Clinical Oral Investigations (2021) 25:6347–6356

https://doi.org/10.1007/s00784-021-03935-3

ORIGINAL ARTICLE

Clinical evaluation of the treatment of multiple gingival recessions

with connective tissue graft or concentrated growth factor using
tunnel technique: a randomized controlled clinical trial
Birsen Korkmaz 1 & Umut Balli 2

Received: 7 December 2020 / Accepted: 30 March 2021 / Published online: 8 April 2021
# The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

Abstract
Objective To assess the effectiveness of the combination of tunnel technique (TT) and concentrated growth factor (CGF) for root
coverage in treating multiple gingival recessions (GR) and compare with the connective tissue graft (CTG).
Materials and methods Forty patients with Miller Class I and II maxillary or mandibular GR were randomly divided into two
groups as follows: TT + CTG and TT + CGF. The results at baseline and 6 months were evaluated for the following clinical
parameters: complete root coverage (CRC), mean root coverage (MRC), gingival thickness (GT), gingival recession width (RW),
gingival recession depth (RD), and keratinized tissue width (KTW).
Results At 6 months, a statistically significant difference was found in RD, RW, MRC, CRC, KTW, and GT compared with the
baseline (p < 0.05). MRC was determined 89.52±16.36% in the TT + CTG and 76.60±24.10% in the TT + CGF (p < 0.05). CRC
was achieved in 66.7% of the TT + CTG and 47.4% of the TT + CGF (p < 0.05). The increase in KTW and GT was significantly
better in the TT + CTG group compared to the TT + CGF (p < 0.05).
Conclusions The study showed that TT + CGF did not improve the results as much as TT + CTG in the treatment of Miller Class I
and II GR. However, this finding is not sufficient to advocate the true clinical effects of CGF on GR treatment with TT.
Clinical relevance CGF could not serve as a direct alternative biomaterial to the gold standard CTG.
Trial registration ClinicalTrials.gov Identification Number: NCT04561947

Keywords Gingival recession . Growth factors . Plastic periodontal surgery . Connective tissue graft

Introduction
Many techniques and biomaterials have been used for treat-
ment of gingival recessions (GR) [1]. Connective tissue graft
(CTG) and coronally advanced flap (CAF) have been accept-
ed as the most effective surgical techniques in regard to root
coverage predictability and long-term stability and have been
stated as the gold standard [1–3]. In some cases, the disadvan-
tages of CTG are inadequate palate tissue thickness, creating a
secondary surgical area that increases morbidity for a patient,
* Birsen Korkmaz
birsenkorkmaz91@gmail.com
1
Department of Periodontology, Faculty of Dentistry, Bulent Ecevit
University, Zonguldak, Turkey
2
Department of Periodontology, Faculty of Dentistry, Bezmialem
Vakif University, Istanbul, Turkey
and inability to always achieve the graft of the desired size [4,
5]. To overcome these disadvantages, attempts have been
made to search for materials alternative to CTG [1, 6]. One
of these materials is platelet concentrates (PCs) [7–9].
Growth factors (GFs) released from platelets are important
for wound healing and increase cell angiogenesis, prolifera-
tion, and extracellular matrix synthesis [10]. Therefore, the
use of platelet-derived GFs for tissue regeneration in peri-
odontal plastic surgery has been suggested [6, 7].
Concentrated growth factor (CGF) is obtained by centrifuging
venous blood in a special centrifuge device at varying speeds
(2400 to 3000 rpm) [11]. In CGF isolation, the modified speed
ratio is used rather than the constant speed used while obtaining
platelet-rich fibrin (PRF). Thus, it is stated that a dense matrix is
formed in a way that allows increase of GF release [12].
