Received: 28 April 2023 Accepted: 4 July 2023

DOI: 10.1002/cap.10257

RESEARCH ARTICLE

Novel biomaterial advanced platelet-rich fibrin plus block for

multiple gingival recession

Jayasheela Mallappa Leena Patil Adi Deepika Mani Triveni M Gowda

Department Of Periodontics, Bapuji Dental

College And Hospital, Davangere, India Abstract
Background: The study was aimed to assess and compare hard and soft tissue
Correspondence augmentation clinicoradiographically with and without advanced platelet-rich
Leena Patil, Department Of Periodontics, Bapuji
Dental College And Hospital, Davangere, 577004,
fibrin + (A-PRF+) block for the treatment of multiple gingival recession using
Karnataka, India. vestibular incision subperiosteal tunnel access (VISTA).
Email: [email protected] Methods: A total of 24 patients, exhibiting multiple Miller’s Class I or II recessions
in the maxillary esthetic zone were included. Participants were divided into two
groups, Group 1 was treated with VISTA & A-PRF+ block whereas Group 2 was
with VISTA technique alone. Clinical parameters probing depth, width of kera-
tinized gingiva, gingival biotype, recession depth, and clinical attachment level
were recorded at baseline and the end of 6 months. The radiographic cone beam
computed tomography measurements of labial plate thickness were taken at
baseline and 6 months postoperatively.
Results: From baseline to 6 months both the groups showed a clinical and statis-
tical improvement in the parameters. However, a statistically significant difference
between the treatment modalities was not observed. In the inter-group compar-
ison radiographically, labial plate thickness was statistically significant at the end
of 6 months when compared to the baseline.
Conclusion: A-PRF+ block along with the VISTA technique can be an alterna-
tive effective root coverage procedure for the management of multiple gingival
recessions in the maxillary esthetic zone.

KEYWORDS
bone graft, cone beam computed tomography, gingival recession, minimally invasive surgical
procedures, PRF

Key points
Why is this case new information?
To the best of our knowledge, this is the first study using advanced platelet-rich
fibrin plus block for the treatment of multiple gingival recession with a thin labial
plate.
What are the keys to the successful management of this case?
Minimally invasive vestibular incision subperiosteal tunnel access technique, and
avoidance of second surgical site morbidity are important factors for treatment
and for patient compliance.
What are the primary limitations of this study?
Short study duration, small sample size, and no histological correlation can be
considered as limitations of the study.

Clin Adv Periodontics. 2023;1–7. wileyonlinelibrary.com/journal/cap © 2023 American Academy of Periodontology. 1

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2 MALLAPPA ET AL.

