EGYPTIAN Vol.

66, 2187:2195, Ocober, 2020

DENTAL JOURNAL Print ISSN 0070-9484 • Online ISSN 2090-2360

Oral Medicine, X-Ray, Oral Biology and Oral Pathology

www.eda-egypt.org • Codex : 12/2010 • DOI : 10.21608/edj.2020.42015.1249

CLINICAL EVALUATION OF PLATELET RICH FIBRIN VERSUS

SUBEPITHELIAL CONNECTIVE TISSUE GRAFT, FOR SOFT TISSUE
AUGMENTATION AROUND IMPLANT IN THE AESTHETIC ZONE:
A RANDOMIZED CONTROL CLINICAL TRIAL

May Mohamed Kamal*, Weam Elbattawy**, Salma Eid *** and Mona Shoeib****

ABSTRACT
Background: the current study investigated platelet rich fibrin and subepithelial connective
tissue graft in preserving crestal bone and soft tissue around delayed implants.

Methods: Twelve participants with thin gingival biotype, were randomly assigned in two equal
parallel groups. Both received delayed implant, augmented by subepithelial connective tissue graft
versus platelet rich fibrin. Crestal bone level was measured at 3, 6 and 9 months. Gingival thickness
and keratinized tissue width were measured at baseline, 3 and 6 months, pink esthetic score at 6
months, pain, swelling and patient satisfaction were reported after 7 days and at the end of the
follow up period respectively.

Results: Both groups showed statistically significant improvement in all clinical outcomes
at 3 and 6 months with no statistically significant difference at different observational periods.
Subepithelial connective tissue graft showed statistically significant increase in gingival thickness
and pink esthetic score compared to platelet rich fibrin after 6 months with no statistically significant
difference regarding the crestal bone loss, keratinized tissue width, postoperative pain, swelling and
overall patient satisfaction between both groups.

Conclusion: Inspite that PRF showed less values of crestal bone loss yet both treatment
modalities could not prevent the postsurgical crestal bone loss to occur, with no statistically
significant difference between them. Subepithelial connective tissue graft is effective at increasing
the gingival thickness around delayed implants.

Clinical relevance: Both treatment modalities could be used safely around dental implant.
Subepithelial connective tissue graft is more effective in thin phenotype for augmenting gingival
thickness.

* M.Sc. of Periodontology, Faculty of Dentistry, Cairo University

** M.Sc, Phd, Lecturer, Department of Oral Medicine and Periodontology, Faculty of Dentistry, Cairo University.
*** M.Sc, Phd, Lecturer, Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Cairo University.
**** M.Sc, Phd, Professor, Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Cairo University.
(2188) E.D.J. Vol. 66, No. 4 May Mohamed Kamal, et al.

INTRODUCTION for soft tissue augmentation have been used and

developed to date[8].
Dental implants have been considered a
good option for partially edentulous patients in PRF gained its popularity as a healing biomaterial
maintaining healthy mucosa with minimal crestal for both soft and hard tissue because of the presence
bone loss and no extensive harm to the adjacent of various growth factors also it would facilitate
natural teeth [1]. Delayed implants placed after tissue healing and regeneration by enhancing
complete healing of the ridge ensured a stable ridge angiogenesis, chemotaxis, cell proliferation
dimension. However, the disadvantage of prolonged and differentiation and extracellular matrix
healing time and bone resorption needed additional synthesis[9, 10]. For best outcomes in human tissue
healing and regeneration, mutual interaction
augmentation procedure [2].
between a scaffold (fibrin matrix), platelets, growth
The pink esthetic success was found to be de- factors, leukocytes, and stem cells are required [11,
pendent on different factors that involved the im- 12]
. Therefore, PRF could promote wound healing,
plant position, multiple implant placement and the bone growth and maturation, graft stabilization
soft tissue management manner. Two mm of facial and hemostasis and even improve the handling
bone thickness has been suggested as a minimum properties of graft materials [13, 14].
to prevent future recession, which would potentially
expose implant collars and lead to loss of the MATERIALS AND METHODS
harmonious gingival margin [3].
Study design
Enough keratinized tissue was considered im-
This study was designed as a parallel,
portant for marinating healthy tissue around dental
randomized, controlled clinical trial to compare
implant [4]. Also soft tissue biotype has been consid-
the clinical and radiographic outcomes of PRF to
ered as a critical factor, where patients would show
SCTG in maintaining crestal bone and enhancing
either thin scalloped gingiva or thick flat biotype [5]. soft tissue around delayed implants. The study
Moreover, it has been proven that thin biotype had protocol was registered in ClinicalTrials.gov (ID:
higher liability for gingival recession from any trau- NCT03219944.) and approved by The Research
ma during the surgical and prosthetic procedures in Ethics committee, Faculty of Dentistry, Cairo
comparison to thick flat biotype and the underlying University (July 2017).
bone could suffer from rapid resorption in associa-
tion with soft tissue recession [6]. Study population

