Platelet-rich fibrin for wound healing of palatal donor sites of free gingival grafts: Systematic review and meta-analysis

Performance of multiple therapeutic approaches for palatal wound healing after soft tissue graft removal - an overview of systematic reviews

OBJECTIVE

To overview the literature to answer the following question: "What is the performance of different therapies on wound healing and postoperative discomfort after palatal ASTG removal?"

METHODS

SRs that evaluated the wound healing (WH), postoperative pain, bleeding, and analgesic consumption of patients submitted to de-epithelialized/free gingival grafts (FGG) or subepithelial connective tissue grafts (SCTG) removed from the palate were included. The searches were conducted on six white and two gray databases up to December 2023. Methodological quality was evaluated through AMSTAR 2. The synthesis of results was described as a narrative analysis.

RESULTS

Ten SRs (involving 25 randomized clinical trials) related to low-level laser therapy (LLLT) (3), platelet-rich fibrin (PRF) (4), cyanoacrylate tissue adhesives (CTA) (2), and ozone therapy (OT) (1) were included in this overview. All techniques demonstrated improvements in WH. LLT, PRF, and CTA reduced pain and analgesic consumption. PRF and CTA reduced bleeding. Regarding methodological quality, the SRs were classified as critically low (2), low (5), moderate (2), or high quality (1).

CONCLUSIONS

In SRs related to LLLT, PRF, CTA, and OT, the use of different therapies after palatal ASTG removal improved WH and postoperative discomfort. Due to the studies' low methodological quality and high heterogeneity, data should be interpreted with caution.

CLINICAL RELEVANCE

The present overview compiles the evidence of SRs related to different therapies for WH and patients' postoperative experience and reveals that different treatments can significantly improve the clinical outcomes of patients who require ASTG removal for periodontal or peri-implant surgeries.

REGISTRATION

PROSPERO registration number: CRD42022301257.

Chitosan-based dressing for management of palatal donor site: A randomized clinical trial

AIMS

This study aimed to evaluate the effectiveness of a chitosan-based dressing (CD) in achieving early wound healing and hemostasis at palatal donor sites in patients undergoing free gingival graft (FGG) surgery.

METHODS

Thirty-two patients requiring FGG were treated in this randomized controlled clinical trial. Complete epithelialization (CE) and color match (CM) at donor sites were assessed by a blinded examiner on postoperative days 7, 14, 21, and 28. Donor sites were compressed for 2 min with wet gauze (WG) alone in control group (CG) or WG + CD in test group (TG) immediately after graft harvesting, and immediate bleeding (IB) was recorded (yes/no). Delayed bleeding (DB) (for 1 week), and number of analgesic tablets consumed, and VAS scores for pain (for 2 weeks) were recorded by patient every day.

RESULTS

Twenty-eight patients (14 in each group) were included in final analysis. The prevalence of CE (at weeks 2 and 3) and VAS scores for CM scores were higher in TG but the intergroup differences were statistically significant only for CM (at week 4). Number of patients exhibiting IB and DB was significantly fewer in the TG (p < .05). Although average pain scores and analgesic consumption were higher in TG up to 5 days, differences between two groups were not statistically significant at any time point.

CONCLUSION

Our data suggests that the application of CD increased re-epithelialization and accelerated wound healing process, although it did not reach statistical significance. Moreover, CD was found to significantly reduce bleeding complications, but it did not decrease the pain levels.

Modifications in the Free Gingival Graft Technique: A Systematic Review

Free gingival grafts (FGGs) have developed beyond covering exposed roots to improve the width and thickness of gingival tissue. While traditional FGGs have shown a high success rate and are easy to apply, they have some drawbacks, such as potential aesthetic concerns and bulky appearance. Recent advancements in FGGs have been explored, with different modifications proposed to overcome these limitations, including partly epithelialized FGGs (PE-FGG), gingival unit grafts, and epithelialized subepithelial connective tissue grafts. This systematic review aims to evaluate published case reports that discuss the utilization of modified approaches to FGG treatment and their outcome.