INTRODUCTION various forms of allografts, demineralized freeze-dried bone

allograft (DFDBA) provides an osteoconductive surface,
The desire for cosmetic dentistry and improved esthet- and in addition, it also acts as a source of osteoinductive
ics has increased tremendously in contemporary society. factors.12
Cosmetic procedures have become an integral part of peri- Gingival recession with deficient labial plate thickness in
odontal treatment. This generates a need for clinicians the maxillary anterior region is quite prevalent with highly
to develop materials and techniques that will predictably significant clinical implications. Labial plate thickness and
satisfy these patient-centered esthetic demands. One of bone resorption depend on the sagittal angle between the
the commonly used esthetic periodontal procedures is tooth’s long axis and the axial inclination of the relevant
coverage of denuded roots.1,2 alveolar bone which is necessary to assess the outcome
Gingival recession is an exposure of the root surface of bone regeneration. For this reason, it is essential to
due to migration of the marginal periodontal tissues api- perform a cone-beam computed tomography (CBCT) so
cal to the cementoenamel junction. Gingival recession is a that the clinician can select the best approach and avoid
common clinical condition resulting in dentinal hypersen- compromising aesthetics in rehabilitation. By considering
sitivity, pain, carious and non-carious lesions, poor esthet- all these factors it can be stated that labial plate thick-
ics, and plaque retention.3 There are numerous anatomic, ness plays a vital role in the outcome of root coverage
pathologic, physiological, and iatrogenic factors causing procedures.13
recession.4 It can be caused because of periodontal dis- A minimally invasive alternative to all the conventional
ease, improper aggressive tooth brushing, inflammation, or techniques given by Zadeh known as vestibular incision
occlusal discrepancies.5 Recession defects can be broadly subperiosteal tunnel access (VISTA) was used for coverage
categorized as localized or generalized involving various of gingival recession.12
tooth surfaces.6 The present study was conducted to assess clinically the
Treatment of isolated or multiple gingival recessions with root coverage and radiographically the labial plate thick-
different surgical procedures depends on various factors ness with and without A-PRF+ block using VISTA for the
such as gingival biotype, defect characteristics, amount of treatment of multiple gingival recession.
keratinized tissue present apical to the recession, position
of the tooth in alveolar housing, and root prominence.7
The main goal of periodontal therapy is to restore health, MATERIALS AND METHODS
function, and esthetics, which requires correcting gingival
recession defects within the esthetic zone. A total of 24 patients with Miller’s class I/II defects13 in
In the current scenario, connective tissue graft (CTG) is the maxillary esthetic region (premolar to premolar) were
considered the gold standard but due to its certain dis- considered in this prospective randomized controlled trial
advantages such as the need for a second surgical site, within the age group of 20–55 years. This trial was con-
limited availability of graft, and post-operative healing ducted from August 2018 to August 2020 in the outpatient
complications various other options have come into the section of the Department of Periodontics, Bapuji Den-
focus.8 tal College and Hospital. Based on the simple coin toss
Platelet concentrates which are generated from autolo- method of randomization participants were divided into
gous blood because of their easy availability, easy handling, groups 1 and 2. The study design has been approved by
cost-effectiveness is gaining popularity these days. It has the institutional review board(BDC/EXAM/467/2018-2019)
been stated that advanced platelet-rich fibrin (A-PRF) pro- which was in agreement with the declaration of Helsinki
vides a greater number of evenly distributed autologous 1975, revised in 2013. (Figure 1) Prior to the procedure
cells within the clot.9 Among all platelet concentrates sec- written signed consent was obtained from all participants.
ond generation platelet concentrates A-PRF+ given by Subjects on immunosuppressant drugs or on any medica-
Ghanaati et al in 2014 is based on the concept of low- tion known to cause gingival enlargement, pregnant and
speed centrifugation concept.10 I-PRF the injectable variant lactating mothers were not considered in this trial.
of platelet concentrates has gained popularity as it is in
injectable form which overcomes the only drawback of
PRF over PRP. Properties of I-PRF such as the high release Clinical and radiographic outcomes
of growth factors, antibacterial in nature, higher cellular
migration, and mixing it with bone grafts form a gel putty Probing depth (PD), width of keratinized gingiva (WKG),
consistency make it a PRF of choice.11 gingival biotype (GB), recession depth (RD), clinical attach-
Various bone graft materials including autogenous bone ment level (CAL), and CRC were measured at baseline and
graft, allograft, xenograft, and alloplast have been used 6 months postoperatively. The radiographic (CBCT) mea-
over the years for the regeneration of lost periodontal surements of labial plate thickness at 1 mm, 3 mm, and
tissues. Apart from autografts, allografts showed several 5 mm above CEJ were recorded at baseline and 6 months
advantages in the reconstructive procedures. Among the postoperatively.
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CLINICAL ADVANCES IN PERIODONTICS 3

FIGURE 1 Study design.

Surgical procedure plex was pulled coronally and secured with a composite
button. Access incision was also sutured with simple inter-
All the selected participants underwent phase I therapy, rupted sutures (Figure 3). The same procedure was carried
after satisfactory oral hygiene maintenance further proce- out for group 2 participants without using the A-PRF+ block
dure was carried out. Preparation of recipient site begins (Figure 2 ) Subjects were recalled after a week for follow
with odontoplasty followed by application of root condi- up and access incision sutures were removed at that time
tioning agent for the removal of smear layer. whereas coronally anchored sutures were removed after
After administration of a local anesthetic agent (2% ligno- the duration of 3 weeks.
caine with 1:80,000 adrenaline) in both groups depending
on the site, the vestibular access incision was given, through
which instruments were passed to create a subperiosteal Statistical analysis and sample size
tunnel. For better coronal advancement and mobilization of calculation
the gingiva, the tunnel was extended beyond the mucogin-
gival junction of one more tooth adjacent to the site of All the clinical parameters like RD, CAL, WKG, GT, and CRC
interest. Without any sulcular incision, the interdental papil- were recorded at baseline and at the end of 6 months. The
lae were also elevated by corona-apical movement. In obtained results were tabulated and subjected to statistical
group 1 patients after the preparation of the surgical site, analysis. Wilcoxon signed-rank test was used for intra-
A-PRF+ was obtained using Ghanaati’s protocol (1300 rpm group comparison and Mann Whitney U test was used for
for 8 min),14 and I-PRF using Miron’s protocol (700 rpm for inter-group comparison. The differences were considered
3 min).15 After the preparation of A-PRF+, the obtained statistically significant at p-value <0.05. The sample size for
membrane was chopped into small pieces in a sterile flat the study was calculated using the following formula:
tray to which DFDBA was added followed by injection of
( )
I-PRF, which formed a cohesive mass of A-PRF+ block in z1−𝛼∕2 + z1−𝛽 2
about 20 min. The prepared block was inserted into the n= 𝜎
𝜇A − 𝜇B
tunnel and the block along with the mucogingival com-
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4 MALLAPPA ET AL.

