How is liquid Platelet-Rich Plasma (PRP) used for treating gingival recession?

How Liquid PRP is Used for Gingival Recession

Liquid PRP (specifically L-PRF membranes) should be used as an adjunct to coronally advanced flap surgery by placing 3-4 sutured membranes over the exposed root surface and receptor bed, offering a viable alternative to connective tissue grafts with the major advantage of significantly reduced postoperative pain, though with slightly inferior aesthetic outcomes. 1

Surgical Technique

Flap Design and Preparation

• Make two horizontal beveled incisions mesial and distal to the recession, positioned at a distance from the papillae tips equal to recession depth plus 1 mm 2
• Create two beveled oblique, slightly divergent incisions extending from the horizontal incisions to the alveolar mucosa 2
• Elevate a trapezoidal flap using a split-full-split approach 2
• De-epithelialize the papillae and perform thorough root planing, with optional root conditioning 2

L-PRF Membrane Application

• Suture together at least 2 and preferably 3-4 L-PRF membranes using absorbable 6-0 sutures 2
• Position these membranes on the receptor bed covering the exposed root surface 2
• Suture the membranes to the periosteum to maximize graft stability 2
• Cover by coronally advancing the flap to achieve primary closure 2

Critical Timing Considerations

• If using flowable PRF mixed with bone substitute (for other applications), mix within 30 minutes of preparation 1
• Storage in cooler environments can extend this time, but prolonged low temperature storage may negatively impact platelet survival and function 1

Postoperative Management

Dietary and Hygiene Restrictions

• Restrict patient to soft food intake with no biting/chewing in the treated area 2
• Prohibit mechanical cleaning of the treated area for 1 week 2
• Begin 0.12% chlorhexidine rinses starting from day 3 (not earlier, to allow initial clot stabilization), twice daily for 1 minute, continuing for at least 3 weeks 2, 3

Pain Management

• Prescribe analgesics for pain management 2
• Significant reduction in postoperative pain is a major advantage of L-PRF compared to connective tissue grafts 1, 2

Expected Outcomes and Clinical Evidence

Efficacy Compared to Other Modalities

• L-PRF with CAF provides statistically significant improvement in relative root coverage and clinical attachment level compared to CAF alone 4
• When compared to connective tissue grafts, L-PRF results in similar clinical attachment level and probing depth changes, but CTG produces statistically significantly better root coverage and keratinized tissue width 4
• No statistically significant differences exist between CAF/PRF and CAF/enamel matrix derivative or CAF/amnion membrane for investigated parameters 4

Clinical Success Rates

• Mean root coverage of 81-84% can be achieved with PRP/PRF techniques 5, 6
• Approximately 60% of patients may experience 100% root coverage at 24 weeks postoperatively 5
• The technique significantly increases width of keratinized gingiva and gain in clinical attachment 7

Critical Limitations and Pitfalls

Standardization Issues

• Insufficient data exist to develop evidence-based guidelines for PRP in regenerative medicine, requiring consensus-based recommendations instead 2
• Significant variability exists in preparation methods, terminology, purity, content, and quality of platelet products 2
• Many clinical trials fail to adequately define or quantify PRP biological properties, leading to varying efficacies and unreliable conclusions 2

Technical Factors Affecting Success

• The number of L-PRF membranes (thickness of the graft) plays a significant role in achieving optimal results 1
• Using fewer than 3-4 membranes may compromise outcomes 2
• Violations from optimal surgical protocol or treatment by less experienced clinicians often explain failures 1

Patient Selection Considerations

• In cases with limited baseline keratinized mucosa width, connective tissue graft may be preferred over PRF 4
• L-PRF is most appropriate for gingival recessions exhibiting adequate baseline keratinized tissue width 4
• The technique is validated for Miller's Class I and II (Cairo RT I) gingival recessions 4

Biological Rationale

The second-generation APCs (L-PRF family) offer multiple benefits including controlled release of growth factors, fibrous structure conducive to cell attachment, enhanced angiogenesis, antibacterial and analgesic activity, promotion of stem cell differentiation toward osteoblasts, anti-inflammatory activity, and shift in macrophage polarization from M1 to M2 phenotype 1. The 3D architecture characterized by high density, elasticity, flexibility, and strength makes them exceptionally well-suited for handling, manipulation, and suturing 1.