|DENTAL SCIENCE - CASE REPORT
|Year : 2015 | Volume
| Issue : 6 | Page : 695-699
A comparison of efficiency of biopolymer and allograft matrix with autogenous gingival graft used in root coverage procedure
K Hameed Fathima, VS Harish
Department of Dentistry, Sri Muthukumaran Medical College and Research Institute, Chennai, Tamil Nadu, India
|Date of Submission||28-Apr-2015|
|Date of Decision||28-Apr-2015|
|Date of Acceptance||22-May-2015|
|Date of Web Publication||1-Sep-2015|
K Hameed Fathima
Department of Dentistry, Sri Muthukumaran Medical College and Research Institute, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Severe surgical techniques have been introduced to augment gingival tissue dimensions like the free gingival graft, free connective grafts, etc., However, both the techniques are associated with significant patient morbidity due to the secondary surgical site. In order to overcome these postsurgical complications, acellular dermal allografts have been used as a substitute for the palatal donor tissue yielding clinically comparable results. However, the cost and origin of the material raises concern regarding the frequent use of the material. As an improved alternative to above-mentioned graft material, the use of platelet-rich fibrin (PRF) and collagen matrices has been promoted in the recent past. The objective of this illustrative case report is to test the efficacy of collagen matrix, PRF to augment attached gingiva and to assess the esthetic outcome when compared to the standard treatment with free autogenous graft.
Keywords: CollaCote, connective tissue graft, envelope flap, platelet-rich fibrin, recession
|How to cite this article:|
Fathima K H, Harish V S. A comparison of efficiency of biopolymer and allograft matrix with autogenous gingival graft used in root coverage procedure. J Pharm Bioall Sci 2015;7, Suppl S2:695-9
|How to cite this URL:|
Fathima K H, Harish V S. A comparison of efficiency of biopolymer and allograft matrix with autogenous gingival graft used in root coverage procedure. J Pharm Bioall Sci [serial online] 2015 [cited 2020 Jan 20];7, Suppl S2:695-9. Available from: http://www.jpbsonline.org/text.asp?2015/7/6/695/163481
The desire for improved gingival esthetics and the consequent demand for cosmetic dentistry have increased tremendously in recent times. One of the commonly used cosmetic procedures in periodontal treatment is coverage of the denuded root surface.
It is well-established that connective tissue grafts (CTGs) are the gold standards in soft tissue grafting for optimal root coverage. Factors such as second surgical site, donor site morbidity and patient anxiety during the surgical procedure  demands a viable alternative providing comparable results which could be of greater value.
Platelet-rich fibrin (PRF) - a versatile biopolymer belongs to a new generation of platelet concentrates showing greater potential in tissue regeneration and wound healing by acting as autologous matrix.  PRF generates a fibrin network improving cell migration and proliferation with a rich concentration of growth factors promoting tissue regeneration. 
The use of noncellular graft matrix is primarily an attempt to provide a physical scaffold for the regenerating wound. CollaCote an allograft matrix possess hemostatic function that facilitates early clot formation and wound stabilization. This bovine-derived type I collagen stabilizes the blood clot with fibrin linkage that enhances connective tissue matrix formation by cell migration and proliferation.
The aim of the present case report was to evaluate the effectiveness, and esthetic outcome of an autologous matrix, allograft matrix in comparison with autogenous gingival tissue graft when used with envelope flap design during the root coverage procedure.
| Illustrative Case Reports|| |
Three systemically healthy patients aged between 20 and 35 years who are categorized under Miller's Class I  recession on the right maxillary first premolar region without buccal prominence were selected for this illustrative case report. Alcoholic, pan chewers, smokers, and patient with a history of mucogingival or periodontal surgery at the experimental site were excluded from this case report. Sites with prosthetic crown or restoration with the cervical edge at the cemento-enamel junction (CEJ) area, presence of a root/crown abrasion at the CEJ level were also excluded.
The surgical procedure was explained to the patients, and informed consent was obtained. Preparation of the patient included scaling and root planning of the entire dentition 2 weeks before the scheduled surgical procedure. All patients received oral hygiene instructions to modify the habits related to the etiology of the recession before the surgery.
The following parameters were recorded with a periodontal probe (Williams' periodontal probe) before and after surgery. Probing pocket depth, recession depth, full-mouth plaque score, and full-mouth bleeding score were recorded for these patients. To proceed with surgery, each patient had to achieve full-mouth plaque index score of <20%, with no plaque on the surgical site.
Recipient site preparation
In the present case report, the surgical sites were anesthetized by local infiltration using 2% lignocaine hydrochloride with 1:200000 adrenalin. The root surface adjacent to the recession site was debrided and conditioned (1 capsule of tetracyclinehydrochloride [HCl], 250 mg mixed with saline).
