Received: 5 April 2022 | Revised: 12 September 2022 | Accepted: 3 November 2022

DOI: 10.1002/cre2.693

ORIGINAL ARTICLE

Effectiveness of using platelet‐rich fibrin to increase

keratinized tissue around the tooth in the modified apical
reposition flap method: A split‐mouth, randomized
controlled trial

Parviz Torkzaban1 | Nazli Rabienejad1 | Zahra Cheraghi2 |

1
Kamran Lahoorpoor

1
Department of Periodontology, Faculty of
Dentistry, Hamadan University of Medical
Sciences, Hamadan, Iran
2
Department of Epidemiology, Hamadan
University of Medical Science, Hamadan, Iran
Correspondence
Kamran Lahoorpoor, Department of
Periodontology, Faculty of Dentistry,
Hamadan University of Medical Sciences,
Shahid Fahmideh Blvd., Pazhohesh Sq,
Hamadan 6517838695, Iran.
Email: drkamranor2@gmail.com
Funding information
Vice Chancellor for Research and Technology,
Hamadan University of Medical Sciences
Abstract
Objectives: One of the simplest methods to increase keratinized gingiva is the
modified apically repositioned flap (MARF) technique. In this method, the
periosteum remains exposed, which may lead to postoperative pain and discomfort.
In the presence of bone dehiscence, bone resorption and gingival recession may
occur. Hence, this study aims to use platelet‐rich fibrin (PRF) to promote wound
healing in the MARF technique and overcome its disadvantages.
Material and Methods: In this randomized controlled trial study, 10 patients (six
males and four females with a mean age of 33.9 ± 11.13) with less than 2 mm of
attached gingiva bilaterally were treated by the MARF + PRF membrane (test group),
on the one hand, whereas, on the other hand, it was treated only by MARF (control
group). Clinical parameters of keratinized gingiva include thickness, width, and
vestibule depth before and 8 weeks after the intervention were measured.
Results: The attached gingival width increased significantly in both groups (1.7 mm in
the MARF and 2.3 mm in the PRF) and this was greater in the PRF group (p < .05).
Gingival thickness in the PRF method was significantly higher than in the control
group (p < .05). Probe depth, vestibular depth, and postoperative pain were not
different in both groups. Wound shrinkage in the MARF group (51%) was
significantly higher than in the PRF group (30%) (p < .05).
Conclusion: Using PRF with the MARF method significantly increased the width and
thickness of the gingiva and reduced shrinkage compared to MARF only.
Postoperative pain and vestibular depth changes were similar in both groups.

KEYWORDS
attached gingiva, MARF, PRF

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2022 The Authors. Clinical and Experimental Dental Research published by John Wiley & Sons Ltd.

36 | wileyonlinelibrary.com/journal/cre2 Clin Exp Dent Res. 2023;9:36–44.


