Introduction
The Leukocyte-PRF (Leukocyte-Platelet Rich Fibrin) belongs to a second generation of platelet concentrates which doesn’t need a biochemical blood manipulation. It is used for tissue healing and regeneration in periodontal and oral-maxillofacial surgery. We report two cases of hyperplastic gingival lesions treated by exeresis and application of PRF membranes in order to improve and accelerate tissue healing.
Case Presentation
Two patients (one Caucasian female, 78-year-old, and one Caucasian male, 30-year-old) were treated for hyperplastic gingival lesions. They underwent to exeresis of lesions and application of PRF membranes. Tissue healing was clinically evaluated after one, three, seven, fourteen and thirty post-operative days. No recurrences were observed after two years of semiannual follow up.
Conclusion                                                                                               
We obtained rapid and good healing of soft tissues probably due to the elevated content of leukocytes, platelets and growth factors in the leukocyte-platelet rich fibrin. According to our results we suggest L-PRF employment for wounds covering after exeresis of oral neoformations such as hyperplastic gingival lesions

Abbate, D.

Dell'Angelo, B.

DI LAURO, ALESSANDRO ESPEDITO

Iannaccone, G. A.

SAMMARTINO, GILBERTO

Scotto, F.

Journal of Medical Case Reports

Archivio della ricerca - Università degli studi di Napoli Federico II

CASE REPORT Open AccessSoft tissue regeneration using leukocyte-platelet rich fibrin after exeresis of hyperplasticgingival lesions: two case reportsA.E. di Lauro1*, D. Abbate2, B. Dell’Angelo2, G.A. Iannaccone2, F. Scotto3 and G. Sammartino4AbstractIntroduction: Leukocyte-platelet rich fibrin belongs to a second generation of platelet concentrates that doesnot need biochemical blood manipulation. It is used for tissue healing and regeneration in periodontal andoral-maxillofacial surgery. We report two cases of hyperplastic gingival lesions treated by exeresis andapplication of leukocyte-platelet rich fibrin membranes in order to improve and accelerate tissue healing.Case presentation: Two patients (a 78-year-old Caucasian woman and a 30-year-old Caucasian man) weretreated for hyperplastic gingival lesions. They underwent to exeresis of lesions and application of leukocyte-platelet rich fibrin membranes. Tissue healing was clinically evaluated after 1, 3, 7, 14 and 30 postoperativedays. No recurrences were observed after 2 years of semi-annual follow up.Conclusions: We obtained rapid and good healing of soft tissues probably due to the elevated content ofleukocytes, platelets and growth factors in the leukocyte-platelet rich fibrin. Based on our results we suggestthe use of leukocyte-platelet rich fibrin to cover wounds after exeresis of oral neoformations such ashyperplastic gingival lesions.Keywords: Epulis, Hyperplastic gingival lesions, PRF, Soft tissue healingIntroductionHyperplastic gingival lesions consist of fibro-epithelialreactions that are secondary to multiple factors: chronicinflammation, local irritation (e.g. dental plaque, tartar,root residues, projecting fillings and reconstructions,incongruous dentures), hormonal factors (puberty, preg-nancy), and drugs such as anti-epileptic drugs (diphenyl-hydantoin sodium, valproate sodium, carbamazepine),immunosuppressive drugs (ciclosporin) and antianginalvasodilators (nifedipine) [1, 2]. A dysplastic hypothesishas been formulated regarding its onset [3, 4]; thishypothesis is suggested by the tendency of some hyper-plastic gingival lesions to grow and not to regress spon-taneously. They tend to recur unless a radical surgicaltherapy is performed. Examples of these lesions aregiant-cell epulis and fibro-osseous epulis. Giant-cell epu-lis is the most common form and it is also calledperipheral giant-cell granuloma (PGCG). It was first re-ported as fungus flesh in 1848 [5], then reported as giantcell reparative granuloma in 1953 [6]. This lesion is theperipheral opponent form of central giant-cell intraoss-eous tumors, characterized by the presence of giant cellsthat seem to originate from osteoclasts in the peri-odontal ligament [7]. Fibro-osseous epulis or periph-eral ossifying fibroma (POsF) was first reported anddescribed as ‘alveolar exostosis’ in 1844 [8]. It pre-sents a dense collagenous stroma in which thin tra-becular bone can be observed.We report two cases of hyperplastic gingival lesionstreated by exeresis and application of leukocyte-plateletrich fibrin (L-PRF) membranes in order to improve andaccelerate tissue healing. L-PRF belongs to a second gen-eration of platelet concentrates which does not needbiochemical blood manipulation [9, 10]. It is used fortissue healing [11, 12] and regeneration in periodontaland oral-maxillofacial surgery [13] because of its ele-vated content of leukocytes, platelets and growthfactors.