A 25-year-old male patient presented with Miller's Class I recession on 14 tooth region. Patient's chief complaint was receding gums. Patient's dental history reveals that he had undergone oral prophylaxis a year back. The recession defect was 3 mm depth exhibiting attachment loss.
Treatment plan of envelope flap associated with PRF membrane was decided. Patient was informed about the therapeutic alternatives to the planned surgical procedure.
Platelet-rich fibrin preparation
The required quantity of blood was drawn in 10 ml test tube without an anticoagulant. Blood was centrifuged immediately using table top centrifuge for 12 min at 2700 rpm. 
Three layers formed after centrifuging the blood:
- Top most layer consist of a cellular platelet-poor plasma
- PRF clot in the middle and
- Red blood cells at the bottom.
Because of the absence of anticoagulant, blood begins to clot as soon as it comes in contact with the glass surface. Therefore, for successful preparation of PRF speedy blood collection and immediate centrifugation before the clotting cascade initiates was absolutely essential. The PRF can be obtained in the form of membrane by squeezing out the fluids in the fibrin clot. 
The recipient site was anesthetized by local infiltration [Figure 1]a. Using a #15C blade, a sulcular incision was made around the tooth adjacent to the recession. A split - thickness envelope was created apical to the papilla and the adjacent radicular surface according to the procedure described by Raetzke [Figure 1]b.  The tissues were gently undermined, beyond the mucogingival junction (MGJ) so as to relax the flap sufficiently to allow placement of PRF. This envelope flap extended 5-10 mm apical to the recessed gingival margin and papilla and 4-6 mm mesial and distal to the denuded root surface. The prepared PRF membrane [Figure 1]c was pushed into the created envelop with a dull instrument (periosteal elevator). Once the graft was completely into the flap on the conditioned root surface, it was positioned coronal to the CEJ. Mild compression with sterile gauze dampened with saline was applied for 5 min. The membrane was secured with cyanoacrylate [Figure 1]d and periodontal pack (Coe pack) was placed [Figure 1]e.
|Figure 1: (a) Preoperative intraoral view of 14 region with recession, (b) Root conditioning done on root surface adjacent to defect and an envelope flap was created beyond the mucogingival junction, (c) Platelet-rich fibrin (PRF) clot and membrane, (d) PRF membrane placed below the created flap and secured with cyanoacrylate, (e) Periodontal pack placed|
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A 28-year-old female patient reported with the chief complaint of sensitivity in her right upper back tooth region. Clinical examination revealed the presence of Miller's Class I recession in relation to 14 region. Further examination revealed a recession depth ranging from 2 to 3 mm with attachment loss.
The treatment of choice was envelope flap with CollaCote matrix. Alternative surgical procedures were explained, and inform consent was obtained.
The mucogingival surgical procedure was initiated after anesthetizing the site by local infiltration [Figure 2]a. A partial-thickness envelope flap was raised by giving intrasulcular incisions that included the interdental papillae adjacent to the defect. Neither horizontal nor vertical incisions were performed [Figure 2]b. Sharp dissection was used to elevate the flap beyond the MGJ until no tension was felt during coronal positioning of the flap.  The CollaCote matrix (CAT #:0101, manufactured by Integra Life Sciences Cooperation Plainsboro, NJ 08536, USA) [Figure 2]c was shaped and trimmed to fit the recipient site at the level of CEJ. The shaped matrix was rehydrated with saline and was inserted into the prepared envelope and positioned to cover the exposed root surface [Figure 2]d. The flap was positioned and sutured with two interrupted proximal sutures using 4-0 vicryl [Figure 2]d (Ethicon, Inc., Johnson and Johnson, Somerville, NJ, USA). Periopack was placed over the surgical site [Figure 2]e.
|Figure 2: (a) Preoperative intraoral view of 14 region with recession, (b) Root conditioning done on root surface adjacent to defect and an envelope flap was created beyond the mucogingival junction, (c) CollaCote matrix, (d) CollaCote matrix placed below the created flap and secured with 4-0 vicryl suture material, (e) Periodontal pack placed|
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A 30-year-old male patient presented with the complaint of sensitivity and recession in relation to right upper back tooth region. The defective site exhibited attachment loss with recession depth ranging from 2.5 to 3 mm with no interdental bone loss. The recession did not extend beyond the MGJ.
The surgical procedure planned for this case was envelope flap design with CTG. Patient was informed on the advantages, disadvantages, risks, and potential complications of the proposed therapy and written inform consent was obtained.
