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CASE REPORT
Year : 2012  |  Volume : 3  |  Issue : 1  |  Page : 49-52

Zucchelli's technique combined with platelet-rich fibrin for root coverage


1 Department of Periodontology, DJ Dental College, Modinagar, India
2 Department of Periodontology, Sardar Patel Institute of Dental and Medical Sciences, Lucknow, India
3 Department of Oral & Maxillofacial Surgery, ITS Dental College, Greater Noida, India

Date of Web Publication27-Sep-2012

Correspondence Address:
Kriti Agarwal
Department of Periodontology, DJ Dental College, Modinagar, UP
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-6944.101678

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  Abstract 

Desire for improved esthetics and the consequent need for cosmetic dentistry have increased tremendously in recent times making esthetic procedures an integral part of periodontal treatment. The treatment of choice for recession coverage should address the biological as well as the patient's esthetic demands. Zucchelli and Sanctis (2000) proposed a modification in the coronally advanced flap technique for treatment of multiple recession defects in esthetic areas. A recent innovation in dentistry is the preparation and use of platelet-rich fibrin for recession defects. This case report highlights the Zucchelli's technique along with the use of PRF for root coverage in multiple recession defects.

Keywords: Cosmetic dentistry, platelet-rich fibrin, root coverage, Zucchelli′s technique


How to cite this article:
Agarwal K, Gupta K K, Agarwal K, Kumar N. Zucchelli's technique combined with platelet-rich fibrin for root coverage. Indian J Oral Sci 2012;3:49-52

How to cite this URL:
Agarwal K, Gupta K K, Agarwal K, Kumar N. Zucchelli's technique combined with platelet-rich fibrin for root coverage. Indian J Oral Sci [serial online] 2012 [cited 2017 Apr 25];3:49-52. Available from: http://www.indjos.com/text.asp?2012/3/1/49/101678


  Introduction Top


Soft tissue recession, defined as exposure of the root surface, is caused by an apical shift of the gingival margin. This results in an unesthetic appearance, root hypersensitivity, and root caries. [1],[2] The risk factors which have been postulated to play a role in the etiology of gingival recession [3] include tooth malposition, path of eruption, tooth shape, profile and position in the arch, alveolar bone dehiscence, muscle attachment and frenal pull, periodontal disease and treatment, iatrogenic restorative or operative treatment, improper oral hygiene methods, and other self-inflicted injuries (e.g. oral piercing). The most important factor increasing the risk of gingival recession is thin gingival biotype. [4]

The search for a perfect root coverage technique has led to the development of a number of innovative surgical procedures to achieve consistently better and more predictable results. Zucchelli and Sanctis modification in the coronally advanced flap technique for treatment of multiple recession defects in esthetic areas. Platelet-rich fibrin (PRF), a concentrated suspension of the growth factors, is found in platelets. These growth factors are involved in wound healing and postulated as promoters of tissue regeneration. [5] This case report highlights the Zucchelli's technique along with the use of PRF for root coverage in multiple recession defects.


  Case Report Top


A 32-year female reported to the Department of Periodontology with the chief complaint of sensitivity and unesthetic appearance in the maxillary right front tooth region for 2 months. Clinical examination revealed Miller's Class I recession in maxillary right central incisor, right lateral incisor, and Miller's Class II recession in right maxillary canine [Figure 1].
Figure 1: Pre-operative.

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Pre-surgical procedure

The surgical procedure was explained to the patient and the informed consent was obtained. Preparation of the patient included scaling and root planing of the entire dentition and oral hygiene instructions.

Platelet-rich fibrin preparation

The required quantity of blood was drawn in 10 ml test tubes without an anticoagulant and centrifuged immediately. Blood was centrifuged using a tabletop centrifuge (REMY Laboratories) for 12 min at 2700 rpm. The resultant product consisted of the following three layers:

  1. The top most layer consisting of acellular platelet poor plasma.
  2. PRF clot in the middle.
  3. Red blood cells at the bottom [Figure 2].
Figure 2: Preparation of platelet rich fibrin

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PRF can be obtained in the form of a membrane by squeezing out the fluids in the fibrin clot [Figure 3]
Figure 3: Platelet rich fibrin membrane

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Surgical procedure

Under local anesthesia, a horizontal incision was made with a scalpel to design an envelope flap. This consisted of oblique submarginal incisions in the interdental areas, and these incisions were continued with the intrasulcular incision at the recession defects. The interdental papilla was kept intact, and only the surgical papilla was dislocated by the oblique interdental incisions [Figure 4]. The surgical papilla mesial to the flap midline was dislocated more apically and distally while the papilla distal to midline was shifted more apically and mesially. A full thickness flap was raised apical to the root exposure, and a partial thickness flap was elevated in the most apical portion of the flap to facilitate the coronal displacement of the flap [Figure 5].
Figure 4: Oblique interdental incisions given

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Figure 5: Elevation of flap

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The PRF membrane was placed over the denuded roots and stabilized [Figure 6]. The interdental papilla was de-epithelialized for the placement of the flap. The flap was then advanced coronally to completely cover the membrane and secured using sling sutures [Figure 7]. Periodontal pack was given.
Figure 6: PRF membrane placed