CGF contains thrombocytes, leukocytes, and abundant
GFs including transforming growth factor-beta 1 (TGF-β1),
platelet-delivered growth factor (PDGF), vascular endothelial
growth factor (VEGF), insulin-like growth factors (IGF),
6348
fibroblast growth factor (FGF), and bone morphogenic protein
(BMP) in a complex three-dimensional fibrin network [11, 13,
14]. This fibrin network is highly cohesive due to the presence
of thrombin, factor XIII, and fibrinogen. Factor XIIIa, activat-
ed by thrombin, causes the coagulation of fibrin. This protects
the clot from plasmin degradation and provides high tensile
strength and stability [11, 15].
Some studies have reported the biological and mechanical
advantages of CGF compared with PRF. CGF has a rigid tex-
ture thanks to its interwoven fiber structure [16, 17]. The fibrin
matrix of CGF is larger and denser and contains more GF as a
result of different centrifuge speeds [18]. Lee et al. stated that
CGF has stronger tensile strength and higher potential to induce
proliferation of osteoblast and gingival fibroblast compared
with PRF [19]. Moreover, the GFs are homogeneously distrib-
uted in the plasma protein layer of CGF, and the release of the
GFs is for a longer duration compared with that for the usual
fibrin clot because of the fibrin matrix [20, 21]. The high tensile
strength and viscosity of CGF protect GFs from proteolysis and
prolong the release time of GFs [15]. GFs release due to con-
tinuous collision and rupture of platelets increases during cen-
trifugation in the preparation of CGF [22]. Studies have shown
that CGF is slowly dissolved and released GFs for more than
13 days [21, 23]. Thus, CGF functions as a biomaterial that is a
reservoir of integrated GFs [24].
Many studies have shown the bioactivity, GFs content, and
GFs release times of CGF [15, 16, 24, 25]. CGF stimulates the
proliferation, osteogenic maturation, and mineralization of
mesenchymal stem cells. Also, it has a good regenerative ca-
pacity and versatility by increasing proliferation of the peri-
odontal ligament stem cells [26]. The high regeneration, vas-
cularization, and angiogenesis capacity of CGF may be asso-
ciated with the presence of CD34 (+) cells [11, 12, 22].
CGF is used in a wide variety of application areas, includ-
ing extraction sockets, sinus-lifting operations, alveolar ridge
augmentation, treatment of GR, and guided bone regenera-
tion, and achieved good results [8, 22, 27].
Scientific and technical innovations in the field of peri-
odontal plastic surgery and the increasing aesthetic expecta-
tions of patients have enabled the development of existing
treatment approaches. These developments have focused es-
pecially on wound healing and on increasing the blood supply
of the treated area [28]. It is believed that the tunnel technique
(TT), in which vertical releasing incisions are not performed,
provides better nutrition to the area because of the blood sup-
ply provided to the flap and graft. Moreover, the aesthetic
results are considered to develop due to avoiding the
use of vertical incisions and no dissection of the papil-
lae [29]. The TT is reported to provide some advantages
such as reduced patient morbidity and faster and earlier
healing [30–32]. The use of TT and its modifications
for treatment of GR have been reported to provide high-
ly effective and aesthetic results [28, 29].
Clin Oral Invest (2021) 25:6347–6356
To the best of our knowledge, this is the first study which
compares CGF and CTG in terms of root coverage efficiency
using TT. The aim of this study was to evaluate the success of
CGF with TT and to compare it with the gold standard CTG in
the treatment of GR.
Materials and methods
Study design
This study was a single-center, parallel-group design, random-
ized controlled clinical study including 40 individuals who
applied to the Department of Periodontology, Bulent Ecevit
University, between October 2017 and July 2018. The study
protocol in accordance with Declaration of Helsinki, as
revisited in 2000, was approved by Clinical Research Ethics
Committee of University with the protocol number 2017-82-
09/08 (ClinicalTrials.gov ID: NCT04561947).
Sample size calculation
Data in two studies were used as guide to estimate sample size
calculation [33, 34]. According to difference in root coverage
of 1±0.9 mm (80% power which is equal β = 0.20 type II error
level with 5% type I error level which is equal α = 0.05
probability level), 14 participants in every group were needed.