Subepithelial connective tissue graft harvest
The donor site was anesthetized by local infiltration. The subepithelial CTG (SCTG) was harvested from the palatal area between the first premolar and first molar region according to the procedure described by Langer and Langer.  A horizontal incision was placed 5-6 mm from the gingival margin of premolars and molar using #15 scalpel blade. The blade was used to undermine a partial thickness flap. Then a more coronally positioned parallel incision was made approximately 3 mm from the gingival margin, it was continued to the same level as the first incision. The blade was angulated towards the bone to ensure adequate graft thickness. This second incision produces a CTG of approximately 1.5-2 mm in thickness. Then two vertical releasing incisions are made mesially and distally to free the terminal ends of the graft. Once the donor tissue was procured, the palatal flap was then replaced and secured with cyanoacrylate. A prefabricated palatal stent was placed to protect the donor site.
Recipient site preparation
The recipient site was anesthetized by local infiltration [Figure 3]a. An envelope was prepared apically and lateral to recession by split incisions [Figure 3]b. The depth of the preparation should be 3-5 mm in all directions. In apical direction, the preparation of the site should extend beyond the MGJ to facilitate the placement of the CTG. The harvested graft [Figure 3]c was placed into the prepared envelope and positioned to cover the exposed root surface till the level of CEJ [Figure 3]d. Pressure was applied for 5 min to closely adapt the graft to the root surface and covering soft tissue. The graft was secured in position with cyanoacrylate, and periodontal dressing was given [Figure 3]e.
|Figure 3: (a) Preoperative intraoral view of 14 region with recession, (b) Root conditioning done on root surface adjacent to defect and an envelope flap was created beyond the mucogingival junction, (c) The palatal flap on the donor site was repositioned secured with cyanoacrylate and a palatal stent placed after the connective tissue graft harvested, (d) Connective tissue graft was placed below the created flap and secured cyanoacrylate, (e) Periodontal pack placed|
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Postsurgical instructions and control
The patients were placed on amoxicillin 500 mg 2 tablets/day for 5 days, combiflam 2 tablets/day for 5 days. Patients were advised to rinse with chlorhexidine gluconate 0.2% mouthwash twice daily for 4 weeks and advised to follow routine postoperative instructions. The surgical site was repacked after 1 week, and the dressing was removed 10 days after surgery.
Postoperative follow-up was done every week for 6 weeks, there was no postoperative complication or morbidity during the review and healing was satisfactory. The patients were recalled, and the clinical parameters were recorded at 3 and 6 months after surgery.
| Discussion|| |
The present illustrative case report was designed to test the effectiveness and esthetic outcome of PRF membrane, CollaCote matrix with that of CTG in the treatment of Miller's Class I single gingival recession.
The envelope flap design was used in this case report to preserves the lateral and apical blood supply of the flap by eliminating vertical release incisions.  Cordioli et al.  stated that the envelope technique produced greater increases in keratinized tissues.
Though SCTG procedure produces predictable and esthetically pleasing outcomes, the major disadvantage of this technique is the second surgical site required to harvest the graft.  The use of PRF membrane and CollaCote matrix in this case report alleviates the need for the donor site procurement of connective tissue.
The growth factors present in PRF accelerates bone repair and promotes fibroblast proliferation and increase tissue vascularity, increases rate of collagen formation, mitosis of mesenchymal cells and endothelial cell which plays a key role in the rate and extent of tissue regeneration.  Though PRF matrix has minor disadvantages like technique sensitive mucogingival surgical procedure and needs to draw blood from the patient. It has various advantages like higher concentration of growth factors which accelerates or enhances regeneration, its prepared without biochemical handling, , provides excellent adaptation onto the recipient site, minimal postoperative edema and discomfort, provides harmonious gingival color and texture, high vascularization of the graft, requires single surgical procedure, and provides unlimited source of graft material. 
In this present case report, PRF yielded a clinically comparable esthetic result with that of CTG [Figure 4] which is in concordance with the study done by Cheung and Griffin. 
|Figure 4: (a) Preoperative view of the recession site to be augmented with platelet-rich fibrin (PRF), (b) 6 months postoperative view of site treated with PRF, (c) Preoperative view of the recession site to be augmented with CollaCote matrix, (d) 6 months postoperative view of site treated with CollaCote, (e) Preoperative view of the recession site to be augmented with connective tissue graft (CTG), (f) 6 months postoperative view of site treated with CTG|
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Though CollaCote matrix used in this illustrative report has advantages like it provides an excellent matrix for tissue ingrowth to assist in wound healing, controls bleeding, stabilizes blood clots, protects the wound bed and accelerates wound healing process. It carries the disadvantage of being a bovine derivative and it lacks growth factor.
To conclude, PRF yielded clinically comparable esthetic result with that of CTG but collagen matrix did not result in optimal root coverage.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]