Evaluation of Post-Operative Morbidity and Palatal Wound Healing after Implant Uncovering Surgical Procedure Performed with Apically Positioned Flap (APF) and Leukocyte and Platelet-Rich-Fibrin (L-PRF): An Original Technique

Background and Objectives: Dental implants are recognized as an effective treatment in the management of edentulous patients; controversies surround the connection between the sufficiency of keratinized gingiva (KG) and peri-implant health. Maintaining an ample amount of peri-implant KG is crucial for minimizing gingival inflammation, highlighting the need for regular consideration of soft-tissue augmentation. Among the diverse periodontal plastic surgical procedures, the apically positioned flap (APF) is notable for its ability to enhance the width of keratinized tissue while minimizing patient morbidity. The aim of this study was to evaluate the effects of L-PRF on palatal wound healing and patient discomfort after surgery. Materials and Methods: Twenty patients with two adjacent submerged fixtures in the maxilla and buccal keratinized gingiva widths < 2 mm were treated with APF and L-PRF. Clinical evaluations were performed at 1, 2, 3, and 4 weeks post-surgery, focusing on parameters such as complete wound epithelialization (CWE), postoperative discomfort (D), changes in feeding habits (CFH), alteration of sensitivity (AS) around the wound area, and the consumption of analgesics. Results: Our data revealed CWE in 5 patients by the end of the second week, with the remaining 15 achieving CWE by the end of the third week. For D and CHF, a statistically significant improvement was recorded for all cases between the first and second weeks, as well as AS, although less substantial, by the third week. No significant changes were noted for AS over the initial two weeks. Conclusions: These findings suggest that L-PRF may enhance wound healing and decrease patient discomfort following APF for fixture uncovering.

Postoperative local interventions for the palate as a gingival graft donor area: a scoping review

OBJECTIVE

This scoping review aimed to systematically identify evidence-based interventions to stimulate healing or protect the harvested palate of patients undergoing gingival grafting.

MATERIAL AND METHODS

The study followed guidelines from the Joanna Briggs Institute and PRISMA-ScR (protocol available at osf.io/zhafn). PubMed, Embase, and seven other databases were searched on November 2022, with additional monitoring until April 2023. The inclusion criteria focused on studies evaluating outcomes related to the donor area (palate) and interventions for healing or protecting it, regardless of publication year and language. Data from the included publications was extracted and presented through narrative text, tables, and figures.

RESULTS

Eighty-one studies (including 64 clinical trials, four case series, five theses, and eight systematic reviews) and 37 clinical trial records were included. The number of studies on this topic has significantly increased, reflecting a growing interest in the field. Thirty-six interventions with published results and 12 interventions with unpublished results from clinical trial registers were identified. Some promising interventions that showed potential for improving patient-reported outcomes include cyanoacrylate adhesive, platelet-rich fibrin (PRF), and the combination of palatal stents and healing agents.

CONCLUSIONS

Thirty-six interventions with published results were identified for postoperative use on the harvested palate, showing varying levels of evidence and conflicting effectiveness for specific outcomes.

CLINICAL RELEVANCE

Postoperative discomfort and pain in the palate are commonly experienced by patients undergoing grafting procedures using this region as the donor area. Awareness of the available options and their levels of evidence is crucial for informed decision-making.

Effect of fibrin-rich plasma and collagen sponge on healing of the palatal mucosa

Background

The purpose was to evaluate the variation in thickness and early healing of the donor area of the palate with the placement of a collagen sponge and the use of fibrin-rich plasma (L-PRF).