In addition to these 14 participants, six more were recruited for
each group to make up for any potential withdrawals.
Investigator calibration
The investigator calibration was provided to determine the
repeatability of clinical measurements made by the researcher.
For this purpose, clinical measurements were made twice at an
interval of 72 h in 20 defects of 5 patients. The repeatability of
the measurements made by the researcher using the correla-
tion coefficient was determined as 90% [7].
Patient population
The inclusion criteria were as follows: (1) age ≥ 18 years; (2)
periodontally and systemically healthy; (3) presence of Miller
Class I or II GR defects in at least two teeth on the buccal
aspect of maxillary or mandibular incisors, canines, and pre-
molars (≥ 2 mm in depth); (4) gingival thickness (GT) ≥
0.8 mm at 2 mm apical from gingival margin; (5) presence
of identifiable cementoenamel junction (CEJ) (step ≤ 1 mm at
the CEJ level and/or presence of a root irregularity/abrasion
with identifiable CEJ was accepted); (6) full-mouth plaque
score (FMPS) and full-mouth bleeding score (FMBS) ≤
20%. The exclusion criteria were as follows: (1) smoking;
(2) contraindications for surgical periodontal treatment; (3)
Clin Oral Invest (2021) 25:6347–6356
presence of recession defects associated with caries, restora-
tion, and deep abrasion; (4) use of systemic antibiotics for any
reason in the last 3 months; (5) pregnant or lactating women.
The study plan was explained to the patients by giving
detailed information about the treatments to be applied before
any procedure, and the informed consent forms were signed.
Four weeks prior to surgery, all patients were given detailed
oral hygiene instructions to modify their oral hygiene habits.
The full-mouth professional tooth cleaning was performed.
The patients were re-evaluated; if they met the inclusion
criteria, they were scheduled for the surgical periodontal treat-
ment. TT + CTG was applied to 20 patients in the control
group (51 defects) and TT + CGF was applied to 20 patients
in the test group (57 defects).
Primary and secondary outcome variables
Complete root coverage (CRC) was established as the primary
outcome variable, while mean root coverage (MRC), GT, gin-
gival recession width (RW), gingival recession depth (RD),
and keratinized tissue width (KTW) were the secondary out-
come variables.
Clinical measurements
FMPS and FMBS were evaluated before the surgery [35, 36].
PD: The distance between the sulcus base and the gingival
margin in the midbuccal aspect of the teeth; CAL: distance
between the sulcus base and the CEJ in the midbuccal aspect
of the teeth; RD: distance between the gingival margin at the
deepest point of recession and the CEJ; RW: horizontal dis-
tance between the mesial and distal margin of the recession
defect at the CEJ; KTW: distance between the gingival margin
and the mucogingival junction; GT: measured midbuccally
from 2 mm apical to the gingival margin with a No. 20 end-
odontic spreader with a rubber stopper and evaluated with a
precision caliper with 0.05 resolution.
The CRC and MRC in the present study were calculated in
the same way as Naik et al.’s study [37]. Acrylic stents were
used to standardize clinical measurements. Clinical measure-
ments were made at baseline and at 6 months by a single blind
investigator (U.B.) using a periodontal probe (UNC-15, Hu-
Friedy, Chicago, IL, USA), guided by previously prepared
acrylic stents. The values obtained were recorded the nearest
0.5 mm.
Surgical technique
All surgeries were performed by the same researcher (B.K.)
using the TT as described by Zuhr et al. [31]. Before the
surgery, temporary suspension points were created with a flu-
id composite at the contact point of the teeth to be treated so as
6349
to advance the flap in the coronal direction and prevent the
collapse of the sutures on the interproximal areas.
The patients were randomly assigned to one of the two
treatment groups by the flip of a coin by an independent third
person immediately before the surgery. After local anesthesia,
the exposed root surfaces were mechanically treated with cu-
rettes (Gracey Curettes, Hu-Friedy, Chicago, IL, USA).