TORKZABAN ET AL.
1 | INTRODUCTION
Gingiva is the part of oral mucosa that covers the alveolar processes of
jaws and surrounds the neck of the teeth. The gingiva is divided
anatomically into marginal (unattached), attached, and interdental areas
(Newman et al., 2020). The attached gingiva contains a keratinized
epithelium and, along with the dense bundles of collagen fibers that are
firmly inserted into the cementum and/or into the underlying bone,
serves as an effective barrier. The attached gingiva is very important for
maintaining the health and hygiene of teeth and implants. The keratinized
gingiva is the part of the oral mucosa that covers the gingiva and hard
palate. It extends from the free gingival margin to the mucogingival
junction and consists of the free gingiva as well as the attached gingiva.
The width of the keratinized gingiva includes marginal and attached
gingiva and differs in different areas of the mouth (Newman et al., 2020).
Various authors consider at least 2 mm of keratinized gingiva around the
teeth to be necessary to maintain periodontal health (Lang & Löe, 1972;
Miyasato et al., 1977; Wennström et al., 1982). Gingival biotype was
associated with age, gender, and keratinized gingival width (Kiani
et al., 2021). Numerous studies have shown the negative effect of the
absence of attached gingiva on plaque accumulation (Adibrad et al., 2009;
Chung et al., 2006; Zigdon & Machtei, 2008). Other studies reported
plaque accumulation, increased pocket depth, increased bleeding on
probing, gingival resorption, and even marginal bone loss (Bouri
et al., 2008; Boynueğri et al., 2013; Schrott et al., 2009). Alveolar bone
loss, muscle and frenum attachments, and shallow vestibule are the
causes of keratinized tissue deficiency (Stimmelmayr et al., 2011). Several
methods have been introduced to increase the width of the attached
gingiva around teeth and implants. One of the basic methods to increase
the width of keratinized tissue is the apically repositioned flap, which was
introduced by Friedman (1962). In this method, the mucoperiosteal flap
with the adherent gingival tissue is moved to its apical position by two
vertical incisions and fixed by sutures. The bone remains denuded and the
wound would heal by means of secondary‐intention healing
(Friedman, 1962). Due to the denudation of the coronal bone in the
range of 3–5 mm, the risk of bone resorption was high. The main
limitation of this technique was its side effects on the patient, including
pain, bleeding, and bone resorption (Matter, 1982; Staffileno, 1969).
Alternatives have been suggested. Free gingival grafting (FGG), double
papillary flap, and modified apically repositioned flap (MARF) are among
these (Staffileno, 1969). MARF was introduced by Carnio in 1999 to
increase attached gingiva for a single tooth (Carnio & Miller, 1999) and in
2006 for several teeth (Carnio & Camargo, 2006). In this technique, the
periosteum remains exposed instead of the bone. The advantages of this
method are simplicity, minimal patient discomfort, and high color
matching (Carnio & Camargo, 2006).
In this method, a horizontal incision is performed in the attached
gingiva and a split‐thickness flap is raised and sutured apically. The
periosteum remains exposed, the granulation tissue forms on top of the
wound, and eventually, the keratinized tissue will mature. Leaving the
periosteum naked may lead to postoperative pain and discomfort. In the
presence of bone dehiscence, marginal bone resorption and gingival
recession may occur, which is a contraindication of this technique.
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| 37
On the other hand, the patient's platelet derivatives have
been used for many years to accelerate wound healing. Various
generations have been introduced to date, the most widely used
of which is the platelet‐rich fibrin (PRF) membrane (Choukroun
et al., 2006a). Due to the disadvantages of the apical reposition-
ing flap technique, to reduce or overcome the disadvantages of
this technique, we utilized the PRF membrane as a biological
dressing. The rationale for using PRF in this method is to release
growth factors and accelerate wound healing so that the under-
lying bone will not be remodeled. PRF acts as a biological
dressing. Therefore, this study aims to use the PRF membrane as
an adjunct to the MARF to reduce pain, swelling, resorption, and
also to increase the width of the attached gingiva compared to
the MARF technique.
2 | M A T E R I A L S AN D M E T H O D S
2.1 | Study design
This study was designed as a randomized controlled trial with a split‐
mouth design. To participate in the study, the following inclusion and
exclusion criteria need to be fulfilled. This study was done to evaluate
the clinical results of using PRF in combination with MARF to
increase the attached gingiva around the teeth.
2.1.1 | Inclusion criteria
Inclusion criteria in the study were: patients with less than 2 mm of
attached gingiva at the buccal site; less than 5 mm of vestibular depth
(VD); and the presence of high frenum pull bilaterally in the mandible.
2.1.2 | Exclusion criteria
Exclusion criteria were systemic diseases, pregnancy and lactation,
smoking, alcohol use, plaque index >20%, gingival recession Class 3
or 4 Miller, and PPD >5 mm.
Patients were invited to participate in the study after being
fully informed. Informed consent was obtained from all partici-
pants. The study was approved by the Ethical Committee of the
Hamadan University of Medical Science. The approval ID is
IR.UMSHA.REC.1400.114.
2.2 | Participants and randomization
The present study was performed in the periodontics department of
the Dentistry School of Hamadan University of Medical Sciences
from May to September 2021; 10 people who had less than 2 mm of
attached gingiva and needed soft tissue augmentation on both sides
were selected.
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38 | TORKZABAN ET AL.

