Evaluation of the Hyaluronic Acid Versus the Injectable Platelet-Rich Fibrin in the Management of the Thin Gingival Phenotype: A Split-Mouth Randomized Controlled Clinical Trial

Efficacy of the injectable platelet-rich fibrin (i-PRF) in gingival phenotype modification: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Gingival phenotype (GP), comprising gingival thickness (GT) and keratinized tissue width (KTW), plays a crucial role in preserving the integrity of gingival and periodontal tissues, thereby enhancing their resistance to trauma and mechanical irritation. This systematic review and meta-analysis aimed to evaluate the current evidence about the changes in GT and KTW following the injection of injectable platelet-rich fibrin (i-PRF) in patients with thin GP.

METHODS

A thorough search was conducted up to April 2024 across the following nine databases: The Cochrane Central Register of Controlled Trials (CENTRAL), PubMed®, Scopus®, Web of Science®, Google Scholar, Trip, CINAHL via EBSCO, EMBASE via OVID, and ProQuest. This review covered parallel-group and split-mouth randomized controlled trials (RCTs) which investigated the changes in GT and KTW following i-PRF injection on the buccal anterior region in both jaws for individuals with thin GP. The risk of bias in the included studies was evaluated using Cochrane's tool (RoB 2), and the GRADE framework was utilized to assess the overall strength of evidence. Agreement between the authors was assessed using Cohen's kappa statistic.

RESULTS

Seven RCTs were included in this review, five of which were appropriate for the quantitative synthesis of data. The meta-analysis showed a statistically significant increase in the GT in the i-PRF group at all assessment times compared to baseline (MD ranged from 0.12 mm to 0.38 mm). Regarding KTW, 4-time injections led to a significant increase in KTW after 3-month and 6-month follow-ups compared to baseline (MD = 0.31 mm, and MD = 0.37 mm, respectively). In contrast, 3-time injections yielded a non-significant increase in KTW after 1 and 3 months of follow-up (MD = 0.14 mm at both assessment times). The strength of evidence supporting these findings ranged from low to moderate. However, when comparing the i-PRF group and the i-PRF + microneedling (MN) group, the pooled estimate exhibited significant differences in the GT at both assessment times, with superiority for the MN + i-PRF group (MD = 0.04 mm after 3 months, MD = 0.11 mm after 6 months). In contrast, there were no statistically significant differences in KTW between the two comparisons (MD = 0.03 mm at both assessment times). The strength of evidence supporting these findings was moderate.

CONCLUSIONS

For patients with a thin GP, i-PRF administration resulted in a significant increase in GT at all assessment times compared to baseline. Regarding the KTW, the results varied depending on the number of injection sessions. When the injections were carried out four times, there was an observed increase in KTW, while repeating the intervention three times revealed a non-significant increase in KTW.

PROTOCOL REGISTRATION

The protocol was registered in the PROSPERO database (CRD42024543374) on 16 May 2024.

LEVEL OF EVIDENCE

According to the GRADE recommendations, the strength of evidence regarding the effect of i-PRF injection on GT and KTW ranged from low to moderate. The evidence strength for differences between the i-PRF group and the i-PRF + MN group in both GT and KTW was moderate. The overall quality of evidence for these outcomes is presented in Table 4.

Efficacy of injectable platelet-rich fibrin (i-PRF) as a novel vehicle for local drug delivery in non-surgical periodontal pocket therapy: A randomized controlled clinical trial

Background

The vehicle in a local drug delivery (LDD) system plays a vital role in delivering the active drug component at the diseased site. Liquid/injectable platelet-rich fibrin (i-PRF), an autologous fibrin matrix, might be used as a vehicle to enmesh drugs and deliver locally at the periodontally diseased sites. This study evaluated the efficacy of the drug (ciprofloxacin [Cip])-loaded i-PRF as a LDD system adjunct to subgingival debridement in subjects with periodontal pockets.

Methods

In a parallel design study, 79 periodontally diseased pocket sites were randomized to 3 groups: group 1 (n=25), scaling and root planing (SRP)+i-PRF+Cip; group 2 (n=25), SRP+i-PRF; group 3 (n=25), SRP without any adjunctive intervention. Clinical parameters (probing depth [PD], clinical attachment level [CAL], gingival index [GI], plaque index [PI]) and microbial quantification (relative quantification of levels of Aggregatibacter actinomycetemcomitans) were assessed from baseline to 6th and 12th weeks of follow-up.

Results

All the treatment groups showed significant improvements in the clinical and microbial parameters assessed. Group 1 showed significantly higher PD and GI reduction with CAL gain and decreased in relative levels of A. actinomycetemcomitans in the 12th week, followed by group 2 compared to group 3.

Conclusion

Thus, within the limits of this study, it can be concluded that i-PRF could be considered a potential LDD vehicle for the delivery of ciprofloxacin in periodontal pocket therapy.

Effect of Platelet-Rich Fibrin Combined With Hyaluronic Acid on Bone Formation in Dental Implant Sockets: An In Vivo Study in Sheep

OBJECTIVES

The goal was to evaluate the effect of the combined growth factor of hyaluronic acid (HA) and advanced platelet-rich fibrin (A-PRF) on acceleration and maturation of bone formation around titanium dental implants in the bone-free space (jumping distance) of an over-preparation socket.