SCTG has been widely utilized aiming at This investigation included 12 delayed implants
increasing the width and thickness of keratinized placed in 12 patients (2 males and 10 females) with
tissue either around natural teeth or around implants missing maxillary tooth in the esthetic zone and
for resisting and treating recession, masking seeking its replacement. Subjects were selected
from the outpatient clinic, Department of oral
the metallic implant color and also for papillary
Medicine and Periodontology, Faculty of Dentistry,
reconstruction [7].
Cairo University between September 2017 and
However, an additional harvesting site in April 2018.
autografts with its associated pain, morbidity,
sometimes poor quality and limited amount of Pretreatment
graft material limited their use. To overcome these Initial examination, including full mouth clinical
problems, a large amount of alternative materials and radiographic examination, was performed.
CLINICAL EVALUATION OF PLATELET RICH FIBRIN VERSUS SUBEPITHELIAL CONNECTIVE (2189)

A preoperative cone beam computed tomography

(CBCT) was performed for each patient who met the
inclusion criteria prior to the surgery to determine
bone height and width and decide the implant
length and diameter to be placed and to evaluate the
underlying bone condition [15].

Randomization
A computer-generated random allocation
sequence was executed by external assistant who
was not involved in the recruitment. Allocation
concealment was achieved by sequentially Fig. (1) (A) Digital periapical radiograph at the base line of
control group (SCTG) showing CBL (B) Digital
numbered, opaque, sealed envelopes including the
periapical radiograph at 9 months of control group
randomization code for each patient. (SCTG) showing CBL (C) Digital periapical radiograph
at base line test group (PRF) showing CBL (D)Digital
Blinding periapical radiograph at 9 months test group (PRF)
showing CBL.
The current trial was a single-blinded clinical
trial. Blinding included the outcome assessor and the
statistician. It was impossible for the operator and (PES), which were measured using William’s
the participants to be blinded as the interventions graduated periodontal probe. GT was measured
were completely different. by transgingival-piercing of the tissues using
an anesthetic needle with a rubber stopper 2mm
Radiographic parameters coronal to the MGJ and in the mid distance mesio-
Standardized periapical digital radiographs were distally [18]. KTW was measured at the mid buccal
taken using PSP sensors (Digora™ PSP Imaging area from the gingival crest to the MGJ. PES was
plate. SOREDEX Inc., Tuusula, Finland) size 1 or measured at 6 months [19].
2 with parallel technique using X-Ray Holder kit
Patient reported outcomes
and custom-made bite block was fabricated for each
case [16]. Post-operative pain and swelling was assessed
by the patient for the first week postoperatively (0 –
Each implant had 8 readings for CBL: mesial
7 days) using Verbal Rating Scale (VRS)[20].
and distal readings on the day of the intervention
(baseline), 3, 6 and 9 months postoperatively. The At the end of the follow up period (9 months),
crestal bone loss along the months was calculated assessment of the patient’s satisfaction was
as the difference between the initial measurement done using Patient Satisfaction Questionnaire
(baseline) and the measurement obtained at the (PSPSQ) [21].
three follow-up phases [17] (Figure 1).
Treatment Protocols
Clinical Parameters All procedures were done under completely
Clinical parameters were measured at baseline, aseptic conditions. Patients were anaesthetized by
3 and 6 months postoperatively. Clinical parameters buccal and palatal infiltration. Crestal incision and
included: gingival thickness (GT), keratinized full thickness mucoperiosteal flap was elevated
tissue width (KTW) and pink esthetic score buccally and lingually. Then the bone width was
(2190) E.D.J. Vol. 66, No. 4 May Mohamed Kamal, et al.

