How is platelet-rich plasma (PRP) used in the treatment of gingival recession?

How PRP is Used for Gingival Recession Treatment

PRP is used as an adjunctive therapy with coronally advanced flap (CAF) surgery for gingival recession by placing multiple L-PRF membranes (typically 2-4 layers) over the exposed root surface and receptor bed, sutured together and to the periosteum, then covered by coronally advancing the flap to achieve primary closure. 1

Surgical Technique for L-PRF Application

The most current evidence-based protocol involves the following specific steps 1:

Incision Design

• Make two horizontal beveled incisions (approximately 3 mm length) mesial and distal to the recession, positioned at a distance from the papillae tips equal to recession depth plus 1 mm 1
• Create two beveled oblique, slightly divergent incisions extending from the horizontal incisions to the alveolar mucosa 1

Flap Elevation and Root Preparation

• Elevate a trapezoidal flap using a split-full-split approach: split thickness for surgical papillae, full thickness over the root exposure area, and split thickness for vertical incisions and apical regions 1
• De-epithelialize the papillae and perform thorough root planing, with optional root conditioning 1

L-PRF Membrane Placement

• Suture together at least 2 and preferably 3-4 L-PRF membranes using absorbable 6-0 sutures to create appropriate dimensions 1
• Position these membranes on the receptor bed with the face portion of the deepest membrane oriented toward the exposed root surface 1
• Suture the membranes to the periosteum to maximize graft stability 1

Flap Advancement and Closure

• Coronally advance the flap passively (without tension) to completely cover the graft 1
• Secure with interrupted sutures and sling sutures at the most coronal aspect of papillae using non-absorbable monofilament sutures 1

Clinical Outcomes and Evidence Quality

Efficacy Compared to CAF Alone

• PRP/L-PRF with CAF significantly improves recession depth reduction and clinical attachment level gain compared to CAF alone 2, 3
• Meta-analysis shows statistically significant reduction in recession depth when platelet concentrates are added to CAF 2
• The width of keratinized tissue is significantly increased with PRP application 4, 2, 5

Efficacy Compared to Connective Tissue Graft (CTG)

• CTG remains superior to L-PRF for root coverage percentage and keratinized tissue width 3
• L-PRF shows similar outcomes to CTG for clinical attachment level and probing depth changes, but CTG achieves statistically significantly better relative root coverage 3
• In cases with adequate baseline keratinized mucosa width, L-PRF represents a valid alternative to CTG; however, when baseline keratinized tissue is limited, CTG should be preferred 3

Additional Benefits

• Platelet concentrates accelerate early wound healing and reduce post-surgical complications 2
• Significant reduction in post-operative pain is a major advantage of L-PRF compared to CTG 1

Post-Operative Management

Strict adherence to the following protocol is essential 1:

• Restrict patient to soft food intake with no biting/chewing in the treated area 1
• Prohibit mechanical cleaning of the treated area for 1 week 1
• Rinse with 0.12% chlorhexidine twice daily for 1 minute, starting from day 3, continuing for at least 3 weeks 1
• Prescribe analgesics for pain management 1

Critical Limitations and Standardization Issues

Major Caveat About PRP Preparations

The field suffers from poor standardization with significant variability in preparation methods, terminology, purity, content, and quality of platelet products 1, 6. This includes variations in:

• Platelet concentration and leukocyte content 1
• Activation methods and timing 1
• Commercial device selection affecting final product characteristics 1

Evidence Quality Concerns

• The International Society on Thrombosis and Haemostasis notes insufficient data exist to develop evidence-based guidelines for PRP in regenerative medicine, requiring consensus-based recommendations instead 1
• Many clinical trials fail to adequately define or quantify PRP biological properties, leading to varying efficacies and unreliable conclusions 1
• The recommendations are primarily based on second-generation APCs (L-PRF family including L-PRF, A-PRF, A-PRF+, CGF, H-PRF, T-PRF) which offer additional advantages over first-generation APCs 1

Clinical Decision Algorithm

Use L-PRF with CAF when:

• Baseline keratinized mucosa width is adequate 3
• Patient desires reduced post-operative pain 1
• Avoiding palatal donor site morbidity is a priority 1

Use CTG instead of L-PRF when:

• Baseline keratinized tissue width is limited or inadequate 3
• Maximum root coverage percentage is the primary goal 3
• Increasing keratinized tissue width is essential 3