|Year : 2021 | Volume
| Issue : 4 | Page : 106-110
Evaluation of efficacy of platelet-rich fibrin for papilla reconstruction
Yesha Haresh Raval, Monali Amit Shah, Rahul Deepak Dave, Aastha Vishwanath Debnath
Department of Periodontology, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
|Date of Submission||04-Jun-2021|
|Date of Decision||20-Jul-2021|
|Date of Acceptance||31-Jul-2021|
|Date of Web Publication||16-Oct-2021|
Monali Amit Shah
Department of Periodontology, K.M.Shah Dental College and Hospital, Sumandeep Vidyapeeth, Vadodara, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: Blood clot or platelet concentrates have been used as a scaffold for regeneration of lost tissues. The most difficult case to date is the restoration of missing interdental papillae in the anterior maxillary area. Hence, the aim of the study is to evaluate the efficacy of the use of platelet-rich fibrin (PRF) membrane in the treatment of black triangles and regeneration of interdental papilla. Materials and Methods: A non-randomised, single-arm study was carried out. Each participant had undergone an initial periodontal diagnosis, including oral hygiene instructions, plaque control and scaling and root planing. All clinical recordings were recorded immediately before surgery (baseline), 1 week, 4-week and after 12-week intervals following periodontal surgery. The measurements recorded were triangle height (TH), triangle width (TW), Papilla Presence Index (PPI) and percentage fill. The split-thickness flap was carried via the semilunar incision, creating a pouch. PRF was obtained using a standard protocol, which was inserted into the pouch allowing interdental papillae to be filled. The periodontal dressing was given for 7 days. The observations were recorded after 1 week, 49 weeks and 12 weeks of surgery. For descriptive analysis, mean ± standard deviation SD at baseline, 1 week, 4 weeks and 12 weeks was calculated, and for non-parametric test, Friedman and Chi-square tests were used. Results: Clinical parameters such as TH, TW and PPI (mm) was 3.96, 3.86 and 3.82 at baseline which after 12 weeks got reduced to 1.36, 1.68 and 1.58, respectively. This reduction in TH, TW and PPI(mm) was statistically significant (P< 0.001). Percentage fill in black triangle area was about 85% after 12-week follow-up. Conclusion: PRF membrane is effective in treating black triangles and regeneration of interdental papilla and can be used successfully.
Keywords: Black triangles, interdental papilla, papilla reconstruction, perio-aesthetics, platelet-rich fibrin
|How to cite this article:|
Raval YH, Shah MA, Dave RD, Debnath AV. Evaluation of efficacy of platelet-rich fibrin for papilla reconstruction. Adv Hum Biol 2021;11:106-10
| Introduction|| |
In the recent decade, aesthetic awareness has dramatically improved. With the introduction of periodontal plastic surgery, it is now able to treat the widespread cosmetic problem of receding gums. However, the most difficult case to date is the restoration of missing interdental papillae in the anterior maxillary area. The loss of the interdental papilla (IDP) not only creates anaesthetic and phonetic problems but also has a functional impact since it leads to food build-up.
Crestal alveolar bone height, interproximal space dimensions, soft-tissue appearance, minimum buccal plate thickness, contact area type and biologic width are all factors that determine the existence or absence of interdental papilla. An ideal embrasure will accommodate the full papillae, preventing food entrapment and being visually unappealing. When the gap between the contact point and the crest of interdental bone is <5 mm, Tarnow et al. postulated that the interdental papillae fill the area. Only 56% and 37% of the papillae could cover the area when the contact was 6 and 7 mm from the bone, respectively.
Dental caries and periodontitis are most commonly found in the interdental space. Periodontal disease progresses quickly because of the intricate structure and blood supply and is the most prevalent cause of the formation of black triangles. It may, however, be missing in situations of naturally occurring diastema, or it may be present in teeth with tapering tooth forms, where the papillae do not entirely occupy the gap, or in teeth with diverging roots, where the contact point is too coronally placed.
Platelet-rich fibrin (PRF) is a kind of platelet gel, an autologous fibrin matrix that outperforms platelet-rich plasma in terms of characteristics, ease of manufacture and cost. Wound healing, wound sealing and haemostasis are all aided by it. As the fibrin matrix is resorbed, platelet cytokines such as platelet-derived growth factor (PDGF), transforming growth factor-beta (TGF) and insulin-like growth factor 1 are progressively released, assisting the healing process.
