The study was conducted to evaluate the predictability of using Platelet rich plasma

Transcription

1 Cairo Dental Journal (25) Number (3), 337:343 September, 2009 The effect of platelet releasate in conjunction with collagen membrane in the treatment of recession defects Abdul Maguid R.F; (1) Al-Refai M; (2) Ezz Elarab A; (3) Abou El-Fadl K (4) and Shaker O (5) 1. Assistant Lecturer, Department of Oral Medicine and Periodontology, Faculty of Dentistry, MSA University, Egypt. 2. Professor, and Chairman of Oral Medicine and Periodontology Department, Faculty of Dentistry, Cairo university. 3. Professor, of Oral Medicine and Periodontology Department, Faculty of Dentistry, Cairo University. 4. Professor, of Oral Medicine and Periodontology Department, Vice Dean of Postgraduate Affairs, Faculty of Dentistry, Cairo University. 5. Professor, of Medicine Biochemistry, Faculty of Medicine, Cairo University. Abstract The study was conducted to evaluate the predictability of using Platelet rich plasma (PRP) in combination with collagen membrane to achieve root coverage in class I and II marginal tissue recession. Furthermore, any added benefit in applying PRP to the collagen membrane when compared to the use of the collagen membrane alone was investigated. Twenty class I millers recession defects were treated using collagen membrane with coronally advanced flap in ten recession defects while the other ten defects using collagen membrane with coronally advanced flap in addition to Platelet rich plasma (PRP). Clinical measurements were measured at baseline and at 6 and 12 months follow up. Wound healing index (WHI) is evaluated at 2 weeks follow up, statistical analysis was performed. Results revealed that both treatment modalities used in the present study are considered as two successful modalities in the treatment of recession defects. The addition of PRP with GTR in root coverage Procedures in Millers Class I provide no clinically measurable enhancement of the final therapeutic outcome of the root coverage procedures. Only concerning early soft tissue wound healing, PRP has shown a significant influence, than the control group. INTRODUCTION Gingival recession is one of the most common esthetic and functional concerns associated with periodontal tissues [Kassab and Cohen 2003].Various techniques have been developed to cover denuded roots [Roccuzzo 2002].Since the early 1990s, clinicians have shown increasing interest in root-coverage techniques based on the principle of guided tissue regeneration (GTR) [Scabbia and Trombelli 1998,Leknes et al 2005]. PRP was applied in root coverage procedures in several studies [Petrungaro 2001, Griffin and Cheung 2004, Cheung and Griffan 2004, Huang et al 2005, Griffin and cheung 2009], owing to it is ability to accelerate the wound-healing process and hasten repair [Marx et al 1998].

2 (338) Abdul Mageed R.F, et al. C.D.J. Vol. 25. No. (3) Materials and Methods The study included 20 recession defects in patients ages ranging from years, Patients were all free from any systemic disease as evidenced by health questionnaire using Cornell index [Kerr and Millar, 1969]. They were non smokers and not receiving any medication that could affect healing of soft tissue and bone. The defects were selected according to the following features: i. Miller class I recession. ii. All defects were on the buccal and /or labial surface. iii. No radiographic evidence of inter proximal bone loss. The 20 recession defects were divided equally as follows: Group A has received collagen membrane with coronally advanced flap. Group B has received collagen membrane with coronally advanced flap in addition to PRP. Prior to surgery, full mouth scaling and root planning were performed by hand instruments and ultrasonic scaler for all patients as well as polishing, in addition to oral hygiene instructions which included tooth brushing with soft tooth brush and interdental cleaning devices. Occlusal adjustment was performed if indicated. All patients were followed up for 3-4 weeks to evaluate the oral hygiene before surgery. Baseline pre surgical clinical soft tissue measurements were performed by using periodontal probe. Recession depth was measured from the cementoenamel junction (C.E.J) to the most apical point of the gingival margin for every tooth, Probing depth was measured from the gingival margin to the apical