Autologous platelet concentrates in root coverage procedures

Abstract

Gingival recessions are vastly prevalent among the general population. With regards to their treatment, recent advancements in periodontal and microsurgical procedures, focusing on minimal invasiveness and patient-centered therapies, have propelled a shift in their contemporary treatment, highlighting the field of biologics and bioactive mediators. Among different classes and types of biologics, autologous platelet concentrates (APCs), also referred to as autologous blood-derived products, are commonly used and preferred among many clinicians. These are essentially obtained via venipuncture (intravenous access) followed by centrifugation, for which numerous protocols and preparation methods have been used, leading to varieties of blood-derived products. In this review, via a systematic search, we explored the efficacy of the different utilized preparation methods and centrifugation protocols of APCs (e.g., platelet-rich plasma (PRP), platelet-rich fibrin (PRF), leucocyte-PRF, advanced-PRF, concentrated growth factor (CGF), etc.) for the treatment of type 1 gingival recessions (RT1, without interproximal attachment loss or noticeable tooth displacement), as well as their effectiveness relative to a common control (treatment with flap advancement alone without any additional material). Based on the available literature from randomized trials found in our systematic search, we observed that utilization of PRF can significantly enhance treatment outcomes when performing a coronally advanced flap, in terms of the amount of root coverage. The improvement in root coverage was further enhanced in the presence of baseline keratinized tissue width, and with an increasing relative magnitude (the more the baseline keratinized tissue width, the better the root coverage outcomes when using PRF). The efficacy of these products needs to be further explored with different graft substitutes and matrices, as well as relative to other commonly applied biologics, through well-conducted and adequately-powered randomized clinical trials.

Keywords: evidenced‐based dentistry; gingival recession; growth factors; periodontal regeneration; tissue engineering.

FIGURE 1

Different generations of autologous platelet concentrates (APCs). PPP, platelet‐poor plasma; PRF, platelet‐rich fibrin; PRGF, plasma rich in growth factor; PRP, platelet‐rich plasma; RBCs, red blood cells.

FIGURE 2

Network meta‐analysis of eligible comparisons among clinical trials. Gray solid lines connect treatments that are directly compared in at least 1 study. Studies contributing with only one arm are not presented. Gray dotted lines display the indirect comparison of the treatments that have not been compared head‐to‐head previously and formed through the network model. Note that distances are for plot clarity alone. The node size is proportional to the number of treated sites. CAF, coronally advanced flap; CGF, concentrate growth factor; PRF, platelet‐rich fibrin; PRP, platelet‐rich plasma.

FIGURE 3

Cases exemplifying possible complications of palatal harvesting. (A) Laceration of the primary palatal flap following single incision technique. (B) Bone exposure following sub‐epithelial connective tissue graft harvesting approach. (C) Epithelial cyst causing a pseudo‐pocket on the mid‐buccal aspect of a canine previously treated with connective tissue graft for root coverage purposes. Reproduced with permission from John Wiley and Sons.

FIGURE 4

Root coverage procedure and gingival phenotype modification with the tunneled coronally advanced flap (TCAF) in combination with a xenogeneic collagen matrix loaded with recombinant human platelet‐derived growth factor‐BB (rhPDGF‐BB). (A) Baseline; (B) TCAF incisions; (C) xenogeneic collagen matrix soaked with rhPDGF‐B; (D) collagen matrix sutured to the de‐epithelialized papilla and to the periosteum and inserted underneath the tunneled portion of the flap; (E) flap closure; and (F) 6‐month outcome.

FIGURE 5

Root coverage of multiple gingival recessions in the anterior maxillary region associated with previously restored non‐carious cervical lesions for a patient planning to undergo orthodontic therapy. (A) Maxillary gingival recessions at baseline. Notice the previously restored, and currently contaminated composite restorations. (B) Incision design for the tunneled coronally advanced flap (TCAF). (C) Reflection of a split‐thickness flap and reflection of the papillae between the canine and premolars. (D) Removal of the previous composite filling and restoration of the coronal portion of the cervical lesion with a composite filling takes place after scaling and root planning and decontamination of the exposed root and coronal surfaces. The anatomic papillae that were incised are also de‐epithelialized. (E) PRF is obtained after venipuncture and during centrifugation, an appropriate size of a human dermal matrix is prepared and hydrated with the obtained growth factors. (F) The growth factor is also applied on the root surfaces and periosteum. (G) The hydrated dermal matrix is secured and sutured using 7‐0 polyglycolic acid suture (PGA) material. (H) The remainder of the obtained growth factors are applied on the graft and (I) the flap is coronally positioned and sutured using 6‐0 polyprolene single interrupted sling sutures. (J) Initial follow‐up at approximately 2–3 week's time frame where sutures are removed. (K) 3‐ and (L) 6‐month healing after the surgical intervention demonstrating satisfactory root coverage results.

FIGURE 6

Demonstration of the clinical healing and ultrasonographic assessment of the treated maxillary canine as part of the previous case (Figure 5). The panels on the right of the clinical photo are representations of the ultrasound imaging modes on the mid‐facial aspect of the same tooth at each healing time (B*: B‐mode, CV: color velocity, and CP: color power). CV and CP display information regarding the perfusion of blood in the region. Note the CV and CP images that correspond to the immediate post‐operative scans that display the grafted soft tissues and the region that is not vascularized, showing the dermal matrix. Note the same region starts to increase in vascularity as the healing progresses and at 3–6 months where the graft and flap are ultrasonographically indistinguishable and graft integration has already occurred at 3 months. The displayed color velocity visualizes the velocity (speed) at which blood flows, while color power shows the amount of blood flowing within the ultrasound beam in the field of view. Color velocity imaging was performed with a constant velocity scale (±2.3 cm/s), with red indicating blood flow toward the transducer and blue denoting blood flow in the opposite direction. Color power is displayed in a single hue of red.