Tunneling knives (Stoma, Emmingen-Liptingen, Germany)
were used to prepare a split-thickness flap and create a con-
tinuous tunnel in the buccal soft tissues, following the
intrasulcular incision with a microblade (69 WS Swann-
Morton, Sheffield, England). Split-thickness flap preparation
was performed beyond the mucogingival junction with
supraperiosteal dissection by placing the tunneling knives to
the soft tissue. This process was repeated by entering through
the sulcus of each tooth. After the elevation of the flap, a
papilla elevator placed under the flap was entered through
the sulcus to mobilize the papilla, the periosteum at the base
of the papilla was cut, and the full-thickness flap was elevated.
Thus, the entire buccal soft tissue complex was mobilized
coronally.
Preparation of CTG and CGF membrane
After the tunnel was prepared, CTG was harvested using the
de-epithelialized graft technique [38]. The epithelial tissue on
the outer surface of the graft was removed with a 15 blade, and
a 1-mm-thick graft was obtained. After the CTG was harvest-
ed, donor site was covered by a hemostatic sponge. The sur-
gical procedure in the test group was prepared as in the control
group. Intravenous blood samples were collected in two tubes
of 10 mL without anticoagulant (Vacuette tubes, Greiner Bio-
One, GmbH, Kremsmunster, Austria) and immediately cen-
trifuged in a CGF centrifuge machine (Medifuge, Silfradent,
S.Sofia, Italy) using a program with the following features:
accelerated for 30 s; centrifuged at 2700 rpm × 2 min, 2400
rpm × 4 min, 2700 rpm × 4 min, and 3000 rpm × 3 min; and
decelerated for 36 s to stop.
After centrifugation, four layers were formed in the tube:
the serum layer at the top, the second buffy coat layer, the third
CGF layer containing GF and unipotent stem cells, and the red
blood cell layer at the bottom [11]. The resulting CGF was
removed from the tube and separated from the red blood cell
layer using microsurgical scissors. CGF was made into a
thickness of 1 mm membrane (Fig. 1) with a special pressing
kit. Both the CTG and CGF membranes were placed horizon-
tally at or 1 mm below the CEJ, and were stabilized with the
monofilament absorbable sutures (PGCL, Katsan 6/0 13 mm
3/8, Izmir, Turkey). The buccal soft tissue complex was
coronally positioned and sutured with a double cross-suture
technique with monofilament nonabsorbable sutures
(Polypropylene, Katsan 5/0 18 mm 3/8, Izmir, Turkey) [39].
6350
Fig. 1 CGF membrane
A nonsteroidal anti-inflammatory drug (ibuprofen 600 mg
twice a day) was prescribed to reduce postoperative pain and
edema. It was recommended to use 0.12% chlorhexidine glu-
conate (CHX) mouthwash three times a day. The sutures were
removed 14 days after the surgery, and plaque control was
provided with CHX for another 2 weeks. Furthermore, the
patients were proposed to gently brush the surgical area using
the roll technique with an ultra-soft toothbrush. They were
regularly invited to control sessions.
Statistical analysis
Statistical evaluation was performed using the SPSS 19.0
program (SPSS Inc., IL, USA). The data were analyzed
in terms of compliance with normal distribution using
the Shapiro-Wilk test. The Mann-Whitney U test was
used to analyze the statistically significant difference be-
tween the medians of the independent groups in the data
that did not fit the normal distribution in terms of nu-
merical variables. Wilcoxon’s signed-rank test was used
to analyze the difference before and after treatment be-
tween groups. Comparison between groups for CRC was
made using the chi-square test. Descriptive statistics were
expressed as mean ± standard deviation. Statistical sig-
nificance was established for p < 0.05.