In the case of papilla reconstruction, a variety of surgical methods have been explored. In necrotising ulcerative gingivitis, Shapiro recommended repeated curettage to encourage the regeneration of interdental papillae. Other methods explored were roll method, utilisation of a pedicle graft with coronal gingivopapillary unit displacement, subepithelial connective tissue grafting, buccal and palatal split-thickness method, as well as interpositional subepithelial connective tissue grafting.
For the treatment of black triangles, there are several therapy options; one of the methods in recent years was the utilisation of PRF. PRF is a second-generation platelet concentrate that is easier to process. Platelet concentration enclosed in the fibrin mesh contains concentrated growth factors that upregulate cellular activity and, as a result, stimulate periodontal regeneration in vivo.,
Hence, the need for this study arises, so we can provide the patient with a simple, economical and effective option for the regeneration of the lost interdental papilla using PRF. The study's aim was to see if PRF may help in papilla reconstruction.
| Materials and Methods|| |
The study was commenced after approval from the Ethics Committee of Sumandeep Vidyapeeth in November 2013 (ethical clearance number: SVIEC | ON | Dent | SRP || 13321). The total number of participants treated in the present study was 25. The following formula was used to determine the sample size.
N = (Zα/2 + Zβ)2 ×2 × σ2/d2 (where Zα/2 is the critical value of the normal distribution at α/2). It was a non-randomised, single-arm study. Each participant underwent an initial periodontal treatment, including oral hygiene instructions, plaque control and scaling and root planing. The patient was informed about the procedure, and written consent was obtained prior to the commencement of the study.
Triangle height (TH), triangle width (TW) and Papilla Presence Index (PPI) and percentage fill were recorded at baseline, 1-week, 4-week and after 12-week intervals following periodontal surgery. TH was measured from the base of the papilla to the contact point on the teeth, and the width of the base of the papilla was measured as TW [Figure 1]. PPI was a score from 1 to 4, in which 1– papilla completely present, 2– apical to contact point, 3– apical and cemento-enamel junction (CEJ) visible and 4– apical to both the CEJ. For percentage fill, papilla loss area was calculated by measuring the surface area of the visible black triangle using the formula area = 0.5× height (mm) × base (mm). The per cent reduction in the black triangle area was calculated by the formula (baseline area – post-operative area) ×100/baseline area.,
The pre-operative photograph is attached as below [Figure 2]. Intraoral antisepsis was performed by rinsing with 0.2% chlorhexidine digluconate before the commencement of the surgical procedure. Adequate local anaesthesia was achieved with 2% lignocaine hydrochloride. A split-thickness semilunar incision was given about 1 mm coronal to the mucogingival junction in the interdental region of the sites [Figure 3]a and [Figure 4]. The split-thickness flap (STF) was carried through the semilunar incision toward the interdental papillae to construct a pouch in the interdental region. The tissue attachment to the surrounding root surface was freed by a curette around the necks of selected sites, allowing the gingivopapillary unit to be displaced coronally [Figure 3]b.
|Figure 2: Pre-operative view showing loss of interdental papilla in 11 and 21 regions. |
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|Figure 3: 'Pouch technique'. (a) the semilunar incision, (b) creating a pouch by relieving the tissue attachment using a curette, (c) placing the platelet-rich fibrin membrane into the pouch and pushed coronally, (d): absorbable sutures taken at the incision.|
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|Figure 4: Created a pouch by relieving the tissue attachment using a curette.|
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PRF was obtained using the standard technique as introduced and recommend by Choukroun et al. Using sterile tweezers, the PRF was retrieved, cut using scissors and transferred to sterile gauze. The membrane was then placed into the pouch and pushed coronally, enabling it to fill the bulk of the interdental papillae [Figure 3]c and [Figure 5]. The incisions were secured using absorbable sutures [Figure 3]d. The surgical site was then covered with the non-eugenol periodontal dressing as a mechanical barrier against any trauma. Participants were administered antibiotics and analgesics for 5 post-operative surgical days. The patients were recalled after 7 days for the removal of the periodontal dressing, and the recording was taken at the same time. The post-operative follow-up recording was performed again at 4-week and 12-week intervals after the surgical procedure was completed. None of the patients reported any adverse effects or discomfort during or after the surgical procedure.
For statistical analysis, mean ± standard deviation (SD) at baseline, 1 week, 4 weeks and 12 weeks was calculated in terms of TH, TW and PPI. For non-parametric analysis, Friedman and Chi-square tests were used to evaluate the statistical significance of the results.
| Results|| |
A total of 25 participants were treated in the present study, out of which 12 (48%) were females and 13 (52%) males. The mean value of the age of the participants was 23.8 ± 4.02, the minimum age was 19 and the maximum age of the participants was 31.