TA B L E 1 Clinical outcomes at baseline and 6 months.

Mean ± SD (In mm)
Clinical parameter Time interval Group 1 Group 2
Recession depth Baseline 2.37 ± 0.46 2.75 ± 0.94
6 months 0.96 ± 0.21 1.10 ± 0.47
CAL Baseline 2.72 ± 0.46 3.02 ± 0.50
6 months 1.43 ± 0.38 1.83 ± 0.36
WKG Baseline 2.42 ± 0.47 2.41 ± 0.53
6 months 2.87 ± 0.49 2.73 ± 0.62
Gingival biotype Baseline 1.19 ± 0.29 1.36 ± 0.20
6 months 1.36 ± 0.57 1.66 ± 0.27
CRC Baseline 15.53 ± 1.47
6 months

RESULTS

Twenty-four patients were treated using these modalities,

there was no dropout in the study thus all the data results
F I G U R E 2 (A) Preoperative site, (B) odontoplasty before the surgery, were included in statistical analysis. The primary outcome of
(C) placement of access incision using 15C blade, (D) preparation of the study was to evaluate the root coverage clinically using
recipient site, (E) immediate postoperative, and (F) 14 days follow up. VISTA for the management of multiple gingival recession
and the secondary outcome was to assess the thickness of
labial plate radiographically.
A statistically significant decrease was observed in mean
recession depth from baseline to 6 months, that is, for
Group 1: 2.37 ± 0.46 to 0.96 ± 0.21 mm; and for Group 2
2.75 ± 0.94 to 1.10 ± 0.47 mm. A statistically significant
decrease was observed in CAL from baseline to 6 months,
that is, for Group 1: 2.72 ± 0.46 to 1.43 ± 0.38 mm; and for
Group 2, 3.02 ± 0.50 to 1.83 ± 0.36 mm. Gain in WKG was
significant from baseline to 6 months, that is, 2.42 ± 0.47
to 2.87 ± 0.49 mm in Group 1 and 2.41 ± 0.53 to 2.73 ±
0.62 mm in Group 2, respectively. The difference in mean
gingival biotype between Group 1 and Group 2 at baseline
and 6 months was not significant. The mean difference in
CRC amongst the two groups, from baseline to 6 months
was 15.53 ± 1.47 showing statistically significant results in
both groups (p = 0.035). Table 1 radiographically labial plate
thickness at 1 mm was 0.03 mm which increased to 0.1 mm
at the end of 6 months, at 3 mm thickness changed from
0.35 to 0.60 mm whereas at 5 mm the difference of 0.22 mm
was seen from baseline to 6 months. (Table 2)

DISCUSSION
F I G U R E 3 (A) Preoperative site, (B) placement of access incision
using 15C blade, (C) preparation of recipient site, (D) preparation of
A-PRF+ block, (E) immediate postoperative, and (F) 14 days follow up. The reconstruction of damaged periodontal tissues has
taken on an increasingly important role in the manage-
ment of mucogingival problems. With changing paradigms
in dentistry, aesthetic dentistry has evolved as an inter-
where σ is standard deviation = 0.85, μ is the expected aver- disciplinary approach to treating a multitude of problems
age (μA = 0.6 & μB = 1.3), α is Type I error = 5%, β is Type II and meeting patients’ expectations. Among the recently
error, meaning 1−β is power = 80%, Calculated sample size encountered aesthetic problems, probably one of the most
is 24, each group having 12 patients for this study. common esthetic concerns associated with periodontal
 21630097, 0, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/cap.10257 by Saveetha University, Wiley Online Library on [30/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
CLINICAL ADVANCES IN PERIODONTICS 5

TA B L E 2 Radiographic outcomes at baseline and 6 months.

Group 1 Group 2
Labial plate Difference
thickness Time interval Mean SD Mean SD Mean ± SD p-Value
At 1 mm Baseline 0.03 0.16 0.00 0.00 0.03 ± 0.06 0.149
6 months 0.10 0.16 0.00 0.00 0.10 ± 0.16 0.033
At 3 mm Baseline 0.35 0.13 0.20 0.09 0.15 ± 0.04 0.005
6 months 0.60 0.29 0.20 0.09 0.40 ± 0.20 0.001
At 5 mm Baseline 0.54 0.07 0.42 0.07 0.12 ± 0.00 0.001
6 months 0.76 0.22 0.42 0.07 0.34 ± 0.15 0.000

