Effect of Platelet-rich Fibrin and Free Gingival Graft

The Journal of Contemporary Dental Practice, July 2018;19(7):895-899 895

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ABSTRACT

Introduction: Free gingival graft is a procedure that is used to increase keratinized tissue around teeth and edentulous sites for future dental implants. Keratinized tissue is critical for main-tainability of surgical site and flap management. Platelet-rich fibrin consists of bioactive and biological components, mainly composed of growth factors. Growth factors attract stem cells to the site of release and stimulate cell proliferation. Moreover, growth factors promote angiogenesis, which accelerates wound healing. Site preparation is critical in implant dentistry, including soft tissue and hard tissue augmentation.

Aim: To improve free gingival graft (FGG) healing by using platelet-rich fibrin (PRF) at the soft tissue defect area of extracted upper right first molar in order to restore keratinized tissue and prepare the site for bone grafting followed by dental implant placement.

Case report: A healthy female patient, 59 years old, presented to the dental clinic at the University at Buffalo, School of Dental Medicine, seeking dental implants to restore missing teeth. The patient had an extraction for upper right first molar 4 months ago. The surgical extraction left severe soft and hard tissue defects at the site. Free gingival graft was placed at the site to increase keratinized tissue band followed by PRF to improve healing. Cyanoacrylate adhesive was used to stabilize PRF. Two months later, a full-thickness flap was reflected, and tenting screws placed with bone grafting at the site. Titanium-reenforced membrane was placed over the bone graft. Three months later, tenting screws were removed and two dental implants were placed at the site.

Effect of Platelet-rich Fibrin and Free Gingival Graft in the Treatment of Soft Tissue Defect preceding Implant PlacementWael Ibraheem

Division of Periodontics, Department of Preventive Dental Sciences, College of Dentistry, Jazan University, Jazan Kingdom of Saudi Arabia

Corresponding Author: Wael Ibraheem, Division of Periodontics, Department of Preventive Dental Sciences College of Dentistry, Jazan University, Jazan, Kingdom of Saudi Arabia, Phone: +00966559871000, e-mail: dr.wael007@yahoo.com

Conclusion: The use of PRF accelerates the healing of FGG. More tissue handling could be achieved by increasing the kera-tinized tissue during surgical procedures.

Clinical significance: The combination of PRF and FGG could help in the healing process during soft tissue procedures.

Keywords: Bone graft, Dental implants, Free gingival graft, Keratinized tissue, Platelet-rich fibrin.

How to cite this article: Ibraheem W. Effect of Platelet-rich Fibrin and Free Gingival Graft in the Treatment of Soft Tissue Defect preceding Implant Placement. J Contemp Dent Pract 2018;19(7):895-899.

Source of support: Nil

Conflict of interest: None

INTRODUCTION

Soft tissue grafts are commonly used procedures in treat-ing soft tissue defects. Free gingival graft is a procedure that is used to increase keratinized tissue around teeth and edentulous sites for future placement of dental implants. The FGG may still be the best treatment of choice to increase keratinized tissue in defective areas.1 Keratinized tissue is critical for maintainability of surgical site and flap management. The presence of the keratinized tissue and the survival rate of dental implants are highly associated.2 The importance of attached gingiva, a minimum of 2 mm, is suggested to maintain healthy gingiva around teeth.3 On the contrary, the presence of keratinized tissue is still controversial and depends on different factors, such as oral hygiene and plaque control.4

Platelet-rich fibrin consists of bioactive and biological components, mainly composed of growth factors. Growth factors attract stem cells to the site of release and stimu-late cell proliferation. Moreover, growth factors promote angiogenesis which accelerate wound healing.5,6 Also, PRF appears to stay long enough during healing which

Case RepoRt10.5005/jp-journals-10024-2353

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gives a promising chance for the growth factors to acceler-ate wound healing.7,8 Moreover, fibrin works as a bridge or scaffold for different cell interactions and migrations during wound healing while platelets contain leukocytes, cytokines, and growth factors.9 Platelet-rich fibrin might have some immunological and antibacterial properties. These properties would help the healing process as well.10

Dental implants are widely used as the first treatment option to restore missing teeth. Site preparation is critical in implant dentistry, including soft tissue and hard tissue augmentation.11 The aim of the present case study was to correct the soft tissue defect following extraction of upper right first molar by using FGG and PRF to restore keratinized tissue and to prepare the site for bone grafting followed by implant placement.