Clin Oral Invest (2021) 25:6347–6356
Results
The study was completed with 108 defects in 40 patients
(mean age 41.1 ± 9.3; min: 26; max: 63). Furthermore, 51
defects in the TT + CTG group were located at 16 incisors
(11 upper, 5 lower), 15 canines (11 upper, 4 lower), and 20
premolars (12 upper, 8 lower). Fifty-seven defects in the TT +
CGF group were located at 21 incisors (13 upper, 8 lower), 13
canines (9 upper, 4 lower), and 23 premolars (14 upper, 9
lower). Seventy of the defects were located in maxilla (TT +
CTG group: 34, TT + CGF group: 36), whereas 38 of the
defects were in mandible (TT + CTG group: 17, TT + CGF
group: 21). Wound healing was uneventful in both groups
after the treatment, and no complications were encoun-
tered in the recipient site. In 5 patients of the control
group, some postoperative complications, such as post-
operative bleeding (one patient) and pain (four patients),
were reported in the donor site. But these cases did not
require any additional intervention. All patients included
in the study completed the study by regularly participat-
ing in the control sessions (Fig. 2).
At baseline, there was no significant difference in the charac-
teristics of the defects and clinical parameters in the test and
control groups. All parameters except PI, GI, and PD were sta-
tistically different at 6 months compared with the baseline (p <
0.05). Patients achieved good plaque control at 6 months of
evaluation compared with the baseline: PI ≤ 20% and GI = 0
scores. The comparisons between the clinical view of the patients
at baseline and 6 months are shown in Figs. 3, 4, 5, and 6.
PD: No statistically significant difference was found in
both groups during the study period (Table 1).
CAL: In both groups, a significant decrease was achieved
at 6 months compared with the baseline. However, there was
no statistically significant difference in the comparison be-
tween groups (Table 1).
RD and RW: A statistically significant decrease was ob-
served in both test and control groups at 6 months compared
with the baseline (p < 0.05). No difference was observed be-
tween the groups at 6 months compared with the baseline
(Table 1).
KTW: The increase of KTW between baseline and 6
months was statistically significant in both groups (p <
0.05). There was a significant higher value in the control
group compared with the test group (Table 1).
GT: In both groups, there was a significant increase in GT
at 6 months compared with the baseline values (p < 0.05). The
increase in the control group was significantly higher than in
the test group (Table 1).
MRC: MRC was 89.52 ± 16.36% and 76.60 ±
24.10%, respectively, in the control and test groups. A
statistically significant difference was found in favor of
the control group in the intergroup comparison at 6
months (p = 0.004) (Table 2).
Clin Oral Invest (2021) 25:6347–6356
Fig. 2 Consort flow diagram of
the study
CRC: CRC was achieved in 34 (66.7%) of 51 defects in the
control group and 27 (47.4%) of 57 defects in the test group.
The difference between the groups was statistically significant
in favor of the control group (p = 0.043) (Table 2).
Discussion
GFs are bioactive proteins secreted by platelets, which control
wound healing [40]. Clinical outcomes can be improved with
the use of GFs in the treatment of GR [41]. Limited data exist
on the use of CGF, the new-generation PC, in the treatment of
GR compared with the commonly used PRF [8, 42]. This
randomized controlled clinical trial was designed to evaluate
the effectiveness of TT + CGF in the treatment of multiple
Miller Class I/II GR and whether CGF was an alternative
biomaterial to CTG. The results showed that both techniques
were effective in the treatment of GR, but better results were
obtained in the CTG group in terms of KTW, GT, and root
coverage percentages at 6 months.
The results of studies comparing CTG and PC were con-
tradictory. A systematic review evaluating the effects of PC on
surgical periodontal treatment results reported that PC did not
provide a significant benefit in the treatment of GR [43].
Another systematic review showed that the use of PC in
Fig. 3 Control group. a
Preoperative view. b Immediate
postoperative view. c 6 months
postoperative view
6351
addition to GR treatment might have positive effects, shorten-
ing the surgical time in patients requiring large amounts of
CTG, and could be a potential alternative [44]. Many studies
comparing CAF with CTG and PRF suggested that PRF
showed good results for all parameters and could be a success-
ful alternative to the gold standard CTG [45].