The sample size was determined based on the assumption that the
test group (MARF + PRF) and the control group (MARF) were equal.
Mean and standard deviation indices were extracted from a similar study
by Temmerman et al. (2018) The confidence level was set at 95%, the
desired sample power was 80%, using Stata (StataCorp. 2015. Stata
Statistical Software: Release 14. College Station, TX: StataCorp LP.), and
the sample size was determined to be 10 patients.
Each lower jaw was divided into two segments. Each side was
randomized as control or test groups in a split‐mouth design, via a
randomization table by a computer‐generated randomization list
(STATA version 11). The treatment codes (test/control) were
available in closed envelopes, which were sealed and opened just
before the surgery by the surgeon. Blindness was not possible due to
the nature of the procedure, and both the patient and the surgeon
were informed about the treatment modality.
2.3.1 | Control group (MARF)
A horizontal incision was made by a blade (no. 15) approximately 0.5 mm
coronal to the mucogingival junction. The split‐thickness flap was
elevated and the dissection was extended 5 mm in an apical direction.
The coronal part of the flap would contain a band of keratinized tissue.
The extension of the incision depends on the teeth involved so that at
least one and a half teeth are extended on each side (mesiodistal). This
extension allows the flap to be repositioned apically. The flap is sutured to
the periosteum in the apical position by resorbable sutures (Vycril® 4.0;
ETHICON, Cincinnati, Ohio, USA). A homogeneous layer of periosteum
with no elastic or fibers remained on the bone. A periodontal dressing
without eugenol (COE‐PAK™; GC Corporation, Alsip, Illinois, USA) was
used on top to protect the wound (Figure 1).

2.3.2 | Test group (PRF)

2.3 | Surgical procedures
Chlorhexidine 0.2% was used for rinsing the oral cavity before
surgery. Local anesthesia (lidocaine 2% with epinephrine 1:80,000)
was performed in the buccal area of the premolars by mental nerve
block.
Patient's blood was collected into 10 ml sterile silica‐coated plastic tubes
without anticoagulants (VACUETTE; Greiner Bio‐OneOne GmbH,
Kremsmünster, Austria). At least two tubes were prepared, and the
tubes were centrifuged immediately in a fixed‐angle centrifuge (Arman
Teb Noor, Iran, Tabriz). According to studies by R. Miron et al. (2018) and

F I G U R E 1 (a) Preoperative view. The first premolars with an attached gingiva width less than 2 mm. (b) A horizontal incision half a millimeter
above the mucogingival junction line, with one‐and‐a‐half tooth extension. (c) Absorbable suture is used to secure the flap in the apical position.
(d) Placement of periodontal dressing to protect the wound. (e) Eight weeks postop.

TORKZABAN ET AL.
R. J. Miron et al. (2019a) to obtain a relative gravity force of 400 g relative
centrifugal force (RCF) clot and device specifications (rotor angulation:
30° and radius at the clot: 60 mm), the centrifuge speed was considered
to be 2400 rpm. PRF clots and membranes were prepared in the same
manner as described by Choukroun et al. (2006a). The PRF clots are
placed in their special container to be compressed and in the form of a
membrane.
The MARF was done exactly as mentioned before. Several layers
of PRF membranes (two or three layers) were placed on the exposed
periosteum and were fixed by sutures around the teeth and finally
dressed with a periodontal dressing (COE‐PAK™; GC Corporation,
Alsip, Illinois, USA) (Figure 2).
All patients were prescribed 0.2% chlorhexidine mouthwash twice a
day for 4 weeks, and ibuprofen 400 mg four times a day or as needed.
The periodontal dressing and sutures were removed after 1 week. The
patient was prohibited from doing any mechanical cleaning in the surgical
area such as brushing and flossing for 4 weeks (Carnio et al., 2020).
2.4 | Primary outcomes: Width and thickness
of keratinized tissue
The patient's oral cavity was examined by a specialist with Williams
Probe (Hu‐Friedy; Chicago, USA) to evaluate the clinical parameters.
F I G U R E 2 (a) Preoperative view. The first premolars with an attached gingiva width of less than 2 mm. (b) A horizontal incision half a
millimeter above the mucogingival junction line, with one‐and‐a‐half tooth extension. (c) Absorbable suture is used to secure the flap in the
apical position. (d) Placing and securing three layers of platelet‐rich fibrin membrane to the periosteum. (e) Periodontal dressing to protect the
wound. (f) Eight weeks postop.
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| 39
The evaluated parameters such as probing pocket depth (PPD),
keratinized tissue width, VD, and gingival thickness (GT) were
measured at the baseline, and after 8 weeks. GT measurements
were taken using an endodontic spreader (#30) from 2 mm of the
buccal gingival margin as shown in Figure 3 under local anesthesia
(Kolte et al., 2014).
2.5 | Secondary outcomes: Postoperative pain and
wound shrinkage
A secondary objective of the study was to assess postoperative pain.
A visual analog score (VAS) questionnaire was used to evaluate the
amount of pain, ranging from 0 (no pain) to 10 (worst pain), and the
patients were asked to fill out the questionnaire on the VAS scales on
the day after surgery.
To assess the wound shrinkage, the amount of apical placement
of the flap at the surgery was compared to the newly attached
gingiva gained after 8 weeks. Wound shrinkage was calculated as
follows:
apically displacement (in mm) − new attached
gingiva gained (in mm) (1)
× 100.
apically displacement
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40 | TORKZABAN ET AL.

