{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T02:44:47Z","timestamp":1787021087345,"version":"build-2736575974"},"reference-count":37,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2025,8,14]],"date-time":"2025-08-14T00:00:00Z","timestamp":1755129600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2025,8,14]],"date-time":"2025-08-14T00:00:00Z","timestamp":1755129600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Maxillofac Plast Reconstr Surg"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>\n                      Excessive gingival display is a common and often distressing aesthetic concern among patients. With the increasing emphasis on dental aesthetics, it has become essential to investigate and develop various treatment modalities to address patients\u2019 expectations. Achieving a balanced and attractive smile has therefore become a key challenge for dental practitioners\n                      <jats:italic>worldwide<\/jats:italic>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This study is a single-center, parallel, randomized controlled open-label trial aimed to compare performing lip repositioning surgery (LRS) utilizing carbon dioxide (CO\u2082) laser with conventional scalpel in managing excessive gingival display (EGD) (4\u20136\u00a0mm) with special consideration to lip dimensions, and 20 participants were included in this study setting in the Faculty of Dentistry, 70% females and 30% males, with an average age of 26.4 and 24.8\u00a0years in laser and scalpel groups, respectively, randomly allocated into two groups. All patients fulfilled the study.<\/jats:p>\n                    <jats:p>A partial thickness flap was excised from the vestibule, with both edges of the donor wound closed using sutures; clinical measurements were recorded preoperatively and followed up for 6\u00a0months.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Postoperative pain was significantly reduced in the laser group; both groups demonstrated a significant decrease in gingival display at 6-month post-operation: external upper lip length was significantly longer in the laser group in smile position at 1-month post-operation, and internal upper lip length at rest was significantly longer in the scalpel group at 3-month post-surgery (significance level was set at\n                      <jats:italic>P<\/jats:italic>\n                      \u2009&lt;\u20090.05).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The CO\u2082 laser is an effective, safe, and conservative alternative to the scalpel in performing LRS, offering decreased pain and improved visualization. Adequate training in laser techniques and safety is essential.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Trial registration<\/jats:title>\n                    <jats:p>The study is registered at International Standard Randomized Controlled Trial, registration number ISRCTN.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s40902-025-00475-8","type":"journal-article","created":{"date-parts":[[2025,8,14]],"date-time":"2025-08-14T02:26:53Z","timestamp":1755138413000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Comparison between the surgical scalpel and carbon dioxide laser in managing excessive gingival display using lip repositioning technique: a randomized controlled clinical study"],"prefix":"10.1186","volume":"47","author":[{"given":"Sara","family":"Alkari","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Omar","family":"Hamadah","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steven","family":"Parker","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,8,14]]},"reference":[{"key":"475_CR1","doi-asserted-by":"publisher","unstructured":"de