Published online Jul 20, 2022. doi: 10.5493/wjem.v12.i4.68
Peer-review started: December 18, 2021
First decision: April 13, 2022
Revised: April 26, 2022
Accepted: June 23, 2022
Article in press: June 23, 2022
Published online: July 20, 2022
Gingival recession is being treated using various therapeutic approaches with varying degrees of success depending on the etiology and treatment approach. Among them, coronally advanced flap technique with a connective tissue graft is considered the gold standard for soft tissue augmentation and periodontal root coverage. However, this technique has some disadvantages, including harvesting from a donor site, limited tissue availability, and increased potential for post-harvesting morbidity. With the introduction of the minimally invasive vestibular incision subperiosteal tunnel access (VISTA) technique, similar results could be obtained. It tries to preserve the interdental papillae and unhampered blood supply while maintaining the marginal integrity and minimizing the micromotion of flap for faster wound healing with no visible scarring to maximize the aesthetic outcome. This study is an attempt to find the efficacy of the VISTA technique using collagen membrane soaked in autologous injectable formulation of platelet-rich fibrin, termed as injectable platelet-rich fibrin (i-PRF) for the treatment of multiple gingival recession coverage.
The main topic is to compare the efficacy of minimally invasive VISTA technique for the treatment of multiple gingival recession coverage using a collagen membrane or a collagen membrane soaked in i-PRF. Placement of the initial vertical access incision and the subperiosteal tunnel entrance being far from the gingival margin reduces the risk of trauma to the gingiva, while at the same time maintaining the integrity of the interdental papilla by avoiding papillary reflection and marginal tissue loss of the teeth being treated. It also provides wider access to the surgical region and improves visualization through a single incision with no visible scarring, maximizing the aesthetic outcome. The positioning of the gingival margin to the most coronal level of the adjacent interproximal papilla rather than to the cementoenamel junction, with the help of the coronally anchored suturing technique on the facial surface of each tooth, effectively minimizes micromotion of the regenerative site and prevents apical relapse of the gingival margin during the initial stages of healing. The use of i-PRF also has similar properties as PRF, but has the added benefit of being available in an injectable form. It contains all components of PRF, including platelets, white blood cells, and all the clotting factors comprising fibrinogen in an uncoagulated form, making them readily available. The major advantage of i-PRF over other platelet concentrates is that it contains a greater number of regenerative cells with higher concentrations of growth factors and leukocytes. With the increased number of cells, there is possibly an increased release of growth factors like platelet-derived growth factor, epidermal growth factor, transforming growth factor and insulin-like growth factor-1.
The main objective is to compare the efficacy of the VISTA technique incorporating collagen membrane alone with the VISTA technique with collagen membrane soaked in injectable platelet-rich fibrin for gingival recession coverage in terms of clinical parameters like pocket depth, recession width, recession depth, width of keratinized gingiva, thickness of keratinized tissue, and the percentage of root coverage. In the overall assessment of the result of the study, it was observed that probing depth, recession depth, recession width, and relative attachment level are similar between the test and control sites. However, the width of keratinized tissue, the thickness of keratinized tissue, and the percentage of root coverage had better results for sites treated with i-PRF than sites where only collagen membrane was used for recession coverage. This can be attributed to the VISTA technique as it was a minimally invasive surgery, which not only reduces the trauma to the operating site, but also preserves the major blood vessels of the flap and blood supply to the area, resulting in better nourishment of the collagen membrane. The use of i-PRF is not only helpful for the enrichment of collagen membrane with various growth factors responsible for tissue regeneration, but also injecting it into the mesial and distal aspects of periodontal ligament and into the facial aspects of gingiva is an added benefit for stimulation of wound healing.
The data was analyzed using SPSS Ver 22 for windows, (IBM Corp, Armonik, United States). Descriptive statistics were expressed as a mean with standard deviations and proportions. Normally distributed data were analyzed using a paired t-test for intragroup comparison and an unpaired t-test for intergroup comparison. Skewed data were analyzed using the Wilcoxon signed rank test for intragroup and Mann-Whitney U test for intergroup comparison. The level of significance was set at P < 0.05.
The result of the study observed that probing depth, recession depth, recession width, and relative attachment level are similar in test sites compared with control sites. However, the width of keratinized tissue, the thickness of keratinized tissue, and the percentage of root coverage had better results in sites treated with i-PRF with collagen membrane than sites where only collagen membrane was used for recession coverage. This can be attributed to the VISTA technique, as it is a minimally invasive surgery which not only reduces the trauma to the operating site, but also preserves the major blood vessels of the flap and blood supply to the area, resulting in better nourishment of the collagen membrane. The use of i-PRF is not only helpful for the enrichment of collagen membrane with various growth factors responsible for tissue regeneration, but also injecting it into the mesial and distal aspects of periodontal ligament and into the facial aspects of gingiva is an added benefit for stimulation of wound healing.
The VISTA technique has been applied for gingival recession coverage using different regenerative materials like connective tissue graft, PRF, titanium PRF, acellular dermal matrix, GEM 21S, recombinant human platelet derived growth factor, and collagen membrane; however, there was no study using i-PRF in combination with collagen membrane using VISTA technique for gingival recession coverage. The results of the study proposed that the use of minimally invasive VISTA technique, along with collagen membrane with the added benefit of the injectable form of platelet-rich fibrin have the capacity of releasing more growth factors and regenerative cells responsible for tissue regeneration, can be successfully used as a treatment method for multiple or isolated gingival recessions of Miller’s class-I and class-II defects.
This study must be interpreted with consideration of the relatively small sample size (13 subjects) and shorter study duration (6 mo). A long term follow-up study with larger sample size is required.