MATERIALS AND METHODS

 Thirty-two titanium dental implants were placed in four sheep and distributed into one control group (A) and three experimental groups (B, C, and D) in two different time periods. Each sheep received eight implants. The eight implants in each sheep were distributed into four groups. The first period was one month after the initial placement, 16 implants were used in two sheep. The second period was three months after the initial placement; another 16 implants were used in the other two sheep. All implants were placed in over-prepared implant sockets, resulting in minimal primary stability. In Group A: the space between the dental implant and the bone of the inner wall of the socket was left without a growth substrate material. In Group B: we added HA between the dental implant and the bone of the inner wall of the socket. In Group C: we added A-PRF between the dental implant and the bone of the inner wall of the socket. In Group D: we added a combination of HA and A-PRF between the dental implant and the bone of the inner wall of the socket. Data was collected for each group at one month and three months at the same time. A high-resolution, desktop micro-CT system (Bruker Skyscan 1275, Kontich, Belgium) was used to scan the specimens. The NRecon software (ver. 1.6.10.4, SkyScan) and CTAn (SkyScan) were used for the visualization and quantitative measurement of the samples. One-way analysis of variance (ANOVA) was used to compare the means of the four study groups in the same period. A post hoc test was used after ANOVA to compare the means of two samples at the same time. A p-value of ≤ 0.05 was considered statistically significant.

RESULTS

After one month and three months of using combined HA and A-PRF on Group D, significant acceleration was observed in bone formation in all tests around dental implants compared with other groups, while no significant acceleration was observed when they were used separately; all three study groups showed significant results when compared with the control group.

CONCLUSION

Our data showed that using a combination of HA and A-PRF had a significant effect on the acceleration of the bone formation and ossification process when added to bone-free space (jumping distance) around implants while leaving space without any growth substrates might delay the bone ossification process.

Comparison Between Autologous Albumin Gel and Liquid Platelet-Rich Fibrin Mixture Versus Connective Tissue Graft to Modify the Gingival Phenotype: A Randomized Controlled Trial

Objectives To assess changes in gingival thickness (GTH) and the width of keratinized gingival tissue (KTW) following treatment with either connective tissue graft (CTG) or an albumin gel-platelet-rich fibrin mixture (Alb-PRF). Materials and methods Twenty treatment sites were included in a split-mouth design involving 10 patients with a thin gingival phenotype in the mandibular anterior region. The sample was randomly divided into two groups, with the Alb-PRF applied to the experimental group and CTG used for the control group. GTH and KTW were measured at baseline and after one, three, and six months. Results GTH increased in both groups during all follow-up periods. However, no statistically significant differences (p > 0.05) between the groups were observed at baseline and six months. At three months, the experimental group exhibited significantly higher GTH (p < 0.001). Additionally, at three and six months, the CTG group showed a superior increase in KTW (p < 0.05). Conclusion Within the constraints of this study, Alb-PRF application for modifying thin gingival phenotypes proved to be an effective therapeutic option, potentially serving as an alternative to CTGs. Although Alb-PRF resulted in thicker gingiva, CTG demonstrated a greater enhancement in KTW.

Injectable platelet rich fibrin effect on laser depigmented gingiva: a clinical randomized controlled split mouth trial with histological assessment

OBJECTIVE

To determine whether intra-mucosal injection of injectable platelet-rich fibrin (i-PRF) can promote healing after Diode Laser Gingival Depigmentation (DLGD).

METHODOLOGY

A total of 20 arch sites of hyperpigmented gingiva of 10 patients underwent DLGD. For each patient, two arch sites were randomly assigned for either intra-mucosal injection of i-PRF (G1-i-PRF) (n=10 sites) or no treatment (G2-Control): (n=10 sites). Wound Healing Score (WHS), patient satisfaction, and Pigmentation Index (DOPI) were measured at 1 week and 1 and 3 months postoperatively. Histological assessment of tissue specimens was performed at baseline and 1 week.

RESULTS

The percentage change in WHS at 1 week was significantly higher in G1 (58.34±15.43) compared to G2 (37.50±11.79). At day 1, 50% of patients in G1 were pain free compared with 75% in G2, who had mild pain. Mean DOPI decreased significantly at 3 months in both groups (P-value <0.001), without significant differences between groups. G1 specimens showed significantly higher epithelial thickness (P-value <0.001), as well as a higher number of blood vessels and less percentage of inflammatory cells.

CONCLUSIONS

i-PRF demonstrated better clinical and histological healing potential and less patient discomfort compared to sites without treatment after DLGD. Registered at https://clinicaltrials.gov/ as (NCT05283668).

Effectiveness of i-PRF in periodontal regeneration - A systematic review and meta-analysis

Background

Periapical diseases are common dental conditions that require non-surgical endodontic intervention (NEI) for successful treatment. However, the impact of diabetes mellitus (DM) on the periapical healing (PH) outcome in diabetic patients remains somewhat unclear. This review aimed to evaluate the PH outcome following endodontic intervention among DM-afflicted individuals.

Methods

A comprehensive search was conducted across multiple electronic databases to identify relevant studies. Specifically devised selection criteria were applied to select studies that assessed PH outcomes in DM sufferers undergoing different treatment protocols. Data extraction and quality assessment were performed following predetermined protocols. ROB - 2 risk assessment tool assessed quality of the included studies.

Results

A total of 11 studies met the inclusion criteria and were included in the investigation. Four studies showed greater occurrence of apical periodontitis and five of them reduced healing and success rate in diabetic as compared to controls. Overall, nine studies showed that diabetes mellitus affected periapical outcome negatively. This suggests that diabetes mellitus is an important factor in the prognosis of endodontic intervention. Assessment tools used were PAI, PR, SC and FD analysis. RoB-2 assessed the included studies to have moderate risk of bias.

Conclusion

This review provided compelling evidence that DM patients experienced a noticeable negative impact on PH outcome as compared to control population. These findings highlight the importance of considering the diabetic status of patients when assessing the prognosis of periapical diseases and planning NEI interventions. Further research is needed to validate these findings and explore potential mechanisms underlying the observed associations.