Menezes Borba DB, et al (2024) Comparison of smile attractiveness in cases with gummy smile treated with botulinum toxin and maxillary impaction surgery: A retrospective study. J Cranio-Maxillofac Surg 52:999\u20131005. https:\/\/doi.org\/10.1016\/j.jcms.2024.06.006","DOI":"10.1016\/j.jcms.2024.06.006"},{"key":"475_CR2","doi-asserted-by":"publisher","first-page":"1","DOI":"10.4236\/oalib.1111137","volume":"11","author":"F Bourzgui","year":"2024","unstructured":"Bourzgui F, Khamlich S, Moustahfid Z, Serhier S (2024) Gummy smile and craniofacial typologies in an adolescent population. Open Access Libr J 11(1):1\u201312. https:\/\/doi.org\/10.4236\/oalib.1111137","journal-title":"Open Access Libr J"},{"key":"475_CR3","doi-asserted-by":"publisher","first-page":"15","DOI":"10.18502\/fid.v18i15.6140","volume":"18","author":"P Haddadi","year":"2021","unstructured":"Haddadi P, Zare H, Azadikhah A (2021) Lip repositioning, a solution for gummy smile. Front Dent 18:15. https:\/\/doi.org\/10.18502\/fid.v18i15.6140","journal-title":"Frontiers in Dentistry"},{"key":"475_CR4","doi-asserted-by":"publisher","unstructured":"Brito MLd, Silva MLS, Carvalho BWL, Silva EM Cd, Lira ADLSd (2023) Prevalence and factors associated with gummy smile in adolescents: a cross-sectional analysis. Braz J Oral Sci 22:e230408. https:\/\/doi.org\/10.20396\/bjos.v22i00.8670408","DOI":"10.20396\/bjos.v22i00.8670408"},{"key":"475_CR5","doi-asserted-by":"publisher","first-page":"55","DOI":"10.4103\/2155-8213.113014","volume":"4","author":"MT Oliveira","year":"2013","unstructured":"Oliveira MT, Molina GO, Furtado A, Ghizoni JS, Pereira JR (2013) Gummy smile: A contemporary and multidisciplinary overview. Dent Hypotheses 4:55\u201360. https:\/\/doi.org\/10.4103\/2155-8213.113014","journal-title":"Dental Hypotheses"},{"key":"475_CR6","unstructured":"Brizuela M, Ines D (2023) StatPearls [Internet]. StatPearls Publishing. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK470437\/"},{"key":"475_CR7","doi-asserted-by":"publisher","first-page":"19","DOI":"10.1902\/cap.2012.120051","volume":"4","author":"AS Balasubramaniam","year":"2014","unstructured":"Balasubramaniam AS, Reddy SR, Thomas LJ, Ramakrishnan T, Ambalavanan N (2014) Surgical lip repositioning in two patients undergoing orthodontic treatment, with degree I vertical maxillary excess and short hypermobile upper lip. Clin Adv Periodontics 4:19\u201324. https:\/\/doi.org\/10.1902\/cap.2012.120051","journal-title":"Clin Adv Periodontics"},{"key":"475_CR8","doi-asserted-by":"publisher","first-page":"446","DOI":"10.1111\/jerd.12695","volume":"33","author":"SA dos Santos-Pereira","year":"2021","unstructured":"dos Santos-Pereira SA (2021) Effectiveness of lip repositioning surgeries in the treatment of excessive gingival display: A systematic review and meta-analysis. J Esthet Restor Dent 33:446\u2013457. https:\/\/doi.org\/10.1111\/jerd.12695","journal-title":"J Esthet Restor Dent"},{"key":"475_CR9","doi-asserted-by":"publisher","first-page":"176","DOI":"10.1055\/s-0041-1736380","volume":"10","author":"K Gonzales-Medina","year":"2021","unstructured":"Gonzales-Medina K, Mendoza-Geng A, Vergara-Buenaventura A (2021) The lip repositioning surgery: a review of the technique\u2019s evolution. Eur J Gen Dent 10:176\u2013182. https:\/\/doi.org\/10.1055\/s-0041-1736380","journal-title":"Eur