measured again using bone caliper to confirm the Test group (PRF):
implant width as detected in CBCT. [22]. Sequential
PRF was prepared by drawing 10 ml of blood
drilling started by the pilot drill till the last drill that
from the antecubital patient vein using butterfly/
suited the planned implant size. Before implant
needle winged infusion set and transferred to a glass
placement a parallel pin was used to check the
test-tube without anticoagulant. The blood sample
implant parallelism. Implant insertion was done
was immediately centrifuged at 3000 rpm for 10-12
in the osteotomy site using torque wrench by self-
min in an electric centrifuge[17]. Then PRF layer
tapping fashion till the implant was placed 0.5-1mm
that needed was separated. Then the immediately
below the alveolar bone crest [23] with adequate
prepared PRF would be squeezed between two
primary stability (torque about 35N) [24]. A split
sterile glass laps to flatten it into a membrane form. A
thickness pouch was created in the labial/buccal flap
double-layered membrane of PRF was placed in the
using blade #15C where it was made parallel to the
pouch over the recipient site below the labial/buccal
periosteum. The pouch was created to receive the
flap and extending palatally without suturing. Flap
graft and allow its fixation [25].
approximation was performed for wound closure
Control group (SCTG): SCTG was harvested and sutured in the same manner as control group
from the palate by single incision technique [26]. The (Figure 3).
SCTG was placed in the pouch over the recipient
Post-surgical phase:
site below the labial/buccal flap and extending
palatally. The graft was sutured in a horizontal Systemic antibiotics )Amoxicillin 1g( were
mattress manner to the labial/buccal flap by prescribed b.i.d. for 5 days to prevent any chance
5-0 resorbable braided polyglycolic acid suture of post-operative infection [28]. Anti-inflammatory
material. Flap approximation and primary wound drugs (Ketoprofen 100 mg) was administrated
closure was achieved with horizontal mattress and every 12 hours to avoid any chance of edema,
single interrupted manner [27]. The palatal wound, pain or swelling [28]. Antiseptic mouth rinse 0.12 %
from which the SCTG was harvested, was sutured chlorhexidine HCL was prescribed for 60 seconds
by sterilized, natural non absorbable silk 5-0 two times per day for 14 days [29]. Patient self-care
(Figure 2). instructions were emphasized on avoiding any

Fig. (2) (A) Preopearive ,(B) Implant placement,(C) placement Fig. (3) (A) Clinical preopearive photo, (B) Implant placement,
of SCTG over implant , (D) 6 months postoperative. (C) Placement of double layer PRF over implant, (D) 6
months postoperative.
CLINICAL EVALUATION OF PLATELET RICH FIBRIN VERSUS SUBEPITHELIAL CONNECTIVE (2191)

vigorous brushing and trauma to the surgical site for the preoperative and postoperative radiographs
one week [30]. Sutures were removed fourteen days after 9 months for the two groups. Comparing
postsurgically. the two groups, there was greater mean crestal
bone loss values in the SCTG group, however, the
Statistical & Power analysis:
results in the follow up 3, 6 and 9 months showed
Values were presented as mean and standard no statistically significant difference between both
deviation (SD) values. Data were explored for groups (P= 0.150, 0.262 and 0.261) respectively.
normality using Kolmogorov-Smirnov test of
normality. For parametric data (GT, KTW and PES), Clinical parameters
independent t test was used to compare both groups, Table (2) shows the clinical parameters recorded
while ANOVA test (followed by Tukey’s post hoc for both groups throughout the study. On comparing
test) were used for comparison between different both groups, it was observed that greater mean
observations within the same group. For non- values were recorded in the SCTG group at all
parametric data, (crestal bone loss) Mann Whiney observation. However, at 6 months the SCTG group
U test was used to compare both groups. Categorial showed a statistically significant increase (P=0.016)
data (Pain and response to questionnaire) were in mean GT compared to the PRF group.
compared using chi square test. The significance
The difference in the mean values of KTW on
level was set at p < 0.05. Statistical analysis was
comparing both studied groups at baseline, 3 and 6
performed with SPSS 18.0 (Statistical Package for
months showed no statistically significant difference
Scientific Studies, SPSS, Inc., Chicago, IL, USA)
postoperatively (P-value = 0.421, 0.401 and 0.154
for Windows.
respectively).
RESULTS The esthetic outcomes were measured by the
PES at 6 months postoperatively and showed greater
Radiographic parameters mean values for the SCTG group in comparison
The mean and standard deviation of CBL to the PRF group with statistically significant
recorded for both groups throughout the study is difference between the both groups (P-value =
represented in table (1), while figure (1) represents 0.035).
TABLE (1): Results of crestal bone level (CBL) in both studied groups throughout the experimental period.

