describes the case of an isolated maxillary gingival recession treated by
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39 means of periosteal inversion technique along with A-PRF membrane placement.

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42 CLINICAL PRESENTATION
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45 A 25-year old male patient with no significant medical history reported to the Department of
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Periodontology, Meenakshi Ammal Dental College and Hospital, Chennai in February 2019
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50 with a chief complaint of sensitivity of cold to upper front tooth for the past 2 months. On intra-
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52 oral examination, an isolated Miller6 Class I gingival recession at labial surface of #11 was
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54 observed. The recession depth and width was 3 mm and the probing depth was 2 mm in relation
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57 to #11 (Fig.1).
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3 CASE MANAGEMENT
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6 Prior to the surgical procedure, a written informed consent was obtained from the patient. The
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9 patient underwent scaling and root planing and oral hygiene instructions were given. The
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11 surgical procedure was initiated after adequate infiltration of a local anesthesia (2% Lidocaine
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13 with 1:100,000 epinephrine). With a number 15C blade, at the line angles of the tooth, two
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vertical releasing incisions extending beyond the mucogingival junction were made (Fig.2);
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18 which was followed by reflection of a partial thickness flap, until an adequate amount of
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20 periosteum was exposed (Fig. 3). The reflected periosteum was then inverted so that the
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cambium layer covered the denuded root surface (Fig. 4). A A-PRF membrane was placed to
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cover the recession and sutured with resorbable sutures. ‡ (Fig. 5). The reflected partial
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27 thickness flap was then coronally advanced such that it covered the periosteum and was sutured
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29 using a 4-0 black silk sling sutures (Fig. 6). Finally, a periodontal dressing was placed. § (Fig.
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7). The patient was instructed not to remove the pack or disturb the surgical site until the sutures
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34 were removed. Antibiotics, (Amoxicillin 500mg TID) and analgesics, (Aceclofenac 100mg +
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36 Paracetamol 325mg, BID for 3 days) were prescribed. Additionally, the use of 0.12%
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chlorhexidine rinse was also advised.
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CLINICAL OUTCOME
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After two weeks the periodontal dressing and the sutures were removed (Fig. 8). Healing was
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47 satisfactory and 100 percent root coverage was obtained which remained stable through the 3rd
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49 month postoperative visits (Fig. 9) and 6th month postoperative visits (Fig. 10). This coincided
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51 with the resolution of dentinal hypersensitivity. Patient was highly satisfied with the treatment
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54 outcome (Fig. 11).
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57 ‡ Ethicon, Johnson & Johnson private limited, India.
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60 § Coe-pak, GC America Inc. USA

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6 DISCUSSION
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9 The most important factor in the etiology of dentin hypersensitivity is the exposure of root
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12 surfaces from gingival recession.7 A treatment modality for this problem includes an attempt
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14 to cover the exposed root surface. Over the past decades numerous periodontal plastic surgery
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16 procedures have been described in an attempt to cover exposed root surfaces.8 The use of a
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supraperiosteal envelope in soft tissue grafting for root coverage was carried out by Andrew L
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21 Allen in 1994.9 Mahajan10 used the periosteal pedicle graft for treatment of gingival recession.
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23 Periosteum is highly vascular so it may prevent the necrosis of the transposed tissue thus
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25 making it a suitable graft over avascular root surfaces.10