J Gen Dent"},{"key":"475_CR10","doi-asserted-by":"publisher","first-page":"e44","DOI":"10.34172\/jlms.2023.44","volume":"14","author":"M Asnaashari","year":"2023","unstructured":"Asnaashari M, Roudsari MB, Shirmardi MS (2023) Evaluation of the effectiveness of the carbon dioxide (CO2) laser in minor oral surgery: A systematic review. J Lasers Med Sci 14:e44. https:\/\/doi.org\/10.34172\/jlms.2023.44","journal-title":"J Lasers Med Sci"},{"key":"475_CR11","doi-asserted-by":"publisher","unstructured":"Coluzzi DJ, Parker SP (2017) Lasers in Dentistry--Current Concepts. https:\/\/doi.org\/10.1007\/978-3-031-43338-2_4","DOI":"10.1007\/978-3-031-43338-2_4"},{"key":"475_CR12","doi-asserted-by":"publisher","first-page":"1149","DOI":"10.3758\/BRM.41.4.1149","volume":"41","author":"F Faul","year":"2009","unstructured":"Faul F, Erdfelder E, Buchner A, Lang A-G (2009) Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behav Res Methods 41:1149\u20131160. https:\/\/link.springer.com\/article\/10.3758\/brm.41.4.1149","journal-title":"Behav Res Methods"},{"key":"475_CR13","doi-asserted-by":"publisher","first-page":"523","DOI":"10.1111\/jerd.12433","volume":"30","author":"A Alammar","year":"2018","unstructured":"Alammar A, Heshmeh O, Mounajjed R, Goodson M, Hamadah O (2018) A comparison between modified and conventional surgical techniques for surgical lip repositioning in the management of the gummy smile. J Esthet Restor Dent 30:523\u2013531. https:\/\/onlinelibrary.wiley.com\/doi\/abs\/10.1111\/jerd.12433","journal-title":"J Esthet Restor Dent"},{"key":"475_CR14","doi-asserted-by":"publisher","first-page":"5907","DOI":"10.1007\/s00784-021-03896-7","volume":"25","author":"RI Andijani","year":"2021","unstructured":"Andijani RI, Paramitha V, Guo X, Deguchi T, Tatakis DN (2021) Lip repositioning surgery for gummy smile: 6-month clinical and radiographic lip dimensional changes. Clin Oral Investig 25:5907\u20135915. https:\/\/doi.org\/10.1007\/s00784-021-03896-7","journal-title":"Clin Oral Investig"},{"key":"475_CR15","doi-asserted-by":"publisher","first-page":"e088","DOI":"10.5435\/JAAOSGlobal-D-17-00088","volume":"2","author":"DA Delgado","year":"2018","unstructured":"Delgado DA, et al (2018) Validation of digital visual analog scale pain scoring with a traditional paper-based visual analog scale in adults. JAAOS Global Res Rev 2:e088. https:\/\/doi.org\/10.5435\/JAAOSGlobal-D-17-00088","journal-title":"JAAOS Glob Res Rev"},{"key":"475_CR16","doi-asserted-by":"publisher","first-page":"e99485","DOI":"10.1371\/journal.pone.0099485","volume":"9","author":"P Kersten","year":"2014","unstructured":"Kersten P, White PJ, Tennant A (2014) Is the pain visual analogue scale linear and responsive to change? An exploration using Rasch analysis. PLoS One 9:e99485. https:\/\/journals.plos.org\/plosone\/article?id=10.1371\/journal.pone.0099485","journal-title":"PLoS ONE"},{"key":"475_CR17","unstructured":"Osunde O, Adebola R, Omeje U (2011) Management of inflammatory complications in third molar surgery: a review of the literature. Afr Health Sci 11.  