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Figure 7: Flap coronally positioned and sutured

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Postoperative care

The patient was prescribed antibiotics for 5 days and 0.12% chlorhexidine digluconate mouth rinse for 2 weeks. Both the dressing and sutures were removed 10 days after surgery [Figure 8]. The patient was recalled after 6 weeks, and the complete root coverage was observed [Figure 9]. 6 months follow-up showed stable results [Figure 10].
Figure 8: Post-operative view-2 weeks

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Figure 9: Post-operative view- 6 weeks

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Figure 10: Post-operative view- 6 months

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  Discussion Top


Treatment of gingival recession is becoming an important therapeutic issue due to an increasing demand for cosmetic treatment and the complete root coverage is the goal to be achieved when the patient complains about unesthetic appearance of teeth. The ultimate goal of any therapeutic intervention aimed at root coverage should be to restore the tissue margin at the cemento-enamel junction and to achieve an attachment of the tissues to the root surface so that a normal healthy gingival sulcus with no bleeding on probing and a minimal probing depth is present. [6]

The coronally advanced flap procedure has been demonstrated to be a reliable and predictable treatment modality for obtaining root coverage in isolated types of gingival recessions. [7],[8] In the case report, a modification of the technique was used. The clinical and biological advantages were the preservation of the blood supply as the vertical releasing incisions were avoided. The split-thickness flap elevation also provided advantage of better coronal advancement of the flap. Usually, the absence of a wide zone of keratinized tissue is considered a limitation of the coronally advanced flap technique. [7],[8] However, the case report demonstrated an increase in the keratinized tissue after surgery. This could be due to the tendency of the mucogingival line to regain its genetically defined position following coronal dislocation with the flap procedure [9] or due to the formation of new connective tissue attachment and epithelial attachment.

A recent innovation in dentistry has been the preparation and use of PRF, a concentrated suspension of the growth factors found in platelets. PRF was first developed in France by Choukroun et al.[10] This second generation platelet concentrate eliminated the risk associated with the use of bovine thrombin. Placement of the PRF membrane in recession defects can be used to restore the functional properties of the labial gingiva of the maxillary anterior teeth by repairing gingival defects and re-establishing the continuity and integrity of the zone of keratinized gingiva.


  Conclusion Top


Soft tissue maintenance is the primary line of defense in protecting the tissue from bacterial infection. This technique showed complete root coverage as well as increased the zone of keratinized gingiva. Although the growth factors and the mechanisms involved are still poorly understood, the ease of applying PRF in the dental clinic and its beneficial outcomes, including reduction of bleeding and rapid healing, holds promise for further procedures.

 
  References Top

1.Tugnait A, Clerehugh V. Gingival recession: Its significance and management. J Dent 2001;29:381-94.  Back to cited text no. 1
[PUBMED]    
2.Paolantonio M. Treatment of gingival recession by combined periodontal regenerative techniques, guided tissue regeneration, and subpedicle connective tissue graft: A comparative clinical study. J Periodontol 2002; 73:53-62.  Back to cited text no. 2
[PUBMED]    
3.Wennström J. Mucogingival therapy. Ann Periodontol 1996; 1:671-701.  Back to cited text no. 3
    
4.Muller HP, Eger T, Schorb A. Gingival dimensions after root coverage with free connective tissue grafts. J Clin Periodontol 1998;25:424-30.  Back to cited text no. 4
    
5.Tözüm TF, Demiralp B. Platelet-Rich Plasma: A Promising Innovation in Dentistry. J Can Dent Assoc 2003;69:664.  Back to cited text no. 5
    
6.Gupta R, Pandit N, Sharma M. Clinical evaluation of a bioabsorbable membrane (polyglactin 910) in the treatment of miller type II gingival recession. Int J Periodont Restorat Dent 2006; 26:271-7.  Back to cited text no. 6
    
7.Wennström, J, Zucchelli G. Increased ginigival dimensions. A significant factor for successful outcome of root coverage procedures? A 2-year prospective clinical study. J Clin Periodontol 1996; 23:770-7.  Back to cited text no. 7
    
8.Allen EP, Miller PD. Coronal positioning of existing gingiva: Short term results in the treatment of shallow marginal tissue recession. J Periodontol 1989; 60:316-9.  Back to cited text no. 8
    
9.Ainamo A, Bergenholtz A, Hugoson A, Ainamo J. Location of the mucogingival junction 18 years after apically repositioned flap surgery. J Clin Periodontol 1982; 9:49-52.  Back to cited text no. 9
    
10.Choukroun J, Dohan DM, Simonpieri A, Schoeffler C, Dohan SL, Dohan AJ, et al. Platelet rich fibrin (PRF): A second generation platelet concentrate: Part V: Histologic effects of PRF effects on bone allograft maturation in sinus lift. Oral Surg Oral med Oral Patho Oral Radio Endod 2006; 101:299-303.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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