tissues is a gingival recession which has the highest preva- loss of labial bone plate, as the thickness of the plate main-
lence and is especially difficult to treat when it involves the tains the shape and size of the gingiva which is of prime
anterior maxillary zone.16 The treatment of gingival reces- concern in the esthetic areas. A recent study done using A-
sion defects is indicated to reduce root sensitivity, eliminate PRF block for regeneration has stated that the use of the
muscle pull, and create or augment keratinized tissue as block has shown increased osteoblastic activity, with better
well as to improve smile esthetics.17 wound healing and increased tissue remodeling, keeping
The main objective of treatment of gingival tissue reces- this notion in mind, A-PRF block was used in the current
sion includes complete coverage of the exposed root study for the management of gingival recession.24
surface and regenerating the lost components of the peri- Based on that concept in the present study, clinical and
odontium which ultimately improves the esthetics. Various radiographic assessment was done in multiple recession
surgical procedures have been carried out to date for defects with A-PRF+ block using the VISTA technique.
recession coverage such as pedicle graft procedures, and A significant gain in the width of keratinized gingiva was
advanced flap procedures with or without the combination observed in the test group in comparison to the control
of gingival grafts, barrier membranes, and enamel matrix group these results are in accordance with the study done
derivative.18 Currently the concept of minimally invasive by Joshi et al in contrast to our study a comparison of clinical
surgeries has grabbed the attention due to its advantage outcome of coronally advanced flap (CAF) procedure in root
of minimal soft tissue trauma and placement of smaller coverage with platelet-rich fibrin (PRF) or subepithelial CTG
incisions.19 (SCTG) for the treatment of Miller’s Class-I gingival recession
The minimally invasive VISTA approach used in this study was assessed and it showed nonsignificant decrease even at
provides the advantage of less tissue trauma as intrasulcu- the end of 6 months.25
lar incisions are avoided leading to favorable healing. Thus, The gain in CAL was significant from baseline to 6 months
this technique can be considered as a solution to the impor- in the A‑PRF+ block group. Using CAF with PRF for root cov-
tant yet unsolved problem of multiple gingival recession in erage, Aroca et al.26 observed a similar gain in attachment.
clinical periodontics. Earlier studies have shown 84% of root The decrease in PPD and increased recession coverage can
coverage using PRF, as it incorporates many growth factors attribute to the gain in clinical attachment. Another possi-
and other bioactive compounds that support the revascu- ble reason can be the formation of new connective tissue
larization and regeneration of bone and soft tissues.20,21 attachment and secretion of the growth factors by PRF
Recently, a low-speed centrifugation concept has been pro- which leads to better attachment of cells in the overlying
posed by Choukroun and Ghanaati which states reducing flap to the membrane and of the membrane to the under-
the relative centrifugation forces with modification in time lying root surface, thereby resulting in the prevention of the
increases the total number of cells left contained within the flap shrinkage.27
top layer of PRF enabling a higher number of leukocytes Many studies have emphasized that gingival biotype is
“trapped” within the fibrin matrix.10 Addition of bone graft essential for mean or complete root coverage, and stabil-
to PRF increases the osteopromotive action of bone grafts ity of clinical outcome.28–32 In this current study significant
which results in the time-bound release of growth factors increase was observed in the gingival biotype which is
also PRF assists in angiogenesis, engagement of the stem in line with a study done by Aroca et al.,26 which can
cells, and migration of osteogenic cells in the central part be explained by the fact that gingival and periodontal
of the graft.12,22 Gingival thickness plays an important role ligament fibroblast proliferation is associated with PRF
in the treatment outcome, as the blood supply is hampered membrane.
in cases of thin gingival biotype, which makes underlying Apart from autografts, allografts showed several advan-
bone susceptible to resorption. It has been noticed that tages in reconstructive procedures and showed consider-
thin underlying bone over the labial root commonly results able success clinically and histologically. Among the various
in dehiscence and fenestration.23 Using bone grafts along forms of allografts, DFDBA has been used extensively in
with PRF can be considered a preventive approach for the periodontal regeneration. The majority of the bone grafts
 21630097, 0, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/cap.10257 by Saveetha University, Wiley Online Library on [30/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
6 MALLAPPA ET AL.

are osteoconductive, but DFDBA also provides an osteoin- tion; Leena Patil: Writing – original draft, Methodology, and
ductive effect, since it contains bone morphogenic proteins Investigation; Adi Deepika Mani: Visualization and Method-
(BMPs). which helps to induce new bone formation during ology; Triveni M Gowda: Writing – review & editing and
the healing process. It elicits mesenchymal cell migration, Validation.
attachment, and mitogenesis, owing to the presence of
BMPs. DFDBA acquired from younger cadavers has higher
osteogenic potential in comparison with grafts from older C O N F L I C T O F I N T E R E S T S TAT E M E N T
individuals due to variations in BMP levels in different The authors declare no conflict of interest.
batches of DFDBA.33
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