Modified Apically Repositioned Flap for Increasing the Width of Attached Gingiva Along with Platelet-rich Fibrin - a Case Series with 6 Months Follow-up

Introduction: The presence of a certain zone of attached gingiva (AG) is essential for maintenance of gingival health, prevention of soft tissue recession, and unaltered levels of the connective tissue attachment. In a clinical study by Lang and Loe, it was demonstrated that in areas with less than 1mm of attached gingiva, inflammation persisted despite optimal plaque control. The earliest documented surgical techniques to increase the width of AG were the push-back procedure, the vestibular extension technique, an apically repositioned flap, and an autogenous free gingival graft. Later, Carnio et al. found that a modification of the apically repositioned flap is an effective method to increase both keratinised and attached tissue width. Platelet-rich fibrin (PRF) is a natural fibrin-based healing biomaterial. It encourages angiogenesis, immunity, epithelisation, and is used to shield open wounds, thereby promoting faster healing and soft tissue maturation. Objective: Taking into consideration the advantages of PRF, it was assumed that the combination (MARF+PRF) therapy might be a beneficial modality in patients with Miller's class III and IV recession over single/ multiple adjacent teeth. Materials and methods: A total of 6 teeth were treated in 3 systemically healthy patients (1 male, 2 females; age range- 21-38). Subjects were non-smokers with an inadequate zone of attached gingiva (0.5-2.0mm) and minimal sulcus depth with no bone dehiscence. All the clinical parameters, namely width of attached gingiva, keratinised tissue, marginal tissue recession, and probing depth, (PD) were measured on the mid-buccal aspect of the treated teeth using a UNC-15 probe. Measurements were taken at baseline (immediately before surgical treatment) and 6 months after surgery. When measuring the apico-coronal dimension of KT, an iodine solution was used to visualise the mucogingival junction. The width of attached gingiva was determined by subtracting the PD from the apico-coronal height of KT. Marginal tissue recession was regarded as the distance between the cemento-enamel junction and the gingival margin. Following local anaesthesia, a single horizontal incision parallel to the mucogingival junction was given in keratinised tissue. It is a bevelled incision which allows a coronal portion of gingiva to remain intact in its original position and prevents recession and alveolar bone loss. The mesiodistal extension of the horizontal incision depends on the number of teeth involved and should be extended at least one half tooth mesial and distal to the area where augmentation is required; this allows apical repositioning of the flap without requiring vertical incisions. A spilt-thickness flap was elevated and PRF membrane prepared using a table-top centrifugation machine at 3000 rpm for 10 minutes. The flap was moved apically, PRF membrane placed, and simple interrupted bioabsorbable suturing was done. Results and conclusions: Treatment with this procedure resulted in an increase in width of both keratinised gingiva and attached gingiva. Gingival recession decreases at 4 treated areas, which may be the result of creeping attachment. In view of the above findings, it may be concluded that (MARF+PRF) may be used as an alternative to other procedures such as FGG with reliable results and minimal patient discomfort. Keywords: Attached gingiva, aesthetics, fibrin, gingival recession, mucogingival surgery, wound healing