A recent meta-analysis reported that PRF used in addition
to CAF surgery was associated with higher percentage of root
coverage, but did not create a significant change in terms of
KTW. Studies comparing CTG and PRF achieved better re-
sults in the CTG group in terms of KTW and percentage of
root coverage, and CTG was a better option in patients with
KTW insufficiency and deficiency [46].
Based on the available information and results, it was still
not possible to clearly conclude about the use of PRF in the
treatment of GR. The variety of results could be explained
considering different PRF properties resulting from different
PRF preparation protocols, process of collecting blood, cell
counts, and concentrations of GFs [47].
Unlike other PCs, CGF is obtained with a centrifuge pro-
tocol at varying speeds in a special centrifuge device (accel-
erated for 30 s; centrifuged at 2700 rpm × 2 min, 2400 rpm × 4
min, 2700 rpm × 4 min, and 3000 rpm × 3 min; and deceler-
ated for 36 s to stop) [11]. The centrifuge devices and proto-
cols used for PRF production vary considerably. The changes
6352
Fig. 4 Test group. a Preoperative
view. b Immediate postoperative
view. c 6 months postoperative
view
to be made in centrifuge speed and time might affect the
PRF’s cell content and number, growth factor, and fibrin ma-
trix directly; change its biological activities; and cause differ-
ences in clinical results [48, 49]. In this respect, it has been
reported that CGF may be more stable and suitable for acquir-
ing predictable results since CGF is obtained with more con-
sistent centrifuge protocols [50].
CTG is still the most suitable graft material in the treatment
of gingival recession. However, it causes increased patient
morbidity [4, 5]. PRF has positive effects on wound healing
in various soft tissue defects and reduces postoperative pain
and discomfort regardless of the type of PRF used [51, 52]. In
addition, it is easy to use and inexpensive, and requires less
time. PRF should be considered a living tissue for natural
guided tissue regeneration rather than just a growth factor–
rich surgical adjuvant [52]. With these advantages, the use
of PRF and/or CGF in treatment of gingival recession may
be effective.
In the present study, MRC and CRC were found to be
89.52% and 66.7%, respectively, in the CTG group and
76.6% and 47.4%, respectively, in the CGF group. The
MRC and CRC values in the TT + CTG group in this study
were compatible with the recent systematic review [53]. In a
study by Bozkurt Dogan et al. [8], MRC and CRC were re-
ported as 86.67% and 45.8%, respectively, in the CAF + CGF
group, with no significant difference between the groups.
They stated that CGF did not provide an additional benefit
in terms of root coverage. Akcan and Unsal [42] in their study
comparing CAF + CTG and CAF + CGF stated the MRC is
52.45% for the CGF group and 72.45% for the CTG group.
They reported that CTG provided superior results in terms of
GT, KTW, and root coverage, but CGF was more preferable
in reducing postoperative pain. According to these results,
although CGF did not improve the outcomes of root coverage,
it is not possible to reach a clear conclusion due to insufficient
clinical evidence. In a case report, multiple Miller Class II GR
were treated with TT + PRF and TT + CTG and followed up
for 45 days, revealing that successful root coverage (90%) was
Fig. 5 Control group. a Preoperative view. b 6 months postoperative view
Clin Oral Invest (2021) 25:6347–6356
achieved with both techniques [54]. In the 6-month results of
their study comparing the modified TT + CTG and the mod-
ified TT + titanium-prepared PRF (T-PRF), Uzun et al. [9]
showed the MRC was 91.06% for T-PRF and 92.04% for
CTG, with no difference between groups. In the 12th month
results of their study, the MRC was reported to be 93.29% for
the T-PRF and 93.22% for the CTG group; the results obtain-
ed at the end of the study period were stable. The MRC and
CRC in the present study were lower than those in their study.
The details of TT in their study indicated that the researchers
used a 3-mm vertical incision in the alveolar mucosa close to
base of the vestibule. No vertical incision was used in the TT
applied in the present study. It was believed that this situation
might directly affect the CRC and MRC. The lower MRC and
CRC in the present study may be related to the different sur-
gical approaches used.