https:\/\/www.ajol.info\/index.php\/ahs\/article\/view\/73446"},{"key":"475_CR18","unstructured":"Kasapo\u011flu \u00c7, Brki\u0107 A, G\u00fcrkan-K\u00f6seo\u011flu B, Ko\u00e7ak-Berbero\u011flu Hl (2013) In: A Textbook of Advanced oral and Maxillofacial surgery. IntechOpen. https:\/\/www.intechopen.com\/chapters\/44949"},{"key":"475_CR19","doi-asserted-by":"publisher","first-page":"1107","DOI":"10.4103\/njcp.njcp_1700_21","volume":"25","author":"B Konuk","year":"2022","unstructured":"Konuk B, \u015eent\u00fcrk M (2022) Three-Dimensional evaluation of the effect of platelet-rich fibrin on edema in lower impacted third molar surgery performed with piezosurgery. Niger J Clin Pract 25:1107\u20131114. https:\/\/journals.lww.com\/njcp\/fulltext\/2022\/25070\/Three_Dimensional_Evaluation_of_the_Effect_of.20.aspx","journal-title":"Niger J Clin Pract"},{"key":"475_CR20","doi-asserted-by":"publisher","first-page":"162","DOI":"10.4103\/1735-3327.86031","volume":"8","author":"F Sortino","year":"2011","unstructured":"Sortino F, Cicci\u00f9 M (2011) Strategies used to inhibit postoperative swelling following removal of impacted lower third molar. Dent Res J 8:162. https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC3221082\/","journal-title":"Dent Res J"},{"key":"475_CR21","doi-asserted-by":"publisher","first-page":"25","DOI":"10.1007\/s10103-011-1024-9","volume":"28","author":"GE Romanos","year":"2013","unstructured":"Romanos GE, et al (2013) Oral mucosa response to laser patterned microcoagulation (LPM) treatment. An animal study. Lasers Med Sci 28:25\u201331. https:\/\/link.springer.com\/article\/10.1007\/s10103-011-1024-9","journal-title":"Lasers Med Sci"},{"key":"475_CR22","doi-asserted-by":"publisher","first-page":"75","DOI":"10.1089\/pho.2008.2353","volume":"28","author":"I Tuncer","year":"2010","unstructured":"Tuncer I, \u00d6z\u00e7ak\u0131r-Tomruk C, \u015eencift K, \u00c7\u00f6lo\u011flu S (2010) Comparison of conventional surgery and CO2 laser on intraoral soft tissue pathologies and evaluation of the collateral thermal damage. Photomed Laser Surg 28:75\u201379. https:\/\/www.liebertpub.com\/doi\/abs\/10.1089\/pho.2008.2353","journal-title":"Photomed Laser Surg"},{"key":"475_CR23","doi-asserted-by":"publisher","first-page":"1088","DOI":"10.1016\/j.jcms.2021.06.006","volume":"49","author":"FJD de Oliveira","year":"2021","unstructured":"de Oliveira FJD, Brasil GMLC, Soares GPA, Paiva DFF, de Souza J\u00fanior FdA (2021) Use of low-level laser therapy to reduce postoperative pain, edema, and trismus following third molar surgery: A systematic review and meta-analysis. J Cranio-Maxillofac Surg 49:1088\u20131096. https:\/\/www.sciencedirect.com\/science\/article\/pii\/S101051822100158X","journal-title":"Journal of Cranio-Maxillofacial Surgery"},{"key":"475_CR24","doi-asserted-by":"publisher","first-page":"110","DOI":"10.4103\/njcp.njcp_77_21","volume":"25","author":"A Martinez-Martinez","year":"2022","unstructured":"Martinez-Martinez A, Molinares-Villa C, Diaz-Caballero A (2022) Use of diode laser for lip repositioning, evolution of the conventional technique. A case report. Niger J Clin Pract 25:110\u2013113. https:\/\/journals.lww.com\/njcp\/fulltext\/2022\/25010\/use_of_diode_laser_for_lip_repositioning,.18.aspx","journal-title":"Niger J Clin Pract"},{"key":"475_CR25","doi-asserted-by":"publisher","first-page":"164","DOI":"10.4103\/jisp.jisp_411_16","volume":"21","author":"S Farista","year":"2017","unstructured":"Farista S, Yeltiwar R, Kalakonda B, Thakare KS (2017) Laser-assisted lip repositioning surgery: novel approach to treat gummy smile. J Indian Soc Periodontol 21:164\u2013168. https:\/\/journals.lww.com\/jisp\/fulltext\/2017\/21020\/laser_assisted_lip_repositioning_surgery__novel.17.aspx","journal-title":"J Indian Soc Periodontol"},{"key":"475_CR26","doi-asserted-by":"publisher","first-page":"e22","DOI":"10.34172\/jlms.2022.22","volume":"13","author":"PRB Florez","year":"2022","unstructured":"Florez PRB, Guzm\u00c3 