part of the pocket [Glavind and Loe, 1967].Clinical attachment level was measured from C.E.J to the apical part of the pocket [Glavind and Loe, 1967], Width of keratinized gingiva was measured from the gingival margin to the mucogingival junction [Lang and Loe, 1972]. Plaque index (PI).was examined in the distofacial surface, facial, mesiofacial and lingual surface [Silness and Loe, 1962], and Gingival index (GI) was assessed on the distofacial papilla, the facial margin, the mesiofacial papilla and the entire lingual gingival margin [Loe and Silness, 1963]. Surgical Treatment Following anaesthesia, an intrasulcular incision was made through the bottom of the crevice of the involved tooth. Two horizontal right angle incisions were made in to the adjacent interdental papilla at or slightly coronal to the C.E.J of the tooth presenting the defect. The horizontal incisions were connected to two oblique releasing incisions extending beyond the mucogingival junction. Trapezoid full/partial thickness flap was raised. Following flap elevation, the exposed root surface was gently planed with sharp curettes.the membrane was sized and shaped so that sharp edges were avoided. The membrane extended a minimum of 3mm beyond the defect margins. The membrane was properly adapted to ensure coverage of root. It was fitting smoothly, avoiding folds or overlaps. Simple interrupted resorbable (vicryl sutures) were recommended, and primary closure was desirable. Both groups had the same surgical intervention and membrane placement and adjustment, only in the PRP group the PRP has been prepared according to the following method. PRP preparation A blood sample (8ml) was drawn into a citrated tube. The sample tube was then spun in a standard centrifuge for 10 minutes at 2400 rpm to produce PPP. The result is a separation of whole blood into a lower red blood cell

3 The effect of platelet releasate (339) (RBC) region and upper straw-colored plasma region (the PPP) as shown in, later the PPP was taken up into a syringe with a long air-intake cannula and placed into a new tube for a second centrifugation. A second centrifugation (15 minutes at 3600 rpm) was performed to concentrate the platelets. This results in an upper portion of clear yellow supernatant serum and the bottom red tinged layer consisting of highly concentrated PRP as shown. For each 8 ml of blood, the volume of the PRP was about ml, PRP was further collected by a long air intake cannula to be used for the surgical procedure [Weibrich et al 2001]. At the time of the application, the PRP was combined with a sterile saline solution containing 10% calcium chloride (a citrate inhibitor that allows the plasma to coagulate) and 100 U/ ml of sterile bovine thrombin in a ratio of 10:1 [Haung et al 2005], the supernatant containing the released platelet factors was removed from the platelet clumps and used immediately. The resultant Platelet releasate (PR) should be a sticky gel that will be relatively easy to apply to the surgical defects [Kark et al 2006]. The PRP was then applied under the membrane. Simple interrupted resorbable (vicryl sutures) were recommended, and primary closure was desirable. Patients were prescribed 0.12% chlorhexidine gluconate and instructed to rinse gently (1-2min) twice daily for 3 weeks. They were also given antibiotics (amoxicillin, 500 mg, three times daily, for 7 days to prevent postsurgical infection., analgesics (ketophan 50 mg) were prescribed, the post-surgical. brushing with an ultra soft tooth brush was recommended. Professionally plaque control was performed at 1, 2, 3, and 6 weeks and 3, 6, 9 month postsurgical.clinical parameters were evaluated at 6 and 12 months, and were compared to baseline measurements. Wound healing index (WHI) was recorded after surgery using the following criteria: score 1= uneventful healing with no gingival edema, erythema, suppuration, patient discomfort, or flap dehiscence; score 2= uneventful healing with slight gingival edema, erythema, patient discomfort, flap dehiscence, or any suppuration; and score 3= poor wound healing with significant gingival edema, erythema, patient discomfort, flap dehiscence, or any suppuration [Huang et al 2005]. Figure (1), (2). Fig. (1) Wound healing index WHI measurements after 2 weeks follow up denoting WHI of 2. Fig. (2) wound healing index WHI measurements after 2 weeks follow up.