TH (mm) taken at the baseline was subjected to statistical analysis with a mean of 4.12 ± 0.83 showing a statistically significant reduction of 1.95 ± 0.83, 2.16 ± 0.72 and 2.76 ± 0.77 from baseline to 1 week, 4 weeks and 12 weeks, respectively. Similarly, the mean of triangular width (mm) calculated at baseline was 3.28 ± 0.89. This showed a statistically significant reduction of 0.82 ± 0.89, 1.28 ± 0.76 and 1.60 ± 0.85 from baseline to 1 week, 4 weeks and 12 weeks, respectively. For PPI, mean ± SD at baseline was 3.82, and a statistically significant reduction of 0.26 ± 0.68, 1.22 ± 0.71 and 1.46 ± 0.60 was seen from baseline to 1 week, 4 weeks and 12 weeks, respectively [Table 1]. Percentage fill in black triangle area was 65%, 74% and 85% at 1-week, 4-week and 12-week time intervals, respectively [Table 2], [Figure 6] and [Figure 7].
|Table 1: Triangle height, triangle width and Papilla Presence Index at various recording intervals|
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|Table 2: Percentage fill in black triangle area at different time intervals|
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| Discussion|| |
The form and volume of the interdental space are governed by the morphology of the teeth, which is the physical space between two neighbouring teeth. The gingival tissue that fills this gap is called the interdental papilla, and it is made up of thick connective tissue covered by the oral epithelium.,, It is regulated by the height of the alveolar bone, the distance between the teeth and the interdental papilla. The black gingival space is the gap between the cervical black space and the interproximal contact on the gingiva. A smile with black gingival gaps detracts from the patient's appearance. Gingival spaces more than 3 mm are regarded as a noticeable aesthetically problem by both dentists and the general public, according to Kokich.
In a classic study by Tarnow et al., the presence or absence of interdental papilla was linked to the distance between the bone crest and the contact point at 288 interproximal positions in 30 subjects. The existence of the papilla was found in nearly 100% of instances with a distance of ≤5 mm, 56% of instances with a distance of 6 mm and only 27% of instances with a distance of 7 mm or more. The distance between the roots, according to Azzi, is another element that might impact the presence or absence of interdental papilla. According to the author, an inter-radicular distance of <0.3 mm jeopardises the presence of the proximal bone and, as a result, is generally accompanied by the absence of the interdental papilla. A study done by Ahila et al. concluded that the augmentation of the papilla using PRF in the new position was stable when reviewed at 3 and 6 months post-operatively. Furthermore, the use of PRF achieved was successful and predictable results in the management of papillary recession.
Shapiro supported that by repeated curettage, the regeneration of interdental papillae can be encouraged. He stated that repeated scaling, root planing and curettage of the papillary tissue every 15 days for 3 months may induce a proliferative hyperplastic inflammatory reaction of the papilla and may be used to reconstruct papillae destroyed by acute necrotising ulcerative gingivitis. Utilisation of a pedicle graft with coronal gingivopapillary unit displacement, subepithelial connective tissue grafting, buccal and palatal split-thickness method, as well as interpositional subepithelial connective tissue grafting are some of the methods which have been demonstrated for papilla recontruction.,,,, The use of interdental papilla augmentation in conjunction with interdental bone restoration to provide enough support for the gingival papilla has been documented.
PRF membrane has both mechanical adhesive capabilities and biological functions like fibrin glue; it keeps the flap in place, promotes neoangiogenesis, minimises flap necrosis and shrinking and keeps the gingival flap in the highest covering position. PRF is simple to obtain, inexpensive and can be produced in a matter of minutes. PRF is a kind of fibrin that has excellent healing qualities. This fibrin matrix, which includes platelets, leucocytes and cytokines, allows for interdental papilla remodelling.PRF is organised as a dense fibrin scaffold with a specific release of growth factors (TGF1, PDGF-AB and vascular endothelial growth factor and glycoproteins) over the course of 7 days. This period has been discovered to be critical for the grafted PRF membrane to take hold.,
The absence of blood flow in that smaller region is the main limitation of any papilla repair technique; the graft that will be put in the region of the smaller triangle will encounter not such a favourable environment since it will be walled off between two non-vascular tooth surfaces. Because of this restriction, the outcome of this therapy is exceedingly uncertain.