CASE REPORT

A healthy female patient aged 59 years presented to the dental clinic at University at Buffalo, School of Dental Medicine, seeking dental implant to restore missing teeth. The patient had an extraction for upper right first molar 4 months ago while the adjacent premolar was missing for few years. The surgical extraction left severe soft and hard tissue defect at the site (Fig. 1). Periapical X-ray was taken and the bony defect was noticed. The treatment plan was to increase the width of the keratinized tissue by FGG followed by bone graft followed and implant place-ment. On the day of the surgery, venous blood extracted from the patient’s right hand into 10 mL tube (total of two tubes). Choukroun’s method (a light spin method) was used to prepare PRF. Blood was softly centrifuged immediately after collection without anticoagulant and then separated into three components with the forma-tion of a fibrin clot at the middle of the tube. The clot PRF was taken and placed in the press system to unify it (Fig. 5). Anesthesia was applied to the surgical site using

lidocaine 2% with epinephrine 1:100,000. Partial thickness flap is made around the area of the defect as a recipient site for FGG using 15C blade (Fig. 2). Measurements were done for the recipient site. Free gingival graft was taken from the right palatal side (Fig. 3). Stabilization of the FGG at the recipient site was done using 5-0 poly-propylene suture (Fig. 4). Platelet-rich fibrin was placed at the top of the FGG. Cyanoacrylate adhesive was used to stabilize PRF in place (Fig. 5). Laser was used at the donor site to achieve homeostasis (Fig. 6). Postoperative instructions were given to the patient. Chlorhexidine gluconate mouthrinse 0.12% and amoxicillin 500 mg TID was prescribed for a week. The patient came back 1 and 2 weeks later for follow-up, and the healing was uneventful (Fig. 7). The sutures were removed after 2 weeks. Two months later, lidocaine 2% with epinephrine 1:100,000 was applied to the area. Full-thickness flap was reflected using 15C blade. Tenting screws were placed with 10-mm length to support bone grafting. Allograft particulate bone graft mixed with normal saline was placed at the site. Titanium-reenforced membrane was trimmed and

Figs 1A and B: (A) Side view showing the defect with the minimal keratinized tissue and vertical bone deficiency at the area of upper right molar and premolar; (B) occlusal view showing the horizontal bone deficiency

Fig. 2: Partial-thickness flap to prepare the recipient site extending from canine to the second molar

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Effect of Platelet-rich Fibrin and Free Gingival Graft

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Figs 3A and B: (A) Donor site (right palatal area) after harvesting the FGG; (B) FGG, which is wet and ready to be transferred to the recipient site

Figs 4A and B: (A) Adaptation of the FGG at the recipient area; (B) Stabilization and suturing of the FGG with 5-0 polypropylene suture

Figs 5A and B: (A) Platelet-rich fibrin is pressed to be unified and membrane like. It is ready to be used at the defective site to cover the FGG; (B) Using sutures and cyanoacrylate adhesive to stabilize PRF over the FGG

placed over the bone graft (Fig. 8A). Primary closure was achieved and 3-0 polytetrafluoroethylene suture was used to reposition the flap. Postoperative instruc-tions were given to the patient. Chlorhexidine gluconate mouthrinse (0.12%) and amoxicillin 500 mg TID were prescribed for 1 week. The sutures were removed after 2 weeks. The healing was uneventful. Three months later, lidocaine 2% with epinephrine 1:100,000 was applied to the area. Full-thickness flap was reflected using 15C blade. Titanium-reenforced membrane and tenting screws were

removed, and two dental implants were placed at the site (Fig. 8B). A 3-0 polytetrafluoroethylene suture was used to reposition the flap. Follow-up was done 2 weeks later and sutures were removed.

DISCUSSION

The present case study was done to correct the soft tissue defect following extraction by using FGG and PRF to restore keratinized tissue and prepare the site

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for bone grafting before implant placement. Platelet-rich fibrin is a type of platelet concentrate containing leukocytes and platelets in a fibrin network, which acts as a scaffold for embedding of the growth factors and, thereby, accelerating wound healing.7,8 The leukocytes present have antibacterial and immunological proper-ties.10 According to Kawase et al,12 the sustained release of growth factors from PRF between 1 and 4 weeks significantly affects the total healing time. They noticed in their in vitro study that the compression of PRF to

Fig. 6: Using laser to achieve hemostat at the donor site

Figs 7A and B: (A) Side view showing the healing at 2 weeks; (B) Occlusal view showing the healing at 2 weeks

Figs 8A and B: (A) Periapical radiograph showing the titanium-reenforced membrane and the tenting screws at the day of the surgery; (B) Periapical radiograph showing two dental implants in place after removing titanium-reenforced membrane and tenting screws

membrane reduces the porosity and delays degrada-tion of PRF.

This bioresorbable scaffold has the ability to guide the migration of epithelial cells to the surface and promote the vascular formation around the area.13 It has been proven that PRF can be used in guided bone regenera-tion as a resorbable membrane. The PRF can prevent the unwanted cells from migration to the wound site and helps maintain the space.14

The PRF has been showing a significant wound-healing response when used to cover the palatal wound after FGG. Clinical and biological parameters improved when PRF was used along with FGG, which is in agree-ment with the study by Ozcan et al,15 where the authors used PRF at the donor side.

Some studies have shown that the use of PRF has a possibility for soft and hard tissue regeneration without or with minimal signs of inflammation at the wound site. It can help in homeostasis and improve the quality of wound healing.16-18 The faster healing rate is due to increased proliferation of fibroblasts and collagen, and the release of growth factors in the early stages of healing.19,20 The use of PRF in the present case study also showed improved healing time and enhanced protection of FGG. Conclusively, the preparation of PRF is simple, efficient, and open to all clinicians to be used in daily clinical life.