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28 In this case report, the periosteum acted as a vascularized transplant graft for root coverage.
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31 The periosteum remained inverted and coronally repositioned without adverse tension forces.
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33 The vascularized periosteum can therefore be used for defect coverage in a similar way as a
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connective tissue graft and can be epithelialized by the neighboring mucosa which remains a
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vital and well-vascularized tissue.11 The advantages of this technique are: the presence of
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40 periosteum adjacent to the defect; no second surgical site; less surgical trauma; less
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42 postoperative complications and; better patient satisfaction.
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45 Platelet concentrates are concentrated suspensions of growth factors and these stimulate
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healing and regeneration of tissues. They are autologous sources of platelet derived growth
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50 factor (PDGF) and transforming growth factor beta (TGF-β) that is obtained by collection and
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52 concentrating platelets by gradient density centrifugation.12 These have been shown to
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54 stimulate healing and the renewal of tissues.13 It is also seen that A-PRF contains more living
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57 progenitor cells and platelets when compared to conventional PRF. The subsequent significant
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59 increase in total protein release may therefore present additional advantages for clinical use.14
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3 Recent studies have shown that neutrophilic granulocytes have tissue regeneration properties
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6 as well. They also facilitate trafficking of monocytes into the wound to phagocytose
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8 inflammatory remnants (necrotic and apoptotic cells).15 Moreover, they also participate in the
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10 process of wound debridement by secreting several proteases, including matrix
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metalloproteinase 9, (MMP9) which is an extracellular matrix digesting enzyme.16 Thus, the
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15 distribution of neutrophilic granulocytes within the A-PRF clot might be the basis for a better
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17 functionality of the transplanted but also resident monocytes/macrophages and lymphocytes
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and their deployment to support tissue regeneration. To the best of our knowledge this is one
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22 of the first case reports to treat gingival recession by using the periosteal inversion technique
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27 CONCLUSION
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30 A large variety of mucogingival grafting procedures for coverage of exposed roots exists.
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32 Selection of the appropriate procedure and precise and a meticulous surgical technique will
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35 provide successful and highly predictable results in the treatment of gingival recession. The
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37 periosteal inversion technique along with A-PRF membrane placement, in the present case
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39 report, seems to be an effective, innovative and a more predictable method in treating isolated
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gingival recession. Further longitudinal and randomized controlled clinical studies are needed
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3 SUMMARY
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6 Why is this case new information ?  The periosteum is outer osseous covering
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9 having niche of pluripotent cells and can be
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11 used as a barrier membrane.
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13 What are the keys to successful management of  Selection of Miller Class I or II
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16 this case ? recession.
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19 What are the primary limitations to success in  Technique sensitive.
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21 this case ?
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27 Conflict of interests
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30 No potential conflict of interest relevant to this article was reported.
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33 REFERENCES
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36 1. Bouchard P, Malet J, Borghetti A. Decision making in aesthetics: root coverage

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38 revisited. Periodontol 2000 2001;27:97-120.
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40 2. Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent
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43 Assoc 2003;134:220-225.
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45 3. McGuire MK, Nunn M. Evaluation of human recession defects treated with coronally
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47 advanced flaps and either enamel matrix derivative or connective tissue. Part 1:
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50 comparison of clinical parameters. J Periodontol 2003; 74:1110-1125.
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52 4. Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, et al. Platelet-
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54 rich fibrin (PRF): a second-generation platelet concentrate. Part IV: clinical effects on
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tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:56-60.
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3 5. Khiste SV, Naik Tari R. Platelet-rich fibrin as a biofuel for tissue regeneration. ISRN
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6 Biomaterials 2013;1:1-6.
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8 6. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics
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10 Restorative Dent 1985;5:8-13.
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7. Watson PJ. Gingival recession. J Dent 1984;12:29-35.
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15 8. Tonetti MS, Jepsen S; Working group 2 of the European Workshop on Periodontology.
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2 of the 10th European Workshop on Periodontology. J Clin Periodontol 2014;41
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24 9. Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage.
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26 I. Rationale and technique. Int J Periodontics Restorative Dent 1994;14:216-227.
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29 10. Mahajan A. Periosteal pedicle graft for the treatment of gingival recession defects: a
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31 novel technique. Aust Dent J 2009;54:250‐254.
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33 11. Singh AK, Kiran P. The periosteum eversion technique for coverage of denuded root
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surface. J Indian Soc Periodontol 2015;19:458-461.
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38 12. Civinini R, Macera A, Nistri L, Redl B, Innocenti M. The use of autologous blood
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40 derived growth factors in bone regeneration. Clin Cases Miner Bone Metab 2011;8:25-
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45 13. Sohn DS, Moon JW, Moon YS, Park JS, Jung HS. The use of concentrated growth
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49 14. Ghanaati S, Booms P, Orlowska A, Kubesch A, Lorenz J, Rutkowski J et al. Advanced
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52 platelet-rich fibrin: a new concept for cell-based tissue engineering by means of
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54 inflammatory cells. J Oral Implantol 2014;40:679-689.
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56 15. Kolaczkowska E, Kubes P. Neutrophil recruitment and function in health and
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3 16. Christoffersson G, Vagesjo E, Vandooren J, Liden M, Massena S, Reinert RB et al.
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6 VEGF-A recruits a proangiogenic MMP-9 delivering neutrophil subset that induces
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8 angiogenesis in transplanted hypoxic tissue. Blood 2012;120:4653-4662.
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14 Figure legends
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17 Figure 1 - Preoperative photograph
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20 Figure 2 - Incisions placed
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23 Figure 3 - Partial thickness flap elevated in relation to tooth #11
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26 Figure 4 - Periosteal inversion done in relation to tooth #11
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32 Figure 6 - Flap coronally advanced and sutured

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35 Figure 7 - Coe pak placed
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38 Figure 8 - Postoperative view (2 weeks)
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41 Figure 9 - Postoperative view (3rd month)
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Figure 10 - Postoperative view (6th month)
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Figure 11 - Before and after
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Page 21 of 21 Clinical Advances in Periodontics

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