4 (340) Abdul Mageed R.F, et al. C.D.J. Vol. 25. No. (3) Results The mean recession width for the control group was 2.2mm. At 12 months follow up there was an average of (0.6 mm) reduction in recession width. The mean recession depth was 3.6 mm. At 12 months follow up, there was an average of 54.8% (2mm) root coverage. For the PRP group the mean RW was 2.6mm.At 12 months an average of (0.8mm) reduction in recession width has been obtained. The mean RD was 2.6mm; at 12 months follow up there was an average of 53% (1.4mm) root coverage. The mean CAL for the control group was 5.2mm. At 12 months follow up there was an average of 1.9mm.For the PRP group the mean CAL was 4.2mm. At 12 months follow up there was an average of 1.8m. The mean KGW for the control group was 2.2mm.At 12 months follow up there was a 2 mm increase in KGW. For the PRP group the mean KGW was 3.4mm.At 12 months follow up there was a 1mm increase in KGW, for both groups there were a statistically significant increase in KGW. The mean PI for the control and the PRP groups showed a non statistically significant difference, the mean PI showed a statistically significant increase after 6 months for the control group and after 6 weeks in the PRP group, but PI reduced in both groups at 12 months follow up near to the baseline records. The mean GI showed a non statistically significant difference between the control and the PRP groups, after the baseline records there was an insignificant increase in mean GI followed by an insignificant decrease at 12 months follow up for both groups. The mean GI of the PRP group at 6 weeks was lower than the mean GI of the control group, but the difference was not significant. On comparison of root coverage % of both groups, there was no statistically significant difference. Table (1) Figure (3).Control group has shown a statistically significant higher mean WHI than the Study group. Table (2) Figure (4) Table (1) The mean % changes in RD, standard deviation (SD) values and results of Mann Whitney U test for comparison between the two groups Period Group Control PRP Mean% ±SD Mean % ±SD P-value Baseline 6 months -55% ± % ± months 12 months 0% ±0-20% ± Baseline 12 months -55% ± % ± Table (2) The means, standard deviation (SD) values and results of Student s t-test for comparison between wound healing indexes of the two groups Period Group Control PRP Mean SD Mean SD P-value 2weeks * *: Significant at P 0.05

5 The effect of platelet releasate (341) Fig. (3) Mean % changes in RD of the two groups Fig. (4) Mean wound healing index of the two groups Discussion The goal of treating gingival recession is to resolve esthetic problems, treat dentinal hypersensitivity, and prevent root surface caries. (Ito et al 2000). Several techniques developed over the years, including the laterally positioned pedicle graft, coronally advanced flap, free gingival graft, and subepithelial connective tissue graft, have yielded promising results [Nelson, 1987]. Investigators have reported successful root coverage using surgical techniques based on the principles of guided tissue regeneration (GTR) (Trombelli et al 1995, Wang et al 2000). GTR based root coverage, however, offers the additional potential benefit of new attachment formation (bone, cementum, periodontal ligament, and connective tissue) along the previously denuded root surface [Miller, 1985]. Furthermore, it offers an unlimited supply of materials and eliminates the need for a second surgical site [Wang et al, 2002]. PRP has shown to enhance soft tissue healing, promote initial stabilization, and revascularization of the flaps and grafts for root coverage [Petrugaro 2001]. Therefore, the present study was designed to investigate the effects of PRP on GTR root coverage procedures.].the recession defect was chosen to be Miller class I, with no loss of interdental bone or soft tissue to achieve good prognosis [Miller, 1985]. The PRP perpetration used in this study is in accordance to Weibrich et al. (2001).The average PRP production per 8ml whole blood was ml and the platelet concentration increased approximately four times in mm 3 blood. The technique of producing PRP by Weibrich et al 2001 was followed. In the present study the PRP was combined with an equal volume of a sterile saline solution containing 10% calcium chloride and 