JA (2022) Laser-Assisted Lip Repositioning Surgery: A Modification to The Conventional Technique: Laser-Assisted Lip Repositioning Surgery. J Lasers Med Sci 13:e22\u2013e22. https:\/\/journals.sbmu.ac.ir\/jlms\/article\/view\/35404","journal-title":"Journal of Lasers in Medical Sciences"},{"key":"475_CR27","unstructured":"Suh J-J, Lee J, Park J-C, Lim H-C (2020) Lip Repositioning Surgery Using an Er, Cr: YSGG Laser: A Case Series. Int J Periodontics Restor Dent 40. https:\/\/search.ebscohost.com\/login.aspx?direct=true&profile=ehost&scope=site&authtype=crawler&jrnl=01987569&AN=142568029&h=W0c4eKpxah%2FxbvT2FH0zUvyAbA%2BOgorfhTpln3zL1GLs7P3Hx53UboqujQANXKQQVaLjC8FeUA13x77E%2Fm7%2FQA%3D%3D&crl=c"},{"key":"475_CR28","doi-asserted-by":"publisher","first-page":"e277","DOI":"10.1097\/SCS.0000000000001285","volume":"26","author":"Z Huang","year":"2015","unstructured":"Huang Z (2015) The application of a carbon dioxide laser in the treatment of superficial oral mucosal lesions. J Craniofac Surg 26:e277\u2013e279. https:\/\/journals.lww.com\/jcraniofacialsurgery\/FullText\/2015\/05000\/The_Application_of_a_Carbon_Dioxide_Laser_in_the.157.aspx","journal-title":"J Craniofac Surg"},{"key":"475_CR29","first-page":"664","volume":"120","author":"V Suter","year":"2010","unstructured":"Suter V, Altermatt HJ, Sendi P, Mettraux G, Bornstein MM (2010) CO2 and diode laser for excisional biopsies of oral mucosal lesions. A pilot study evaluating clinical and histopathological parameters. Schweiz Monatsschr Zahnmed 120:664\u2013671. https:\/\/europepmc.org\/article\/med\/21038754","journal-title":"Schweizer Monatsschrift fur Zahnmedizin= Revue mensuelle suisse d\u2019odonto-stomatologie= Rivista mensile svizzera di odontalgia e stomatologia"},{"key":"475_CR30","doi-asserted-by":"publisher","first-page":"282","DOI":"10.1097\/ID.0b013e3182885fcc","volume":"22","author":"GE Romanos","year":"2013","unstructured":"Romanos GE, Gupta B, Yunker M, Romanos EB, Malmstrom H (2013) Lasers use in dental implantology. Implant Dent 22:282\u2013288. https:\/\/journals.lww.com\/implantdent\/fulltext\/2013\/06000\/lasers_use_in_dental_implantology.15.aspx","journal-title":"Implant Dent"},{"issue":"3","key":"475_CR31","doi-asserted-by":"publisher","first-page":"290","DOI":"10.4103\/jisp.jisp_548_18","volume":"23","author":"A Ramesh","year":"2019","unstructured":"Ramesh A, Vellayappan R, Ravi S, Gurumoorthy K (2019) Esthetic lip repositioning: A cosmetic approach for correction of gummy smile\u2013A case series. J Indian Soc Periodontol 23:290\u2013294. https:\/\/journals.lww.com\/jisp\/fulltext\/2019\/23030\/esthetic_lip_repositioning__a_cosmetic_approach.18.aspx","journal-title":"Journal of Indian Society of Periodontology"},{"key":"475_CR32","doi-asserted-by":"publisher","DOI":"10.1097\/GOX.0000000000005521","volume":"12","author":"N Adel","year":"2024","unstructured":"Adel N (2024) Modified lip repositioning surgery with and without dual-layered suturing for treatment of gummy smile patients. Plast Reconstr Surg Glob Open 12:e5521. https:\/\/journals.lww.com\/prsgo\/fulltext\/2024\/01000\/modified_lip_repositioning_surgery_with_and.40.as","journal-title":"Plastic and Reconstructive Surgery-Global Open"},{"key":"475_CR33","doi-asserted-by":"publisher","first-page":"355","DOI":"10.4103\/jisp.jisp_65_20","volume":"25","author":"S Farista","year":"2021","unstructured":"Farista S, Chaudhary A, Manohar B, Farista S, Bhayani R (2021) Modified laser-assisted lip repositioning surgery to treat gummy smile. J Indian