Platelet-rich fibrin vs. connective tissue graft: a literature review

Gingival defects can be treated in multiple ways. The current gold standard is connective tissue graft (CTG) in order to treat Class I and II Miller defects (Chambrone, 2008). One of the newer procedures is the use of platelet-rich fibrin (PRF) therapy, which involves drawing the patient’s own blood and forming a membrane to heal gingival defects. This process has shown potential to regenerate periodontal structures due to various growth factors, which promote cell proliferation and regeneration. This literature review looks at scholarly articles comparing the use of PRF to CTG in healing clinical attachment loss (CAL) over a period of 6 months and whether one is more effective than the other in gaining CAL. According to data from the 2009 and 2010 National Health and Nutrition Examination Survey (NHANES), over 47% of the adult population of the United States age 30 and over has periodontal disease, which can be approximated to 64.7 million Americans. Periodontitis is a disease of the gums surrounding the teeth in the oral cavity and may lead to serious consequences if not treated appropriately. The most common reason for tooth loss in adults over the age of 45 is periodontitis and has also been linked to a variety of systemic diseases as well, including Type II diabetes, osteoporosis, obesity, and many other conditions (Amar, 2006). The American Academy of Periodontology classifies the severity of periodontitis through a variety of factors, one of which is clinical attachment loss (CAL) (Tonetti, 2018). The CAL is a sign of how much attached gingiva is missing from its original height on the tooth and is usually an indicator of active or previous history of periodontitis. When bone starts to recede, the gingival tissue may follow, which is why maintaining CAL is important. Gum and bone recession are both possible indicators of periodontitis. Gum recession can result from multiple reasons, with periodontal disease being one of the most common. The gum separating the teeth starts to pull away, revealing more of the tooth’s root surface. Miller’s classification is one standardized way of measuring the severity of gum recession. A Class I Miller defect is recession that has not extended to the mucogingival junction (MGJ) yet, and a Class II is one that has extended to or beyond the MGJ without any loss of bone or soft tissue (Akram, 2016). When a patient has multiple gum defects or severe gum recession, one of the options for treatment is gum surgery. Some of the possible indications for gum surgery include dentinal hypersensitivity, esthetics, and preventing the progression of further recession. The risk of developing root caries also increases with root exposure. One common surgery is the gum graft in which tissue is taken from a different source and grafted onto the area of recession. Tissue can be taken from the patient’s own body from a separate location or from a donor, such as a cadaver or animal tissue. The current gold standard for gum surgery is connective tissue graft (CTG) surgery. This involves taking a piece of tissue from the patient’s own body, and the donor site is usually the hard palate. The difference between CTG compared to other types of tissue graft is that CTG takes specifically subepithelial tissue and leaves the epithelial tissue intact at the donor site (Chambrone, 2008). This accelerates the healing process due to leaving behind intact epithelium. CTG surgery is often used in conjunction with a coronally advanced flap (CAF), in which a pedicle flap is formed at the site of the recession and the connective tissue is placed between the periosteum and the overlying pedicle flap. This provides continued blood supply to the area. One of the relatively newer innovations in gum surgeries is the use of platelet-rich fibrin (PRF) therapy in conjunction with the surgery. This process was the result of experimentation with platelet-rich plasma (PRP), which was a technique used to isolate large amounts of platelets from the blood and use them to aid in accelerating wound healing. One of the limitations of PRP was the need to combine the resulting liquid with other biomaterials such as bone graft particles, so PRF was developed as a means to have all healing factors in a solid state of matter that was more manageable. The material could not have any anticoagulants to prevent clotting before placement into the body and centrifuging specimens was the only way to retrieve healing factors in a solid layer. The platelet clot has been shown to contain various growth factors, which help promote cell proliferation and tissue regeneration. PRF is becoming increasingly widespread due to its promotion of accelerated healing. It is being used due to its ability to potentially regenerate periodontal structures such as the periodontal ligament. The growth factors in PRF have been shown to stimulate fibroblasts to differentiate at an increased rate, therefore promoting regeneration of the PDL (Goel, 2018). The PRF material is most commonly used in combination with surgery, similarly to CTG, with the most frequent being a pedicle flap. It is meant to be replacing the connective tissue used in CTG in adjunct with CAF and does not replace the need for a surgical flap. One of the reasons for using PRF instead of CTG is the lack of a second donor site for tissue, which could potentially cause less discomfort for the patient. The PRF procedure is also relatively easier compared to CTG since it requires fewer steps. Both CTG and PRF procedures are very similar, since both often require the need for a surgical flap, and the major difference is the chosen material underlying the tissue flap. The current generation of PRF involves extracting blood from the patient’s own body and collected in tubes without anticoagulants. The blood is centrifuged immediately after collection. A fibrin clot forms in the tube between the layer of red blood cells and plasma, and this yellow clot is separated from the clotted blood cells. The clot is compressed into a thin membrane that is a uniform thickness. The membrane is placed in the area of the mucogingival defect and a pedicle flap is used to hold the membrane in position to allow for maximum integration with the surrounding tissue