100 U/ml of sterile bovine thrombin resulting in platelets degranulation and release of the mediators and cytokines [Camargo et al 2002]. The mean root coverage percent (RC%)for the control group was 54.8% (2mm), where as for the PRP group the mean RC% was 53% (1.4mm) root coverage at 12 months follow up. RC% of the present study is comparable RC% reported by [Shieh et al 1997, Trombelli et al 1998, Müller et al 2001] using GTR based procedures, bioabsorbable membrane with a coronally advanced flap, at 6 months follow-up.four groups of investigators [Cheung and Griffin 2004; Huang et al, 2005; Keceli et al, 2008; Griffin and Cheung 2009] researched the application of platelet concentrate (PC) in root-coverage procedures. The present study showed a non statistically significant difference between % changes in RD of the two groups through all periods and this is in accordance to Keceli et al [2008] and Jancovic et al [2007] but they has compared CTG (control group), with CTG+PRP (study group).through the period (6 months 12 months, the present study showed no changes concerning mean RD, for both groups and this is in accordance to [Leknes et al 2005]. The variations in root coverage percent between

6 (342) Abdul Mageed R.F, et al. C.D.J. Vol. 25. No. (3) those previous studies and the present study may due to the multifactorial healing response of defects treated with GTR including: technique, patient compliance, tissue thickness, depth of the vestibule,occlusion and muscle strength [Griffin and Cheung 2009], in addition to that most of the present study cases were for mandibular teeth,only one case was for maxillary teeth a root coverage % was confined with the study by Trombelli et al [1995] which revealed a 50.6% of root coverage in mandibular teeth versus 84.3% of root coverage in maxillary teeth in GTR treated 24 mucogingival defects. The reduction in recession width (RW) after 6 months and after 12 months for the control group and the RPR group respectively was statistically significant when compared to base line in both groups and this has a similar finding to Huang et al [2005]. The mean RW for both groups showed a non statistically significant difference and this is in accordance to Keceli et al [2008] and Jancovic et al [2007]. Control group has shown a significant higher mean WHI than the Study group, and this is in accordance with Jancovic et al [2007] and Huang et al [2005]. Results of the healing index (HI) indicated improvements of early wound healing (1st and 2nd week post-surgery) in the group treated with PRP, compared with the group treated without this fraction of plasma. This outcome may be related to the extremely elevated density of fibrin fibers (100 times more than normal) detected in the region treated with PRP. Moreover the improvements of HI achieved in the PRP group could be explained as action of PDGF, VEGF (vascular endothelial growth factor) and TGF, the main growth factors from PRP. These growth factors might enhance soft tissue healing by increasing the angiogenesis and matrix biosynthesis during wound healing [Huang et al, 2005]. This may explain the role of PRP in soft tissue wound healing in accordance to [Lindeboom et al 2006; Petrungaro 2001; Cheung and Griffin 2004]. Conclusions The addition of PRP with GTR in root coverage Procedures in Millers Class I provide no clinically measurable enhancement of the final therapeutic outcome of the root coverage procedures and this is in accordance to [Huang et al, 2005]. Only concerning early soft tissue wound healing, PRP has shown a significant influence, than the control group. References 1. Camargo PM, Lekovic V, Weinlaender M, Vasilic N, Madzarevic M, Kenney EB. Platelet-rich plasma and bovine porous bone mineral combined with guided tissue regeneration in the treatment of intrabony defects in humans. J Periodontol Res. 2002; 37: Glavind L, Löe H. Errors in the clinical assessment of periodontal destruction. J Periodont Res 1967; 2: Gottlow J, Njinan S, Lindhe J, Karring T, Wennstrom J. New attachment formation in the human periodontium by guided tissue regeneration. Case reports. J Clin Periodontol 1986; 13: Goultschin J, Cohen H, Douchin M, Brayer L, Soskolne W. Association of smoking with periodontal treatment needs. J Periodontol 1990; 61: Griffin TJ, Cheung WS. Guided