2.6 | Statistical analysis 3 | RESULT

The data were checked for normality in distribution using a
normal quantile plot. The confidence level was determined
at 95%. The patient was used as a statistical unit. After a
rejection of normality, a paired t‐test was used. The level of
significance was set at .05.
FIGURE 3 Preoperative measurement of gingival thickness
Ten patients participated in this trial. The mean age was 33.9 ± 11.1
years old and the male/female ratio was 6:4. None of the subjects
dropped out during the 8‐week follow‐up. One side of each patient
was randomly assigned to the test (MARF + PRF) or control (MARF)
group, while the contralateral side was assigned to the other group. A
flow diagram of the study participants is provided (Figure 4).
PPD at baseline and follow‐up were almost the same and there
was no difference in either group.
At baseline, the average width of the attached gingiva was
1.15 ± 0.52 for the test group and 0.8 ± 0.82 for the control group. The
mean increase in the attached gingiva after 8 weeks was 1.7 mm in the
MARF group and 2.3 mm in the PRF group, which was significantly higher
in the PRF group compared with the MARF group (p < .05).
At baseline GT was 0.79 ± 0.16 and 0.74 ± 0.22 mm for the test and
control groups, respectively. After 8 weeks, the GT was 1.09 ± 0.09 in the
PRF group and 0.86 ± 0.16 mm in the MARF group. GT is increased by
0.11 mm in the MARF group and 0.29 mm in the PRF group, with a
significant statistical difference between those values (p < .05).

FIGURE 4 Flow diagram of the study

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TORKZABAN ET AL. | 41

T A B L E 1 Clinical measurements at
Mean ± SD Group differences
baseline and 8‐week postop (mean ± SD)
Index PRF group MARF group (mean ± SD) p Value
and clinical parameter change (Δ) from
baseline to 8 weeks postop PPD

Baseline 1.9 ± 0.5 1.80.8

Follow‐up 1.9 ± 0.4 1.7 ± 0.9

Δ 0 ± 0.5 0.1 ± 0.9 0.1 ± 0.4 .849

p Value .811 .778

AG

Baseline 1.15 ± 0.52 0.8 ± 0.82

Follow‐up 3.45 ± 0.49 2.5 ± 0.94

Δ 2.3 ± 0.53 1.7 ± 0.97 0.6 ± 0.32 .049

p Value .000 .002

GT

Baseline 0.79 ± 0.16 0.74 ± 0.22

Follow‐up 1.09 ± 0.09 0.86 ± 0.16

Δ 0.29 ± 0.15 0.11 ± 0.17 0.18 ± 0.07 .012

p Value .000 .034

VD

Baseline 4 ± 0.52 4 ± 1.49

Follow‐up 5.9 ± 0.45 5.4 ± 1.41

Δ 1.9 ± 0.65 1.4 ± 1.04 0.5 ± 0.32 .143

p Value .000 .001

Note: Data were assessed with two‐sample t‐tests.

Abbreviations: AG, attached gingiva; GT, gingival thickness; MARF, modified apically repositioned flap;
PPD, probing pocket depth; PRF, platelet‐rich fibrin; VD, vestibular depth.