Material and Methods

Thirty patients who required mucogingival surgery treatment were selected and distributed into 2 groups. After obtaining the free palate graft, L-PRF was placed in Group A, and a collagen sponge was placed in Group B. The healing process of the palate was evaluated at 24 hours and 7, 14, 21 and 28 days postsurgery. The thickness of the donor area (palate) was evaluated using an acrylic splint. These measurements were made before and 4 months after surgery.

Results

In the collagen sponge group, less gain of the palatal mucosa was observed, with a mean difference of 0.1 ± 0.8 mm (CI: -0.341-0.518) (p=0.691), whereas in the fibrin-rich plasma group, a mean difference of 0.0 ± 0.5 mm (CI: -0.229-0.229) (p=0.934) was found; however, when comparing the gain of the palatal mucosa in both groups, no significant difference was observed (p=0.932). The healing index at 24 hours indicated the presence of clots, on Day 28 vascularisation and total epithelialisation (100.0%), and finally, the collagen sponge group on Day 14 presented 93.3% partial vascularisation of connective tissue and 33.3% L-PRF (p=0.001).

Conclusions

There was no statistically significant difference in the thickness of the palatal mucosa after the use of L-PRF and the collagen sponge. Key words:Palate thickness, connective tissue graft, fibrin-rich plasma, collagen sponge, palate healing.

The use of platelet-rich fibrin in vestibuloplasty: A 36-month follow-up technique report

INTRODUCTION

Vestibuloplasty is a mucogingival procedure that aims to increase the vestibule and the amount of keratinized tissue (KT) around teeth and dental implants. Currently, the gold standard in this procedure is still represented by free gingival grafts (FGGs); however, they require a second surgical site, which means more morbidity for the patient and a higher risk of surgical complications, as well as surgical time and chromatic alteration of the recipient area.

CASE PRESENTATION

This is a description of the vestibuloplasty technique with platelet-rich fibrin (PRF) in a 35-year-old female patient with a thin gingival phenotype and no medical history of interest. The reason for consultation was tooth sensitivity during brushing and the presence of recessions in the fifth sextant.

CONCLUSIONS

The use of PRF as a graft biomaterial in vestibuloplasty is a valid and effective option as an alternative to secondary epithelialization of the surgical site, as well as to FGGs, with acceptable results in terms of KT gain and root coverage, and with minimal postoperative discomfort.

KEY POINTS

Why is this case new information? The use of PRF is an interesting option as an alternative to second-intention healing, as FGGs in vestibuloplasty. What are the keys to successful management of this case? The most important part of the membranes is the part that was in close relation to the erythrocyte fraction in the blood collection tube, so this part must be oriented toward the recipient bed. A minimum of four membranes should be obtained, overlapping one on top of the other. What are the primary limitations to success in this case? The stability of the PRF.

Effect of leukocyte and platelet-rich fibrin on free gingival graft healing: A clinical and histological study in rabbits

Background. Recently, the use of leukocyte- and platelet-rich fibrin (L-PRF) has been recommended due to the presence of various growth factors to increase the success of free gingival grafts (FGG). This study evaluated the effect of using L-PRF in the healing of FGG in rabbits. Methods. Twenty rabbits were randomly divided into two groups. In each group, FGG was performed in two separate sites with or without L-PRF. One of these groups was sacrificed on the 7th day and the other on the 28th day and analyzed in terms of clinical indices, including wound healing, gingi-val thickness (GT), and keratinized tissue width (KTW). Then histologic sections were obtained and stained for type and degree of inflammation and rate of vascular formation analysis. SPSS 22 was used for statistical analysis. Results. The extent of changes in GT, KTW, wound healing index, and vascular formation between the test and control groups was not statistically significant. The difference in the type of inflammation was significant only between the -7day and -28day control groups (P=0.003). The degree of inflammation between the -7day test group and the -28day control group, as well as the -7day and -28day control groups, were statistically significant (P=0.011 and P=0.002, respectively). Conclusion. Using L-PRF with FGG could improve FGG healing compared to using FGG alone, but the results were not statistically significant.