The filling of the interdental papilla was shown in a case report published by Arunachalam et al., which supports the findings of this study, and optimal fill of the interdental space was noted. Singh et al. did a study in which STF surgery in combination with PRF or connective tissue graft (CTG) for interdental papilla reconstruction was conducted. Results of the study showed an increase in papilla height with mean values of 3.10 mm (87.3%) and 3.45 mm (95.8%) for Group I (STF + PRF) and Group II (STF + CTG), respectively, and percentage fill of 90% was obtained in Group I (STF + PRF) and 95% in Group II (STF + CTG), with no statistically significant difference between both the groups. Similarly, this study was also able to reproduce percentage fill around 85% of the black triangle. An advantage of this procedure is that a second site for graft harvest is avoided, vastly improving patient compliance and reducing post-operative discomfort. This study found a substantial decrease in the height and width of black triangles, as well as an increase in the PPI.
However, this study has its own limitations. Bigger sample size could be used in the investigation. The radiographic parameter could have been added before the enrolment. On a Visual Analogue Scale, patients' comfort and compliance can be monitored for therapy acceptability and aesthetic improvement. A randomised controlled trial can be designed to compare different surgical methods. For future investigation, the above-mentioned aspects might be added in the study.
| Conclusion|| |
Hence, this study concludes that PRF is effective in the treatment of interdental papilla reconstruction and can be used successfully.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Saadoun AP. Current trends in gingival recession coverage--Part II: Enamel matrix derivative and platelet-rich plasma. Pract Proced Aesthet Dent 2006;18:521-6.
Prato GP, Rotundo R, Cortellini P, Tinti C, Azzi R. Interdental papilla management: A review and classification of the therapeutic approaches. Int J Periodontics Restorative Dent 2004;24:246-55.
Zetu L, Wang HL. Management of inter-dental/inter-implant papilla. J Clin Periodontol 2005;32:831-9.
Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol 1992;63:995-6.
Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics Restorative Dent 1997;17:326-33.
Shapiro A. Regeneration of interdental papillae using periodic curettage. Int J Periodontics Restorative Dent 1985;5:26-33.
Choukroun J, Adda F, Schoeffler C, Vervelle A. A opportunite' in parp-implantology: The PRF. Implantodontie 2000;42:55-62.
Sharma P, Vaish S, Sharma N, Sekhar V, Achom M, Khan F. Comparative evaluation of efficacy of subepithelial connective tissue graft versus platelet-rich fibrin membrane in surgical reconstruction of interdental papillae using Han and Takie technique: A randomized controlled clinical trial. J Indian Soc Periodontol 2020;24:547-53. [Full text]
Cardaropoli D, Re S, Corrente G. The papilla presence index (PPI): A new system to assess interproximal papillary levels. Int J Periodontics Restorative Dent 2004;24:488-92.
Awartani FA, Tatakis DN. Interdental papilla loss: Treatment by hyaluronic acid gel injection: A case series. Clin Oral Investig 2015;20:1775-80.
Shenoy BS, Punj A, Ramesh A, Talwar A. Salvaging the lost pink triangle: A case series of papilla reconstruction. Case Rep Dent 2020; 1-7
Han TJ, Takei HH. Progress in gingival papilla reconstruction. Periodontol 2000 1996;11:65-8.
Azzi R, Etienne D, Carranza F. Surgical reconstruction of the interdental papilla. Int J Periodontics Restorative Dent 1998;18:466-73.
Ahila E, Saravana Kumar R, Reddy VK, Pratebha B, Jananni M, Priyadharshini V. Augmentation of interdental papilla with platelet-rich fibrin. Contemp Clin Dent 2018;9:213-7.
] [Full text]
Del Corso M, Sammartino G, Dohan Ehrenfest DM. Re: “Clinical evaluation of a modified coronally advanced flap alone or in combination with a platelet-rich fibrin membrane for the treatment of adjacent multiple gingival recessions: A 6-month study”. J Periodontol 2009;80:1694-7.
Singh D, Jhingran R, Bains VK, Madan R, Srivastava R. Efficacy of platelet-rich fibrin in interdental papilla reconstruction as compared to connective tissue using microsurgical approach. Contemp Clin Dent 2019;10:643-51. [Full text]
Vijayalakshmi R, Sathyapriya R, Prashanthi P, Burnice C. Advanced-platelet rich fibrin assisted papilla reconstruction by modified beagle's technique – A Novel Approach. J Clin Diagn Res 2020;14:???.
Arunachalam LT, Merugu S, Sudhakar U. A novel surgical procedure for papilla reconstruction using platelet rich fibrin. Contemp Clin Dent 2012;3:467-70.
] [Full text]
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2]