CBL mean (± SD) SCTG PRF Mean difference CI (95%) P-value

Baseline 0.58c (±0.16) 0.51d (±0.07)

3 months 1.78b (±0.22) 1.45c(±0.40)

6 months 1.95b (±0.29) 1.71b(±0.36)

9 months 2.28a (±0.28) 2.06a(±0.14)

p-value <0.001* <0.001*

Baseline-3 months 1.20 (±0.22) 0.95(±0.39) 0.25 [-0.17,0.68] 0.150ns

Baseline-6 months 1.37(±0.28) 1.20(±0.36) 0.17 [-0.25,0.59] 0.262ns

Baseline-9 months 1.70(±0.20) 1.55(±0.15) 0.15 [-0.08,0.38] 0.261ns

Significance level p<0.05, *=significant, ns=non-significant

(2192) E.D.J. Vol. 66, No. 4 May Mohamed Kamal, et al.

TABLE (2): Results of clinical periodontal outcomes in both studied groups throughout the experimental
period.

Baseline 3 months 6 months P-value

GT mean (± SD)

SCTG 1.12(±0.22) 2.57(±0.67) 3.07(±0.65) 0.003*

PRF 1.10 (±0.36) 2.50(±0.63) 2.13(±0.46) 0.004*

Mean difference CI (95%) 0.02 [-0.38,0.41] 0.07 [-0.77,0.9] 0.94 [0.2,1.67]

P-value 0.925ns 0.862ns 0.016*

KTW mean (± SD)

SCTG 4.17(±1.17) 4.23(±1.13) 4.27(±1.16) 0.097ns

PRF 3.97(±0.85) 3.67(±1.21) 3.67(±1.21) 0.717ns

Mean difference CI (95%) 0.20 [-1.13,1.53] 0.56 [-0.94,2.07] 0.60 [-0.92,2.12]

P-value 0.421ns 0.401ns 0.154ns

PES mean (± SD)

SCTG 12.50(±1.05)

PRF 11.33(±0.52)

Mean difference CI (95%) 1.17 [0.10,2.23]

P-value 0.035*

Significance level p<0.05, *=significant, ns=non-significant

Patient reported outcomes of patient opinions between both groups showed no

The postoperative pain was reported that the statistically significant difference in response to the
intensity of pain was greater in the SCTG group questionnaire (P=0.72, 0.57 and 0.53) for questions
at different observation times but the difference 1 to 3 respectively.
between groups was not statistically significant (P
≥ 0.05) at days 0 to 7 respectively. DISCUSSION

Postoperative swelling as reported by VRS, SCTG has been considered as the gold standard
greater value was noted at the PRF group at the for soft tissue augmentation, yet it still have the
day of the surgery with statistically significant disadvantages of an additional harvesting site
difference (P=0.034). However, in the subsequent associated with pain, morbidity and limited amount
observation dates, greater swelling intensities were of graft material [7]. Therefore, different alternatives
observed in the SCTG group, with no statistically have been suggested such as PRF [31].
significant difference between groups (P ≥ 0.05) at PRF gained its popularity as a healing
days 1 to 7 respectively. biomaterial for both soft and hard tissue because of
Patient satisfaction was measured according to the presence of various growth factors. Therefore,
a questionnaire answered by the patients at the end PRF could offer several advantages as promoting
of the follow up period, where the mean difference wound healing, bone growth and maturation, graft
CLINICAL EVALUATION OF PLATELET RICH FIBRIN VERSUS SUBEPITHELIAL CONNECTIVE (2193)