Soc Periodontol 25:355\u2013359. https:\/\/journals.lww.com\/jisp\/fulltext\/2021\/25040\/modified_laser_assisted_lip_repositioning_surgery.17.aspx","journal-title":"J Indian Soc Periodontol"},{"issue":"1","key":"475_CR34","doi-asserted-by":"publisher","first-page":"49","DOI":"10.4103\/ijds.ijds_150_21","volume":"15","author":"S Ghumman","year":"2023","unstructured":"Ghumman S, et al (2023) Laser Assisted Modified Lip Repositioning Surgery for the Treatment of Excessive Gingival Display Using YV Plasty: A Case Report. Indian J Dent Sci 15:49\u201353. https:\/\/journals.lww.com\/ijds\/fulltext\/2023\/15010\/Laser_Assisted_Modified_Lip_Repositioning_Surgery.10.aspx","journal-title":"Indian J Dent Sci"},{"key":"475_CR35","doi-asserted-by":"publisher","first-page":"84","DOI":"10.1016\/j.sdentj.2023.08.011","volume":"36","author":"A Dawadi","year":"2024","unstructured":"Dawadi A, Humagain M, Lamichhane S, Sapkota B (2024) Clinical and psychological impact of lip repositioning surgery in the management of excessive gingival display. Saudi Dent J 36:84\u201390. https:\/\/doi.org\/10.1016\/j.sdentj.2023.08.011","journal-title":"Saudi Dent J"},{"key":"475_CR36","doi-asserted-by":"crossref","unstructured":"S B, A Z, D AS (2024) Lip repositioning surgery: a simple smile and life transformation procedure. Case Rep Dent 2024:6156806. https:\/\/onlinelibrary.wiley.com\/doi\/abs\/10.1155\/2024\/6156806","DOI":"10.1155\/2024\/6156806"},{"key":"475_CR37","unstructured":"Rosenblatt A, Simon Z (2006) Lip repositioning for reduction of excessive gingival display: a clinical report. Int J Periodontics Restor Dent 26. https:\/\/www.bauersmiles.com\/wp-content\/uploads\/2013\/03\/Lip-repositioing-Ziv.pdf"}],"container-title":["Maxillofacial Plastic and Reconstructive Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s40902-025-00475-8.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s40902-025-00475-8\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s40902-025-00475-8.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,9]],"date-time":"2025-09-09T13:05:26Z","timestamp":1757423126000},"score":1,"resource":{"primary":{"URL":"https:\/\/jkamprs.springeropen.com\/articles\/10.1186\/s40902-025-00475-8"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8,14]]},"references-count":37,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["475"],"URL":"https:\/\/doi.org\/10.1186\/s40902-025-00475-8","relation":{},"ISSN":["2288-8586"],"issn-type":[{"value":"2288-8586","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,8,14]]},"assertion":[{"value":"15 June 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"31 July 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"14 August 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The study was registered at the International Standard Randomized Controlled Trial, registration number ISRCTN11661014.(\n                      \n                      ).This study was conducted as a randomized clinical trial, in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Damascus University (date:9\/5\/2022\/No.: 2609).Written informed consent was obtained from all participants prior to their inclusion in the study.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"It is contained in the ethical approval granted by the ethics committee of the university; no personal or clinical details of the participants compromise anonymity so that no further consent for publication from patients is required.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"20"}}