* Correspondence: alessandroespedito.dilauro@unina.it1Department of Neuroscience, Reproductive and OdontostomatologicalSciences, University of Naples “Federico II”, Via Pansini 5, Naples 80131, ItalyFull list of author information is available at the end of the articleJOURNAL OF MEDICALCASE REPORTS© 2015 di Lauro et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.di Lauro et al. Journal of Medical Case Reports _#####################_DOI 10.1186/s13256-015-0714-5Case presentationCase number oneA 78-year-old Caucasian woman presented with a com-plaint of a swelling in her right mandibular molar teetharea that was painful at mastication. The swelling hadarisen 4 months previously and had grown quickly. Onextraoral examination she presented a right facial swell-ing and the skin of her face was healthy. Her regionallymph nodes were not palpable. On intraoral examin-ation she showed poor oral hygiene. A 45×30×20 mmsessile, lobular, soft tissue mass was evident in her rightposterior mandibular gingiva (Fig. 1). The mucosal cov-ering of the lesion looked rosy-purple with a focal areaof ulceration. The lesion was painful and bleeding onpalpation with a parenchymatous consistency. At ortho-pantomography two premolar residual roots were ob-served in the area of the lesion (Fig. 2) with no othersignificant findings.Case number twoA 30-year-old Caucasian man presented with a complaintof a swelling in his left hard palate region which had arisenapproximately 2 months previously after contact with hotfood. The lesion was not painful but was responsible fordiscomfort on swallowing and phonation. On extraoralexamination facial skin lesions or swellings were nothighlighted and his regional lymph nodes were not palp-able. An intraoral examination showed a sessile and de-tected lesion of hard palate in correspondence with leftmaxillary lateral incisor, left maxillary canine and left max-illary first premolar. The lesion was characterized by adiameter of 10 mm and the mucosal which covered itlooked eutrophic (Fig. 3). The lesion was not painfulon palpation and it had a hard consistency. Heshowed good level of oral hygiene. The adjacent teethdid not have carious or periodontal lesions and theyresponded positively to the vitality test. At orthopan-tomography no signs of pathology were found.Surgical proceduresIn both cases we decided to proceed with a surgical ap-proach characterized by complete excision of lesions andapplication of L-PRF membranes in order to improveand accelerate tissue healing.Prior antibiotic therapy with amoxicillin clavulanate(2g 1 hour before operation) infiltrative anesthesia(mepivacaine 30mg/mL and epinephrine 0.01mg/mL)was performed. Full thickness incisions were realized byBard-Parker blades number 15 and they included at least2 mm of healthy tissue. The lesions strongly adhered tothe floor below. They were lifted by Prichard’s periostealspatulas and surgical tweezers (Fig. 4). At the same timeblood samples (40cc for patient) were collected in testtubes without anticoagulant to obtain the L-PRF. L-PRFprotocol [9] is realized with the Intra-Spin L-PRF whichprovides blood centrifugation at 2700 revolutions perFig. 1 Intraoral appearance of the lesion, Patient 1Fig. 2 Orthopantomography, Patient 1Fig. 3 Intraoral appearance of the lesion, Patient 2di Lauro et al. Journal of Medical Case Reports _#####################_ Page 2 of 5minute (rpm) for 12 minutes. Centrifugation determinesthe formation of the clot and the activation of thegrowth factors. After centrifugation L-PRF clots werecollected together with some red blood cells from thetest tubes using sterile scissors. L-PRF clots were com-pressed between two sterile gauzes to obtain manageablemembranes useful to cover the wounds. The L-PRFmembranes were stabilized with horizontal mattress andsingle sutures in Vicryl 3/0 (Figs. 5 and 6) removed after7 days. After the surgery, the patients were encouragedto take, in case of pain, acetaminophen (1g/8 hours) oribuprofen (600mg/8 hours) and a collutory with chlor-hexidine 0.20% was prescribed for 7 days. Tissue healingwas clinically evaluated after 1, 3, 7, 14 and 30 postoper-ative days (Fig. 7). Healing was quick and without dehis-cences. Therefore, complete excision of the lesion wasperformed and the entire specimen submitted forhistopathological examination (Fig. 8). Histological re-ports highlighted giant-cell epulis for the first caseand fibro-osseous epulis for the second case. No re-currences were observed after 2 years of semi-annualfollow up (Figs. 9 and 10).Fig. 4 Enucleated lesion, Patient 1Fig. 5 Suture and stabilization of leukocyte-platelet rich fibrin mem-branes, Patient 1Fig. 6 Leukocyte-platelet rich fibrin membranes on the surgicalwound, Patient 2Fig. 7 Healing, photo after 14 postoperative days, Patient 1di Lauro et al. Journal of Medical Case Reports _#####################_ Page 3 of 5DiscussionAlthough the epulis in its form of giant-cell epulis andfibro-osseous epulis is a benign disease, it is importantto find time to make the correct therapy. Both youngand old patients must take prompt actions to avoidgrowth of oral lesions that can begin