stabilization and hemostasis and even improving who reached a 1.3(±0.61) mm increase in gingival
the handling properties of graft material [13]. thickness when augmenting using SCTG after one
year. Also, this study results were in a line with a
Standardized intra-oral periapical radiographs
randomized controlled clinical trial done by Cairo
with paralleling technique and XCP positioner for
et al [18], where the buccal gingival thickness showed
assessment of CBL over different time intervals is
an increase by 1.2(±0.3) mm in the when using
an accurate method in minimizing distortion and
SCTG after 6 months. Marrelli and Tatullo [28],
magnification [15, 32]. CBL was identified immediately
also Hehn et al[37] obtained corresponding results
after implant placement then at 3, 6 and 9 months to the current trial, where complete coverage of
intervals, since it was proved that 50% of total implants and soft tissue thickness gain between 1-3
crestal bone loss recorded in 12 months period after mm were observed after using PRF for soft tissue
implant placement [32, 33]. augmentation around immediate implants.
The present RCT demonstrated a statistically Regarding the keratinized tissue width, there
significant increase in the mean crestal bone was a gradual non statistically significant increase
loss in both groups at 3, 6 and 9 months with no from 4.17(±1.17), to 4.23(±1.13), then 4.27(±1.16)
statistically significant difference between the two mm. While there was a gradual non-statistically
groups. In the SCTG group the mean crestal bone significant decrease in the PRF group from
loss was 1.20(±0.22), 1.37(±0.28) and 1.70(±0.20) 3.97(±0.85) mm at baseline, to 3.67(±1.21) mm
mm respectively. While in the PRF group the mean at 3 months and remained constant 3.67(±1.21)
crestal bone loss was 0.95(±0.39), 1.20(±0.36) and mm 6 months no statistically significant difference
1.55(±0.15) mm respectively. These results were between both studied groups. Superior results by
inferior to an RCT conducted by Wiesner [21] who Lee et al [38] were found with an increase of more
also augmented soft tissue around delayed implants than 3 mm at 2 years postoperative.
by SCTG and showed a mean marginal bone loss
Interestingly, the non-statistically significant
of 1.14(±0.29) mm after 1 year. Also, less crestal
decrease in the KTW after 6 months in the PRF
bone loss was expressed in another clinical trial by
group conflicted with a study by Mufti et al [39] who
Zuiderveld et al [34], who achieved 0.42(±0.06) mm
observed an increase in the KTW after using PRF
and 0.46(±0.04) mm after one month and one-year
for treating gingival recession. On the other hand,
intervals respectively. The results of the current
this was previously stated by Jankovic et al [40] who
study agreed with Kenawy et al [35] who obtained
declared that although PRF could enhance wound
mean marginal bone loss 1.0(±0.5),1.0(±0.5) and
healing properties yet it did not cause any significant
1.5(±0.5) mm after 3, 6 and 9 months respectively
improvement in the KTW when compared to SCTG.
after augmentation with PRF around immediate
implants. In this trial greater statistically significant values
of PES were recorded in the SCTG group when
Regarding the change in gingival thickness in
compared to the PRF group after 6 months. This
this trial the mean increase in SCTG group was
agrees with Wiesner et al [36] and confirms the fact
1.117(±0.223), 2.567(±0.665) and 3.067(±0.650)
that SCTG is still the most promising aesthetic graft
mm at baseline, 3 and 6 months respectively.
material around dental implants. This was further
While the mean increase in the PRF group was
proved by Rojo et al. [41].
1.1(±0.358), 2.5(±0.632) and 2.133(±0.455) mm
respectively. SCTG had statistically significant Concerning the post-operative morbidity
superior results than PRF after 6 months. This and patient satisfaction, although there was no
agrees with a study conducted by Wiesner et al [36] statistically significant difference between both
(2194) E.D.J. Vol. 66, No. 4 May Mohamed Kamal, et al.

treatment modalities, yet it could not be ignored that 8. Lai, P.-C., D. Katwal, and H. Greenwell, Allografts and
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