In a study evaluating the effect of CTG thickness on surgi-
cal outcomes, no statistically significant differences were
found between the 1 mm and 2 mm thick groups, but a ten-
dency for improved outcomes in terms of root coverage, GT,
and KTW for 2 mm thick CTG is noted in the third month
[55]. In the treatment of gingival recessions, PRF should be
applied in at least two layers, if possible in three layers, so that
the desired volume is reached [56]. Studies on this subject are
limited. Culhaoğlu et al. [57] obtained much better results
with 4 PRF layers than with 2 PRF layers in terms of root
coverage in the treatment of gingival recessions and found
that the effects of 4 PRF layers and CTG were similar. In
the present study results, this situation might affect obtaining
lower MRC, CRC, and GT values with CGF compared with
CTG. Increasing the layer of CGF can improve these results;
however, further studies testing this hypothesis are needed.
In the current study, the mean KTW increased from 2.10 ±
0.49 to 4.80 ± 0.57 mm in the TT + CTG group and from 2.26
± 0.40 to 2.81 ± 0.56 mm in the TT + CGF group; this increase
was statistically significantly higher in the CTG group. In the
present study, as in previous studies, KTW increased in the
CGF group [8, 42]. Akcan and Unsal [42] demonstrated a
Fig. 6 Test group. a Preoperative view. b 6 months postoperative view
Clin Oral Invest (2021) 25:6347–6356 6353

Table 1 Descriptive statistics of the clinical parameters measured at the increase in the groups in the present study were consistent
baseline and 6 months after the surgery
with previous studies [57–59]. Many GFs released from plate-
Control group (n = 51) Test group (n = 57) p value lets in the natural fibrin matrix of PRF increased KTW by
Mean ± SD Mean ± SD positively affecting the proliferation of gingival/periodontal
fibroblasts [7, 60]. Based on these studies, it is presumed that
PD
CGF, which contains more GFs [11, 22], may have a similar
Baseline 1.42 ± 0.41 1.37 ± 0.26 0.834
effect. The increase in KTW in the CTG group could be ex-
6 months 1.37 ± 0.40 1.26 ± 0.35 0.314
plained by the ability of CTG to induce the keratinization of
p value 0.284 0.103
the epithelium [61].
CAL
In the present study, an increase of 0.94 ± 0.05 mm in the
Baseline 3.96 ± 0.67 3.83 ± 0.56 0.482 CTG group and 0.26 ± 0.09 mm in the CGF group was ob-
6 months 1.64 ± 0.48 1.88 ± 0.59 0.225 served in the GT values, and this increase was found to be
p value 0.000* 0.000* significantly higher in the CTG group. Studies have reported
RD that the use of CGF increases GT significantly [8, 42]. Most
Baseline 2.53±0.66 2.45±0.45 0.805 studies showed that PRF increased GT values, but better re-
6 months 0.26±0.34 0.62±0.57 0.053 sults were obtained in the CTG group [9, 57]. The results of
p value 0.000* 0.000* the present study were compatible with previous studies. The
RW increase in GT with PRF might be due to the proliferative
Baseline 3.56±0.51 3.37±0.37 0.222 effect of GFs on gingival/periodontal fibroblasts or the space
6 months 1.14±0.99 1.13±1.43 0.585 provided by the PRF membrane with histoconduction [7, 9].
p value 0.000* 0.000* The significant increase in GT in the CTG group compared
KTW with the CGF group may be explained by that CGF does not
Baseline 2.10±0.49 2.26±0.40 0.722 serve as good scaffold supporting the migration of cells from
6 months 4.80±0.57 2.81±0.56 0.000* adjacent tissues.
