Effect of Surgical Intervention for Removal of Mandibular Third Molar on Periodontal Healing of Adjacent Mandibular Second Molar: A Systematic Review and Bayesian Network Meta-Analysis.

BACKGROUND: The aim of this systematic review is to evaluate and synthesize scientific evidence on the effect of surgical interventions for removal of mandibular third molar (M3M) on periodontal healing of adjacent mandibular second molar (M2M). METHODS: The protocol was registered at PROSPERO (International Prospective Register of Systematic Reviews) as CRD42012003059. Medline, Cochrane, and EMBASE databases were interrogated to identify randomized controlled trials (RCTs) up to December 22, 2014. Patients with M3Ms fully developed, unilaterally or bilaterally impacted, were considered. Outcomes were clinical attachment level gain (CALg) and probing depth reduction (PDr) with a follow-up ≥ 6 months. Patient-subjective outcomes, such as pain, discomfort, and complications, and financial aspects and chair time, were also explored. A Bayesian network meta-analysis model was used to estimate direct and indirect effects and to establish a ranking of treatments. RESULTS: Sixteen RCTs were included and categorized into four groups investigating the following: 1) regenerative/grafting procedures (10 RCTs); 2) flap design (three RCTs); 3) type of suturing (one RCT); and 4) periodontal care of M2M (two RCTs). Guided tissue regeneration (GTR) with resorbable (GTRr) and non-resorbable (GTRnr) membrane and GTRr with anorganic xenograft (GTRr + AX) showed the highest mean ranking for CALg (2.99, 90% credible interval [CrI] = 1 to 5; 2.80, 90% CrI = 1 to 6; and 2.29, 90% CrI = 1 to 6, respectively) and PDr (2.83, 90% CrI = 1 to 5; 2.52, 90% CrI = 1 to 5; and 2.77, 90% CrI = 1 to 6, respectively). GTRr + AX showed the highest probability (Pr) of being the best treatment for CALg (Pr = 45%) and PDr (Pr = 32%). Direct and network quality of evidence were rated from very low to moderate. CONCLUSIONS: To the best of the authors' knowledge, the present review is the first one to evaluate quantitatively and qualitatively the effect of different interventions on periodontal healing distal to the second molar after extraction of the third molar. GTR-based procedures with or without combined grafting therapies provide some adjunctive clinical benefit compared to standard non-regenerative/non-grafting procedures. However, the overall low quality of evidence suggests a low degree of confidence and certainty in treatment effects. Evidence on variations of surgical M3M removal techniques based on flap design, type of suturing, and periodontal care of M2M is limited both qualitatively and quantitatively.

Surgical treatment of single gingival recessions: clinical guidelines.

PURPOSE: The purpose of this clinical guidelines project was to determine the most appropriate surgical techniques, in terms of efficacy, complications, and patient opinions, for the treatment of buccal single gingival recessions without loss of interproximal soft and hard tissues. METHODS: Literature searches were performed (electronically and manually) for entries up to 28 February, 2013 concerning the surgical approaches for the treatment of gingival recessions. Systematic reviews (SRs) of randomised controlled trials (RCTs) and individual RCTs that reported at least 6 months of follow-up of surgical treatment of single gingival recessions were included. The full texts of the selected SRs and RCTs were analysed using checklists for qualitative evaluation according to the Scottish Intercollegiate Guidelines Network (SIGN) method. The following variables were evaluated: Complete Root Coverage (CRC); Recession Reduction (RecRed); complications; functional and aesthetic satisfaction of the patients; and costs of therapies. RESULTS: Out of 30 systematic reviews, 3 SRs and 16 out of 313 RCTs were judged to have a low risk for bias (SIGN code: 1+). At a short-term evaluation, the coronally advanced flap plus connective tissue graft method (CAF+CTG) resulted in the best treatment in terms of CRC and/or RecRed; in case of cervical abrasion and presence of root sensitivity CAF + CTG + Restoration caused less sensitivity than CAF+CTG. CAF produced less postoperative discomfort for patients. Limited information is available regarding postoperative dental hypersensitivity and aesthetic satisfaction of the patients. CONCLUSION: In presence of aesthetic demands or tooth hypersensitivity, the best way to surgically treat single gingival recessions without loss of interproximal tissues is achieved using the CAF procedure associated with CTG. Considering postoperative discomfort, the CAF procedure is the less painful surgical approach, while the level of aesthetic satisfaction resulted higher after CAF either alone or with CTG. It is unclear how much tooth hypersensitivity is reduced by surgically covering buccal recessions. It is important to note that the present recommendations are based on short-term data (less than 1 year). SOURCE OF FUNDING: The guidelines project was made possible through self-financing by the authors.

Bayesian network meta-analysis of root coverage procedures: ranking efficacy and identification of best treatment.

AIMS: The aim of this work was to conduct a Bayesian network meta-analysis (NM) of randomized controlled trials (RCTs) to establish a ranking in efficacy and the best technique for coronally advanced flap (CAF)-based root coverage procedures. MATERIAL AND METHODS: A literature search on PubMed, Cochrane libraries, EMBASE, and hand-searched journals until June 2012 was conducted to identify RCTs on treatments of Miller Class I and II gingival recessions with at least 6 months of follow-up. The treatment outcomes were recession reduction (RecRed), clinical attachment gain (CALgain), keratinized tissue gain (KTgain), and complete root coverage (CRC). RESULTS: Twenty-nine studies met the inclusion criteria, 20 of which were classified as at high risk of bias. The CAF+connective tissue graft (CTG) combination ranked highest in effectiveness for RecRed (Probability of being the best = 40%) and CALgain (Pr = 33%); CAF+enamel matrix derivative (EMD) was slightly better for CRC; CAF+Collagen Matrix (CM) appeared effective for KTgain (Pr = 69%). Network inconsistency was low for all outcomes excluding CALgain. CONCLUSION: CAF+CTG might be considered the gold standard in root coverage procedures. The low amount of inconsistency gives support to the reliability of the present findings.