Tissue Regeneration Based Root Coverage With a Platelet Concentrate Graft: A 3-Year Follow-Up Case Series. J Periodontol 2009, 80: Griffin TJ, Cheung WS. Treatment of gingival recession with a platelet concentrate graft: A report of two cases. Int J Periodont Rest Dent 2004; 24: Huang LH, Neiva RE, Soehren SE, Giannobile WV, Wang HL. The effect of platelet-rich plasma on the coronally advanced flap root coverage procedure: A pilot human trial. J Periodontol 2005; 76: Ito K, Oshio K, Shiomi N, Murai S. A preliminary comparative study of the guided tissue regeneration and free gingival graft procedures for adjacent facial root coverage. Quintessence Int. 2000; 31: Jankovic SM, Zoran AM, Vojislav LM, Bozidar DS, Kenney BE. The use of platelet-rich plasma in combination with connective tissue grafts following treatment of gingival recessions. Periodontal Practice Today 2007; 4:

7 The effect of platelet releasate (343) 10. Kark LR, Karp JM, Davies JE. Platelet releasate increases the proliferation and migration of bone marrow-derived cells cultured under osteogenic conditions. Clin Oral Implants Res. 2006; 17: Karring T, Cumming BR, Oliver RC, Löe H. The origin of granulation tissue and its impact on postoperative results of mucogingival surgery. J Periodontol 1975; 46: Kassab MM, Cohen RE. Free full text treatment of gingival recession.review. J Am Dent Assoc. 2002; 133: Keceli HG, Sengun D, Berberoğlu A, Karabulut E. Use of platelet gel with connective tissue grafts for root coverage: a randomized-controlled trial. J Clin Periodontol 2008; 35: Kerr DA, Millard HD. Oral diagnosis. 2 nd ed. C.V. Mosby Co. 1969; p Lang NP, Löe H. The relationship between the width of the keratinized gingiva and gingival health. J Periodontol 1972; 43: Leknes KN, Amarante ES, Price DE, Bøe OE, Skavland RJ, Lie T. Coronally positioned flap procedures with or without a biodegradable membrane in the treatment of human gingival recession. A 6-year follow-up study. J Clin Periodontol 2005; 32: Lindeboom JAH, Mathura KR, Aartman IHA, Kroon FHM, Milstein DMJ, Ince C. Influence of the application of platelet enriched plasma in oral mucosal wound healing Clin. Oral Impl. Res. 2007; 18: Löe H, Silness P. Periodontal disease in pregnancy. Acta Odontol Scand 1963; 21: Miller PD Jr. A classification of marginal tissue recession. Int J Periodont Rest Dent 1985; 5: Müller H-P, Stahl M, Eger T. Failure of root coverage of shallow gingival recessions employing GTR and a bioresorbable membrane. Int J Periodont Rest Dent 2001; 21: Nelson SW. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987; 58: Petrungaro P. Platelet-rich plasma for dental implants and softtissue grafting. Interview by Arun K.Garg. Dent Implantol Update 2001; 12: Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions: a systematic review. J Clin Periodontol 2002; 29: Scabbia A, Trombelli L. Long-term stability of the mucogingival complex following guided tissue regeneration in gingival recession defects. J Clin Periodontol 1998; 25: Shieh AT, Wang HL, O Neal R, Glickman GN, MacNeil LR. Development and clinical evaluation of a root coverage procedure using a collagen barrier membrane. J Periodontol 1997; 68: Silness P, Löe H. Periodontal disease in pregnancy. Acta Odontol Scand 1962; 22: Trombelli L, Scabbia A, Tatakis DN, Checchi L, Calura G. Resorbable barrier membrane and envelope flap surgery in the treatment of human gingival recession defects. A case report. J Clin Periodontol 1998 b; 25: Trombelli L, Schincaglia GP, Zangari F, Griselli A, Scabbia A, Calura G. Effects of tetracycline HCl conditioning and fibrin-fibronectin system application in the treatment of buccal gingival recession with guided tissue regeneration. J Periodontol 1995; 66: Wang H, Kimble K, Eber R. Utilization of bone grafts for the enhancement of a GTR-based root coverage procedure: A pilot case study. Int J Periodont RestDent 2002; 22: Weibrich G, Kleis WK, Kunz-Kostomanolakis M, Loos AH, Wagner W. Correlation of platelet concentration in plateletrich plasma to the extraction method, age, sex, and platelet count of the donor. Int J Oral Maxillofac Implants 2001; 16: Weibrich, G.; Gnoth, S. H.; Otto, M.; Reichert, T. E.; Wagner, W. Growth stimulation of human osteoblast-like cells by thrombocyte concentrates in vitro. Mund. Kiefer. Geschtschir 2002; 6: