Don't miss a digital issue! Renew/subscribe for FREE today. Search... View Current Issue Noteworthy Categories CE Articles Feature Stories Innovations Roundtable Viewpoint Editorial Categories CAD/CAM Diagnosis & Treatment Planning Digital Imaging Endodontics Implantology Infection Control Magnication Materials Occlusion Oral Medicine Orthodontics Pain Management Pediatric Dentistry Periodontics Practice Management Prevention Prosthodontics Restorative Direct Restorative Indirect Related Articles Peri-Implant Health and Esthetic Challenges After Extraction Inside Dentistry November 2011 Volume 7, Issue 10 Optimizing Root Coverage With L-PRF The allogeneic and xenogeneic tissues have shown excellent results in the short term. By Robert A. Horowitz, DDS Esthetic results are one of the objectives of coronal advancement of the gingival margin. Obscuring the margin of a tooth- or implant-supported restoration or leveling the smile line are some of the aims of periodontal plastic surgery. Often abfraction, abrasion, or carious lesions will render the exposed root surface more sensitive to thermal and chemical stimuli. In addition, restorative materials may not remain where placed in smaller lesions. These indications often drive a patient to have the area treated biologically. There are many products and methods for augmenting gingival tissues around natural teeth. These range from autogenous grafts (ie, subepithelial connective tissue, free gingival tissue) to allograft products (processed dermis, amnion, and pericardium). Xenogeneic and synthetic materials are used in the periodontal plastic surgical arena. Biologic activating factors and wound enhancers such as bone morphogenetic protein 2 (BMP-2), platelet-rich plasma (PRP), leucocyte- and platelet-rich plasma (L-PRF) ( Figure 1), recombinant human platelet-derived growth factor (rhPDGF bb), and enamel matrix proteins are often used in the procedure. More than 40 years ago, questions were raised on the biologic and physiologic needs for keratinized gingiva at the margin of teeth. Most periodontists prefer giving patients the ability to maintain restorations around teeth and implants surrounded by a zone of pink, attached, keratinized tissue. It has been shown that when there is < 2 mm of keratinized tissue around teeth, there is more gingival inammation. Increased inammation and plaque accumulation have been found around implants with non-keratinized marginal mucosa. These supercial soft tissue signs were not associated with additional loss of alveolar bone. However, there have been no denitive studies demonstrating longer retention of teeth, implants, and/or the restorations on them if the marginal gingival is mucosa or keratinized in histologic composition. Harvesting of autogenous tissue from the maxillary arch requires involvement of a second surgical donor site; removing a free gingival graft from the palate leaves a large, bleeding wound site. Signicant shrinkage of the grafts has also been noted. Although the connective tissue in the tuberosity area is thick, the quantity of material available for harvest is often limited. In an attempt to decrease these and other complications, grafts have been harvested from inside the palatal soft-tissue ap. In this way, connective tissue can be harvested in a subepithelial manner. This technique gives the surgeon the ability to obtain a signicant quantity of soft tissue and leave the patient with minimal discomfort and bleeding. In an attempt to increase patient acceptance of gingival augmentation procedures, allogenic tissues have been used. When the surgeon takes a product “off the shelf,” there is an unlimited supply of material to treat multiple recipient sites. On the other hand, these products have minimal to no inductive activity. For this reason, blood-concentrate products have been recently used alone or added to acellular dermal grafts in an attempt to improve healing. In some of the studies, there has been an improvement in patient perception of the initial healing sequelae. The cases shown in this evaluation will demonstrate some of the uses of leucocyte-rich platelet-rich brin (L-PRF) with the addition of a resorbable barrier for root coverage. The blood-concentrate technique used in these cases is simpler to fabricate than some others on the market. Studies have also shown that there is a longer release of growth factors from the brin clot produced by the L-PRF method. The combination of materials may yield a sustained release for a longer time period in the surgical site. This has the potential of maximizing healing and root coverage in a decient area. Case Reports Patient 1 This patient presented with a narrow alveolar ridge in an edentulous site ( Figure 2). The adjacent teeth each had a 3-mm-deep x 5-mm-wide facial recession with sensitivity to extreme temperature. Cone-beam computed tomography demonstrated sucient alveolar bone in which to place a tapered endosseous implant, fully embedded in bone. In an attempt to augment the sites at the time of implant placement, a combination soft- and hard-tissue enhancement was performed at the same visit. Two 9-mL tubes of blood were drawn from the patient’s arm. No anticoagulants or other chemicals were added to the material and it was centrifuged at 2,700 rpm for 12 minutes (PRF Process, Intra-Lock International, Inc., 1 2 3,4 5 6 7 8 9 10,11 × Inside Dentistry