to become difficultto manage. There is unanimous consensus on the surgi-cal excision of these lesions in toto to prevent recur-rence. The target of these case reports is to focus on themanagement of the L-PRF and its placement on thesurgical wounds. The first benefit is given by coveringthe surgical site, which would otherwise heal by second-ary intention, which provides greater comfort to the pa-tient in the postoperative period. The same woundhealing appears to be substantially accelerated becauseof the structural and neoangiogenetical properties of L-PRF [14]. In the polymerization step of the L-PRF,thrombin, which is present in physiological concentra-tions, allows the formation of a fibrin matrix in a slowand natural way obtaining a flexible structure capable ofdetermining entrapment of cytokines, cell migration andtissue healing [15]. The effect of L-PRF on reducing painand postoperative swelling has the same importance.There are countless practices that the L-PRF offers inthe dental field such as the accelerated healing of extrac-tion sockets and use with other biomaterials in boneregeneration (GBR) [16]. In the context of tissueregeneration we evaluated the role of L-PRF in thepromotion of wound healing. We also stress the im-portance of such a gel in the control of hemostasis inpatients taking anti-platelets and/or anticoagulants forwhom extractions can be performed without discon-tinuation of these drugs.ConclusionsAccording to the encouraging results obtained in thesetwo clinical cases about tissue healing after applicationof L-PRF membranes, we suggest that L-PRF be used tocover wounds after exeresis of oral neoformations suchas hyperplastic gingival lesions.ConsentWritten informed consent was obtained from the patientfor publication of this case report and any accompanyingimages. A copy of the written consent is available forreview by the Editor-in-Chief of this journal.Fig. 8 Biopsy specimen, Patient 1Fig. 9 Healing, photo at 1 month, Patient 1Fig. 10 Healing, photo at 1 month, Patient 2di Lauro et al. Journal of Medical Case Reports _#####################_ Page 4 of 5Competing interestsWe have not received reimbursements, fees, funding, or salary from anorganization that may in any way gain or lose financially from thepublication of this manuscript.Authors’ contributionsAEdL conceived the study and was the first surgeon/operator; DA was thesecond surgeon/operator; BDA was the third surgeon/operator; GAIparticipated in the realization and organization of the pictures; FSparticipated in the realization of the manuscript; GS participated in thecoordination of the study. All authors read and approved the finalmanuscript.Author details1Department of Neuroscience, Reproductive and OdontostomatologicalSciences, University of Naples “Federico II”, Via Pansini 5, Naples 80131, Italy.2Private Practice, Oral Surgery Specialist, Naples, Italy. 3Department ofNeuroscience, Reproductive and OdontostomatologicalSciences, University ofNaples “Federico II”, Via Pansini 5, Naples 80131, Italy. 4Department ofNeuroscience, Reproductive and OdontostomatologicalSciences, University ofNaples “Federico II”, Via Pansini 5, Naples 80131, Italy.Received: 16 December 2014 Accepted: 28 September 2015References1. Ficarra G. Manuale di Patologia e Medicina Orale. McGraw-Hill Education.2006. Milano, Italy.2. di Lauro F, Bucci E. Chirurgia Odontostomatologica. Ed. Florio. 2000. Naples,Italy.3. Ramu S, Rodrigues C. Reactive hyperplastic lesions of the gingiva: aretrospective study of 260 cases. World J Dent. 2012;3(2):126–30.4. Chaparro–Averdano A, Berini-Aytes L, Gay–Escoda C. Peripheral giant cellgranuloma. A report of five case and review of the literature. Med Oral PatolOral Cir Bucal. 2005;10(1):53–7.5. Tomes J. A course of lectures on dental physiology and surgery(lectures I–XV). Am J Dent Sci. 1846–1848;7:1–68. 121–134, 33–54,120–147, 313–350.6. Jaffe HL. Giant-cell reparative granuloma, traumatic bone cyst, and fibrous(fibro-osseous) dysplasia of the jawbones. Oral Surg Oral Med Oral Pathol.1953;6:159–75.7. Katsikeris N, Kakarantza-Angelopoulou E, Angelopoulos AP. Peripheral giantcell. Granuloma: clinicopathologic study of 224 new cases and review of956 reported cases. Int J Oral Maxillofac Surg. 1988;17:94–9.8. Shepherd SM. Alveolar exostosis. Am J Dent Sci. 1844;4:43–4.9. Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al.Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part I:technological concepts and evolution. Oral Surg Oral Med Oral Pathol OralRadiol Endod. 2006;101(3):e37–44.10. 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Int J Med Sci.2012;9(10):872–80.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color ﬁgure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitdi Lauro et al. Journal of Medical Case Reports _#####################_ Page 5 of 5

Soft tissue regeneration using leukocyte-platelet rich fibrin after exeresis of hyperplastic gingival lesions: Two case reports

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