p value 0.000* 0.000* A meta-analysis reported no difference between CTG and
GT PRF in terms of PD and CAL [46]. In this study, the decrease
Baseline 1.16±0.05 1.19±0.05 0.101 in PD values and the significant increase in CAL obtained in
6 months 2.10±0.10 1.45±0.14 0.000* both groups were compatible with those in other studies [7, 8].
p value 0.000* 0.000* More reliable results could be obtained with the split-
mouth design to minimize the individual differences depend-
CAL, clinical attachment level; GT, gingival thickness; KTW, keratinized
ing on patient. In such a manner, the inter-patient influence on
tissue width; PD, probing depth; RD, recession depth; RW, recession
width post-surgical wound healing could be reduced for both surgi-
Data are expressed as the mean ± standard deviation cal procedures. This study had some limitations. First, this
Wilcoxon signed-rank test study was designed as parallel group, but initial RD, RW,
*
p < 0.05 GT, and KTW values were similar in both groups, minimizing
the negative effect of this factor. In addition, the results of this
study were limited to only short 6 months follow-up period,
statistically significant increase in KTW in the CTG group and patient-related outcomes (such as pain, patient satisfac-
compared with CGF. Many studies reported that the use of tion, and aesthetics) were not evaluated. Another limitation of
CTG increased the KTW more statistically significantly com- this study was that histological analysis was not performed to
pared with PRF, and the use of CTG to increase KTW was a evaluate the regenerative capacity of CGF. Therefore, no com-
more suitable option [46, 57–59]. Thus, the results on KTW ments could be made on the type of tissue formed.

Table 2 Mean and complete root

coverage in the operated patients Control group (n = 51) Test group (n = 57) p value
6 months after the surgery
Mean root coverage 82.52±16.36 76.60±24.10 0.0041*
Complete root coverage 34/51 (66.7%) 27/57 (47.4%) 0.0432*

Data are expressed as the mean ± standard deviation

1
Wilcoxon signed-rank test
2
Chi-square test
*
p < 0.05
6354
Most studies evaluating the use of CGF/PRF for the treat-
ment of gingival recessions CAF was preferred. Future studies
should investigate the effectiveness of CGF/PRF in root cov-
erage when used with other surgical techniques other than the
CAF. The possible effect of different surgical approaches on
the results needs to be evaluated. It may be valuable to com-
pare CGF, which has been stated to have superior properties in
in vitro studies, along with other PCs or regenerative mate-
rials, such as enamel matrix derivate and collagen matrix, in
terms of clinical effectiveness in periodontal plastic surgery.
Conclusion
The results obtained within the limits of this study showed that
CGF, which did not require a second donor site on the palate,
was cost-effective, prevented complications after harvesting
CTG, and did not improve the root coverage as much as
CTG in the treatment of Miller Class I and II GR. CGF could
not serve as a direct alternative biomaterial to the gold stan-
dard CTG. CGF can be applied in cases with contraindication
to CTG harvesting from the palate and in cases where the
patient and clinician want to reduce morbidity, and are willing
to accept less than optimal results. However, this finding is not
sufficient to advocate the true clinical effects of CGF on gin-
gival recession treatment with TT. More studies are needed to
investigate and compare the effectiveness of CGF in terms of
root coverage.
Acknowledgements The authors do not have any financial interest in the
companies whose materials are included in this study.
Author contribution All authors have made substantial contributions to
conception and design of the study. BK contributed to the design of the
study, treated the patients, analyzed the data, and wrote the manuscript
with input from the other author. UB was involved in data collection and
interpretation, and revised it critically. All authors have given final ap-
proval of the version to be published.
Funding This study was supported by the Scientific Research Fund of
Bulent Ecevit University in Zonguldak/TURKEY (Project Number:
2017-62550515-01).
Declarations
Ethics approval All the procedures performed in the study involving
human participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964
Helsinki Declaration and its later amendments or comparable ethical
standards.
Consent to participate Informed consent was obtained from all individ-
ual participants included in the study.
Conflıct of interest The authors declare no competing interests.
Clin Oral Invest (2021) 25:6347–6356
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