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Effect of Platelet-rich Fibrin and Free Gingival Graft

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It is a one-step centrifuging process with high potential effect on healing.21

CONCLUSION

The use of PRF accelerates the healing of FGG. More tissue handling could be achieved by increasing the keratinized tissue during surgical procedures.

REFERENCES

1. Camargo PM, Melnick PR, Kenney EB. The use of free gin-gival grafts for aesthetic purposes. Periodontol 2000 2001 Oct;27:72-96.

2. Langer B. The regeneration of soft tissue and bone around implants with and without membranes. Compend Contin Educ Dent 1996 Mar;17(3):268-270, 272.

3. Lang NP, Löe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol 1992 Oct;43(10):623-627.

4. Miyasato M, Crigger M, Egelberg J. Gingival condition in areas of minimal and appreciable width of keratinized gingiva. J Clin Periodontol 1977 Aug;4(3):200-209.

5. Kiran NK, Mukunda KS, Tilak Raj TN. Platelet concentrates: a promising innovation in dentistry. J Dent Sci Res 2011 Feb;2(1):50-61.

6. Gupta V, Bains BK, Singh GP, Mathur A, Bains R. Regenerative potential of platelet rich fibrin in dentistry: literature review. Asian J Oral Health Allied Sci 2011 Jan-Mar;1(1):22-28.

7. Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, Gogly B. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part I: technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006 Mar;101(3):e37-e44.

8. Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, Gogly B. Platelet-rich fibrin (PRF): a second-gen-eration platelet concentrate. Part II: platelet-related biologic features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006 Mar;101(3):e45-e50.

9. Laurens N, Koolwijk P, de Maat MP. Fibrin structure and wound healing. J Thromb Haemost 2006 May;4(5):932-939.

10. Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, Gogly B. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part III: leucocyte activation: a new feature for platelet concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006 Mar;101(3):e51-e55.

11. Buser D, Sennerby L, De Bruyn H. Modern implant dentistry based on osseointegration: 50 years of progress, current trends and open questions. Periodontol 2000 2017 Feb;73(1):7-21.

12. Kawase T, Kamiya M, Kobayashi M, Tanaka T, Okuda K, Wolff LF, Yoshie H. The heat-compression technique for the conversion of plate- let-rich fibrin preparation to a barrier membrane with a reduced rate of biodegradation. J Biomed Mater Res B Appl Biomater 2015 May;103(4):825-831.

13. Li Q, Pan S, Dangaria SJ, Gopinathan G, Kolokythas A, Chu S, Geng Y, Zhou Y, Luan X. Platelet-rich fibrin promotes periodontal regeneration and enhances alveolar bone aug-mentation. Biomed Res Int 2013 Mar;2013:638043.

14. Molly L, Quirynen M, Michiels K, van Steenberghe D. Comparison between jaw bone augmentation by means of a stiff occlusive titanium membrane or an autologous hip graft: a retrospective clinical assessment. Clin Oral Implants Res 2006 Oct;17(5):481-487.

15. Ozcan M, Ucak O, Alkaya B, Keceli S, Seydaoglu G, Haytac MC. Effects of platelet-rich fibrin on palatal wound healing after free gingival graft harvesting: a comparative ran-domized controlled clinical trial. Int J Periodontics Restorative Dent 2017 Sep-Oct;37(5):e270-e278.

16. Saluja H, Dehane V, Mahindra U. Platelet-rich fibrin: a second generation platelet concentrate and a new friend of oral and maxillofacial surgeons. Ann Maxillofac Surg 2011 Jan;1(1):53-57.

17. Joseph VR, Sam G, Amol NV. Clinical evaluation of autologous platelet rich fibrin in horizontal alveolar bony defects. J Clin Diagn Res 2014 Nov;8(11):ZC43-ZC47.

18. Yu P, Zhai Z, Jin X, Yang X, Qi Z. Clinical application of platelet-rich fibrin in plastic and reconstructive surgery: a systematic review. Aesthetic Plast Surg 2018 Apr;42(2): 511-519.

19. Annunziata M, Oliva A, Buonaiuto C, Di Feo A, Di Pasquale R, Passaro I, Guida L. In vitro cell type specific biologic response of human periodontally related cells to platelet rich plasma. J Periodontal Res 2005 Dec;40(6):489-495.

20. Hurzeler MB, Weng D. A single incision technique to harvest subepithelial connective tissue graft from the palate. Int J Periodontics Restorative Dent 1999 Jun;19(3):279-287.

21. Simonpieri A, Del Corso M, Vervelle A, Jimbo R, Inchingolo F, Sammartino G, Dohan Ehrenfest DM. Current knowledge and perspectives for the use of platelet-rich plasma (PRP) and platelet-rich fibrin (PRF) in oral and maxillofacial surgery part 2: bone graft, implant and reconstructive surgery. Curr Pharm Biotechnol 2012 Jun;13(7):1231-1256.