Management of Multiple Gingival Recessions Using Zucchelli’s Modified Coronally Advanced Flap Technique with or withoutPlatelet Rich Fibrin Membrane – A Case Report

INTRODUCTION

The keyobjective of periodontal therapy is to assist periodontal health through the reconstruction of lost hard and soft tissues, or by precluding itsadditional loss, and also enhancing the esthetics. One of the most frequent esthetic concerns is Gingival Recession¹ . Gingival Recession can be defined as the location of the gingival margin apical to the Cemento-enamel junction [CEJ]² . The major etiological factors associated are periodontal diseases, high frenal attachment, tooth malposition and traumatic tooth brushing. The affected patients may complain of teeth hypersensitivity, poor esthetic appearance with exposed root and the area may retain plaque, which can lead to root caries.³

Estheticshas been the prime indication for root coverage procedures. Complete coverage of gingival recession defects can be accomplishedonly whenthere is no loss of interproximal soft and hard tissues. Over the last few decades, many different surgical approaches for root coverage have been reported in the literature. The coronally advanced flap (CAF) is the choice in patients with high aesthetic demands, but there is a need of an adequate amount of keratinized tissue apical to the recession defect. With this approach, the soft tissue used to cover the exposed roots needs to be similar in colour, texture, and thickness to that eventually attached to the recession defect; thus the satisfying esthetic demands.⁴ CAF have been frequently combined with various regenerative materials which aim at accomplishing both regeneration of functional attachment apparatus and root coverage. They include Guided tissue regeneration membranes, Enamel matrix proteins derivatives, Fibroblast derivatives etc. Although these materials are frequentlyused, the introduction of autologous agents like platelet concentrates has given new biologic era for the enhanced clinical outcomes in periodontal therapy.¹

Platelet rich fibrin (PRF) is a second generation platelet concentrates system, with simpler and faster preparation methods, because it does not involve additional anticoagulants and chemical activators. PRF demonstrates a greater concentration of growth factors, matrix proteins, platelets, leukocytes and circulating stem cells, which are incorporated in a three dimensional cross linked fibrin system⁵ . These growth factors enhance the wound healing mechanism and are postulated as promoters of tissue regeneration. They can modulate and up-regulate one growth factor’s function in the presence of others. These precise features made PRF as the material of choice in periodontal plastic surgical procedures.⁶

Zucchelli and De Sanctis have described a modified coronally advanced flap design for the treatment of multiple gingival recessions, which allows for optimal flap adaptation following its coronal advancement, without placement of vertical releasing incisions⁷ . This case report presents bilateral multiple gingival recessions treated with Zucchelli’s modified coronally advanced flap with or without the use of PRF.

CASE REPORT

A 51 year old female patient reported to the Department of Periodontology with a chief complaint of root hypersensitivity to cold beveragesin the upper left and right back teeth region since 5 months. She had no significant medical history. On clinical examination, Miller’s class I Gingival recessionswere identified with teeth 15,14, 13,12,11,21,22,23, and 24. The bilateral recession defects were measured by calculating the distance between the CEJ and the gingival margin. It was recorded as 3mm, 5 mm, 3mm, 2mm & 3mm for 15, 14, 13, 12, and 11 respectively (Figure1A) 4mm, 2mm, 4mm & 4mm for 21, 22, 23, and 24 respectively (Figure 2A).The surgical procedure was explained to the patient and informed consent was obtained. Pre-operative preparationincluded scaling and root planning of the entire dentition and oral hygiene instructions. The probing depth was recorded as <3 mm around the involved teeth.

Surgical procedure: Disinfection of the surgical site was done with 2% betadine.The procedure was carried out under localanaesthesia (2% lignocaine hydrochloride with 1: 80,000 adrenaline). After the recipient site preparation, 5 ml of venous blood was drawn in a test tube without an anticoagulant, and immediately centrifuged for 12 minutes at 2700 rpm. The resultant product consisted of the following three layers: The topmost layer consisted of Platelet-Poor Plasma, a PRF clot in the middle, and red blood cells at the bottom. PRF gel was separated from the red blood cell base using scissors, and placed in a sterile bowl(Fig. 2C). The PRF membrane was prepared by compressing it between two sterile gauze pieces.

At the surgical site, a horizontal incision was made with a scalpel todesign an envelope flap. The horizontal incision consisted of oblique sub-marginal incisions in theinterdental areas and continued as intra-sulcular incisions at the recession defects. The oblique interdental incisions were carried out by keeping the blade parallel to the long axis of the teeth in order to create the surgical papilla (Figure1B, 2B). The flap was raised with a split-full-split approach.Gingival tissue apical to the exposure was raised in a full-thickness. Finally, horizontal vestibular incisions were made to facilitate the easier coronal displacement of the flap.