TABLE 2 Comparison postoperative pain and shrinkage 4 | D IS CU SS IO N

Mean ± SD
Index PRF group MARF group p Value A gingival width of 2 mm is sufficient to maintain healthy gingiva
(Wennstrom & Lindhe, 1983). Lack of attached gingiva tissue along
Postoperative pain 3.20 ± 0.91 3.40 ± 0.69 .295
with inadequate plaque control may lead to a gingival recession
Wound shrinkage 30.90 ± 7.9 51.10 ± 20.30 .003
(Freedman et al., 1992).
Abbreviations: MARF, modified apically repositioned flap; PRF, platelet‐ The apical repositioning flap introduced by Friedman increases
rich fibrin. the risk of bone resorption (Lang & Löe, 1972) and a regional
accelerated phenomenon (Freedman et al., 1992). To overcome the
The VD at baseline and follow‐up are recorded in Table 1. Both problems of the apical repositioning flap, a modified method was
treatment modalities lead to an increase in VD. The VD in the PRF proposed by Carnio and Miller in 1999. The MARF has more
and MARF groups increased by 1.9 and 1.4 mm, respectively. advantages over routine techniques for augmenting attached gingiva.
Although their differences were not significant (p > .05) (Table 1). This technique does not lead to further attachment loss, has
Postoperative pain is assessed by using the VAS questionnaire a day predictable results, causes minimal discomfort to the patient due to
after surgery. The VAS values associated with PRF and MARF groups the lack of the need for a donor site, and prevents gingival recession
were almost the same and were not different in either group (p > .05). compared to the classic apical repositioning flap (Carnio &
Wound shrinkage was measured by comparing the apicocoronal Miller, 1999; Carnio et al., 2007).
dimension of the exposed periosteum with the newly attached In a 1‐ to 11‐year follow‐up study, Carnio et al. (2020) evaluated the
gingiva 8 weeks postop. The wound shrinkage was 51.1% in the potential of creating attached gingiva in areas without keratinized tissue
control group and 30.9% in the test group, which was significantly by MARF flap. Their results showed a significant increase in the width of
higher in the MARF group (Table 2). keratinized tissue and attached gingiva and also showed no increase in

42 | TORKZABAN
probe depth and no gingival recession was observed (Carnio et al., 2020).
Their results were also in line with our results. However, the increase in
thickness and width of the attached gingiva was significantly greater in
the PRF group than in the MARF group.
The MARF and PRF groups resulted in a significant increase in
keratinized tissue. MARF is an effective and efficient method to
increase keratinized tissue and the attached gingival width. The main
limitation of this technique is the presence of at least 0.5 mm of
attached gingiva before surgery so that the wound is surrounded by
keratinized tissue. The presence of bone dehiscence is another
contraindication (Swarna et al., 2019). In the present study, it was
shown that the thickness of tissue after surgery in the PRF method is
significantly higher than in the MARF group. The possible reason is
due to the nature of the PRF membrane, which is a three‐
dimensional fibrin network that allows endothelial cells to proliferate
within. Growth factors such as vascular endothelial growth factor and
insulin‐like growth factor also accelerate angiogenesis (Choukroun
et al., 2006b). The result leads to more vascular and thicker
granulation tissue. The results show that the thickness increased by
an average of 0.29 mm in the PRF group compared to the baseline,
while this amount was reported to be 0.11 mm in the MARF group.
Due to the significant increase in tissue thickness, the presence of
growth factors, and promotion of wound healing, this method can
also be used in cases of bone dehiscence.
Alaood et al. (2020) showed that the use of PRF in the treatment
of gingival recession is not only useful but also has a greater effect on
thickness compared to the control group, which used connective
tissue graft with a coronally advanced flap.
Free gingival grafting is the most common method for increasing
keratinized tissue and attached gingiva (Miller, 1993). The main
disadvantages of FGG over MARF are the use of palatal tissue as a
donor, the possibility of postoperative bleeding, color disparity
between the grafted site and adjacent tissues, and increased
morbidity (Carnio et al., 2015). In the study by Carnio et al. (2020),
the MARF technique was performed in areas without the presence of
keratinized tissue in the mid‐buccal site of the tooth and the results
showed that the apicocoronal dimensions of keratinized and attached
tissue increased significantly. There was no increase in pocket depth
and no marginal gingival recession was reported. These results were
also stable over the long term (Carnio et al., 2020). According to the
findings of this study, after 2 months of follow‐up, keratinized tissue
increased by 1.7 mm in the MARF treatment group and by 2.3 mm in
the PRF treatment group. This increase was significant in either
group, but the PRF group was higher. In both groups, the probing
pocket depth and margin of the gingiva position were not changed.
Temmerman et al. (2018) in a randomized controlled trial
examined the increase in keratinized width around the implant by
using PRF. They tried to increase keratinized tissue, on the one had,
using FGG, and, on the other hand, using an apically repositioned flap
with PRF. The obtained keratinized tissue was significantly higher in
the FGG group than in the PRF group. Also, shrinkage was higher in
the PRF group than in the FGG group. Postoperative pain and
duration of surgery were significantly higher in the FGG group
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ET AL.
(Temmerman et al., 2018). In the present study, the keratinized tissue
obtained in terms of width and thickness in the PRF group had a
significant increase compared to the MARF group.
Postoperative pain was also slightly reported in both groups, with
no significant difference. Inflammation peak and maximum post-
operative pain occur within the first 24 h following surgery. Since the
PRF membrane acts as a biological dressing, it was expected to be
effective in reducing postoperative pain. Several studies demonstrate
that PRF decreases postoperative pain (de Almeida Barros Mourão
et al., 2020; Fujioka‐Kobayashi et al., 2021; Bennardo et al., 2021;
Gülşen & Şentürk, 2017). The possible reasons for this lack of
reduction may be the following: the presence of more periosteal
sutures for fixation of the PRF membranes in the PRF group leads to
more inflammation. Using adhesive dressing can reduce the number
of sutures, so the VAS score may be reduced. Rinsing the mouth with
chlorhexidine has a negative impact on PRF cells (Csönge et al., 2021).
Isolating the PRF membrane with adhesive dressing from oral liquids
or using less aggressive mouthwash may lead to better results.
Another possible reason is using silica‐coated blood collection tubes.
Silica in the tube causes negative effects on periosteal cells (Masuki
et al., 2020), clot formation (R. J. Miron et al., 2020), and regeneration
(Tsujino et al., 2019). To overcome the negative impact of silica, chemical‐
free glass tubes are recommended (R. J. Miron et al., 2021).
In the PRF group, wound shrinkage was significantly lower than
in the MARF group. These values were reported to be 30.9% for the
PRF group and 51.1% for the MARF group. PRF group shrinkage
values are comparable to those of Temmerman et al. (2018).
According to the shrinkage results, for obtaining at least 2 mm of
new keratinized tissue, we suggest a 4 mm apically repositioned flap
in MARF and a 3 mm repositioned flap in the MARF + PRF method.
Recent advances in the field of platelet derivatives lead to the use of
low‐speed centrifugation concept (LSCC) and horizontal centrifugation.
LSCC results in an increased growth factor concentration. Therefore,
enhancing the growth factor concentrations improves the potential of
tissue regeneration and wound healing capacity of the fluid PRF‐based
matrices (Choukroun & Ghanaati, 2018). Horizontal centrifugation was
proposed as a means to better separate blood cell layers for the
production of PRF, and higher concentration of platelets and leukocytes
(R. J. Miron et al., 2019b).
Due to recent improvements in platelet derivatives, further
clinical studies are necessary to evaluate LSCC and horizontal
centrifugation to enhance clinical results.
5 | LIMITATION
This study was limited to the mandibular premolar area due to the
split‐mouth design. Also, a small sample size may be subject to
selection bias. Wound shrinkage will continue for months and the
complete shrinkage assessed needs long‐term follow‐ups. Pain
assessment one day after surgery may lead to bias.
To substantiate our findings, further and multicentered studies
are needed.

TORKZABAN ET AL.
6 | C ONC LUS I ON
Using PRF with the MARF method significantly increased the
width and thickness of the gingiva and reduced shrinkage
compared to MARF without PRF. Postoperative pain scores and
VD changes were similar in the test and control groups.
Increasing the GT may allow PRF to be used in the presence of
bone dehiscence.
A U T H O R C O N TR I B U T I O N S
Torkzaban Parviz: Conceptualization (equal); writing – original draft
(supporting); methodology (equal). Nazli Rabienejad: Conceptualiza-
tion (supporting); writing – original draft (supporting); methodology
(equal). Zahra Cheraghi: Formal analysis (lead) Kamran Lahoorpoor:
Conceptualization (equal); writing – original draft (lead); writing –
review and editing (lead); methodology (equal).
A C KN O W L E D G M E N T S
The authors would like to thank the dental research center and vice
chancellor of research at the Hamadan University of Medical
Sciences for their support. This research was fully funded by the
research center, Hamadan University of Medical Sciences.
CO NFL I CT OF INTERES T
The authors declare no conflict of interest.
D A TA A V A I L A B I L I T Y S T A T E M E N T
The applicant has unlimited access to the data after sending the
request via email to the corresponding author.
ETHICS STATEME NT
The study protocol was registered on the IRCT registry, with
Registration reference: IRCT20211124053173N1.
ORCID
Nazli Rabienejad https://orcid.org/0000-0003-2176-9786
Zahra Cheraghi https://orcid.org/0000-0001-9041-559X
Kamran Lahoorpoor http://orcid.org/0000-0002-2303-5471
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