The root surfaces were mechanically debrided with curettes. In relation to 22, 23 and 24, the PRF membrane was placed over the denuded root surfaces (Figure 2D). The remaining tissue of the anatomic interdental papillae was de-epithelized to createconnective tissue beds to which the surgical papillae were sutured. The flap was coronally repositioned and held in position with interrupted sutures (Figure 1C, 2E). The operated site was then covered with periodontal dressing.

The Patient was instructed not to remove the pack or disturb the surgical site and not to brush the treated teeth, but to rinse the mouth with 0.2%Chlorhexidine solution twice daily for 1 minute. Patient was advised to take antibiotics and analgesic (Amoxicillin 500 mg and Diclofenac 50 mg + Paracetamol 325 mg) for 5 and 3 days postoperatively. The periodontal dressing and the sutures were removed after 14 days. Healing was unintentional andsatisfactory root coverage was obtained. Patient was recalled after 1, 3, 6 and 9 months, which revealed satisfactory results with excellent tissuecontour, colour match and increase in the amount of keratinized tissue at 9 months (Figure 1D, 2F).However there were no superior root coverage when compared between the two treated sites after 3 months, the improved gingival tissue thickness and the enhanced wound healing mechanisms of the membrane treated sites can be attributed to the biological and mechanical properties of PRF.

Root coverage: At 9 month post-treatment, thepercentage of root coverage was calculated according to the following formula:⁸

Root coverage = Recession depth (preoperative – postoperative)/recession depth preoperatively × 100

Result: At 9 month follow up, the mean root coverage achieved with Zucchelli’s modified coronally advanced flap alone was 55±13.9 % and Zucchelli’s modified coronally advanced flap with PRF was 75±20.40, showing no statistical significance between the procedures (Table 1). Amount of keratinised gingiva gained at teeth site 14, 21 and 23 were 2mm each.

DISCUSSION

Treatment of gingival recession has always been considered as a clinical challenge in satisfying the patient centred esthetic demands. Gingival recession provides a nidus for microbial plaque and calculus accumulation, which renders the affected area inaccessible with routine oral hygiene measures and there is the potential for development of root caries on thedenuded root surfaces³ . Another factor to be considered is that, most frequently gingival recession affects the multiple adjacent teeth. And these contiguous recessions should be treated at the same time. The CAF procedure has been demonstrated to be the most predictable and reliable modality forobtaining the root coverage with more patient comfort and minimal surgical trauma. In the present case report, a modified approach to the CAF was used to treat multiple adjacent recession defects inpatients with high aesthetic considerations.

In Zucchelli’s modified CAF procedure, vertical releasing incisions are avoided, so that the blood supply to the flap is not interrupted; which is of utmost important in stability of root coverage approaches. Furthermore, vertical incisions couldcause visible scars resulting in un-esthetic clinical outcome.⁴ PRF is a platelet concentrate of second generation, defined as autologous leukocyte and platelet rich biomaterial. It was first developed by Choukroun et al. It has been used widely in combination with bone graft materials for periodontal regeneration, sinus lift procedures for implant placement, ridge augmentation and for root coverage techniques in the form of PRF membrane. This membrane consists of a fibrin polymerized 3-dimesional matrix, with he incorporation of platelets, growth factors, leukocytes and circulating stem cells.⁹ The PRF matrix itself shows mechanical adhesive properties and biologic functions, which maintains the flap in a constant position in turn promotes neoangiogenesis and diminishes the chances of tissue necrosis.

Walker et al⁴ in their case report, demonstrated the effectiveness of Zucchelli’s technique in treatment of multiple recession defects both in terms of root coverage and increasedwidth of keratinized tissue. Agarwal et al.^10,11 have demonstrated the improved biological outcomes with combination use of PRF with Zucchelli’s technique for unilateral adjacent recessions, but there were no clinical comparison made with the conventionally treated sites without PRF.

In a systematic review, evaluating the effects of PRF membrane on the clinical outcomes of treatments of gingival recessionMoraschini et al., suggested that the use of PRF membrane did not improve the amount of root coverage, keratinised tissue width or clinical attachment level in the treatment of Miller Class I and II gingival recessions compared with the other treatment modalities.⁵ However, in the present case, significant increase in percentage of root coverage and width of attached gingiva were found at sites treated with PRF when compared to sites treated without PRF.

CONCLUSION

Within the limitations, the current case report demonstrated the effectiveness of Zucchelli’s modified coronally advanced flaptechnique with satisfactory root coverage, excellent tissue contour and increase in amount of keratinised tissue. Although statistically not significant,the sites treated with the addition of PRF showed clinically significant improvement in thepercentage root coverage and increase in width of attached gingivaresulting in better estheticoutcome. More studies with this procedure would provide the firm evidence of PRF’s impact on wound healing, augmentation procedures and soft tissue reconstruction, in periodontal surgical procedures.