Complementary and alternative therapies for managing postoperative pain after lower third molar surgery: a systematic review and network meta-analysis.

OBJECTIVE: The objective of this study was to evaluate the impact of complementary and alternative treatments on postoperative pain following lower third molar surgeries. METHODS: A comprehensive search of Electronic databases (Embase, MEDLINE via PubMed, and Cochrane Library) and grey literature was conducted up until May 2022. Randomized clinical trials investigating the effect of acupuncture, ozone therapy, laser (LLLT), drainage tube, kinesio-taping, ice therapy, and compressions on pain after LTM surgeries were included. The estimated mean differences (MD) for alternative therapies were pooled using the frequentist approach to random-model network meta-analysis NMA. RESULTS: Eighty-two papers were included in the qualitative analysis; 33 of them were included in the quantitative analyzes. NMA revealed that drainage tube and kinesio-taping were superior in controlling pain 24-hours postoperatively than no-treatment. At 48-hours follow-up, kinesio-taping and LLLT more effective than placebo and drainage tube; and kinesio-taping and LLLT were superior to no treatment. At 72 h postoperatively, ozone therapy was superior to placebo; and drainage tube, kinesio-taping, and LLLT were better than no treatment. At 7-days follow-up, ozone and LLLT were superior to placebo; and LLLT and kinesio-taping were superior to no treatment. The SUCRA-ranking placed drainage tube as top-ranking intervention at 48-hours (98.2%) and 72-hours (96%) follow-ups, and ozone (83.5%) at 7-days follow-up. CONCLUSION: The study findings suggest that these alternative and complementary therapies may be useful in reducing postoperative pain after LTM surgeries, and may offer advantages when combined to traditional pain management methods. CLINICAL RELEVANCE: Non-pharmacological therapies are gaining popularity among healthcare professionals and patients. This study found that some of these therapies, specifically kinesio-taping and drainage tube were effective in controlling postoperative pain after third molar surgeries. These findings have important implications for clinical practice, as they highlight the potential benefits of incorporating these therapies into postoperative pain management plans.

The role of tryptophan and its derivatives in musculoskeletal pains: A systematic review and meta-analysis.

BACKGROUND: Studies present ambiguous findings regarding the role of tryptophan and its metabolites, kynurenine and serotonin in chronic musculoskeletal pain. This systematic review aimed to investigate the expression of tryptophan and its metabolites, serotonin and kynurenine in patients with local and generalized chronic musculoskeletal pain in comparison with pain-free controls. METHODS: An electronic search was conducted in the databases MEDLINE, CINAHL, EMBASE, the Cochrane Central Registry of Controlled Trials (CENTRAL) and Web of Science for clinical and observational trials from the beginning of each database to 21 April 2023. Out of 6734 articles, a total of 17 studies were included; 12 studies were used in the meta-analysis of serotonin, 3 regarding tryptophan and 2 studies for a narrative synthesis regarding kynurenine. Risk of bias was assessed using the quality assessment tool for observational cohort and cross-sectional studies of the National Heart, Lung, and Blood Institute, while the certainty of evidence was by GRADE. RESULTS: All included studies showed a low risk of bias. The meta-analysis showed lower blood levels of tryptophan (p < .001; very low quality of evidence) and higher blood levels of serotonin (p < .001; very low-quality evidence) in patients with generalized musculoskeletal pain, when compared to pain-free individuals. In local chronic musculoskeletal pain, there were higher blood levels of serotonin (p=.251; very low quality of evidence) compared to pain-free individuals. Regarding kynurenine, the studies reported both higher and lower blood levels in generalized chronic musculoskeletal pain compared to pain-free individuals. CONCLUSIONS: The blood levels of tryptophan and its metabolites serotonin and kynurenine seem to influence chronic musculoskeletal pain.

Psychological treatments for temporomandibular disorder pain-A systematic review.

OBJECTIVE: Temporomandibular disorders (TMD) are common. They affect abilities for carrying out daily tasks and influence different psychological aspects. In addition to standard treatment, psychological treatments have been suggested. The aim was to investigate the effects of psychological treatments on patients with painful TMD in a short- and long-term perspective. MATERIALS AND METHODS: An electronic search was conducted in the databases MEDLINE, CINAHL, EMBASE, the Cochrane Central Registry of Controlled Trials (CENTRAL), and Web of Science for randomized clinical trials (RCTs) reporting psychological interventions for TMD. Registered beforehand in PROSPERO (CRD42022320106). In total, 18 RCTs were included; six RCTs that could be used in the meta-analysis, and all 18 RCTs were used in the narrative synthesis. Risk of bias was assessed by the Cochrane's tool for assessing risk of bias and certainty of evidence by GRADE. RESULTS: The narrative synthesis indicates that psychological treatment options seem equivalent to standard treatment for painful TMD. The meta-analysis showed that a combination of psychological treatment and standard treatment and manual treatment (very low-quality evidence) are significantly better in pain reduction than just counselling and standard treatments of TMD. CONCLUSION: This study indicates that psychological treatments seem to reduce pain intensity in individuals with painful TMD, and that the effect seems to be equally good as standard treatment. However, a combination of psychological treatments and standard treatments seems to have an even better effect. This indicates that psychological treatments are promising as an additional treatment approach for painful TMDs.

Treatment for Adult Mandibular Condylar Process Fractures: A Network Meta-Analysis of Randomized Clinical Trials.

PURPOSE: Using network meta-analyses (NMA) has become increasingly valuable as it enables the comparison of interventions that have not been directly compared in a clinical trial. To date, there has not been a NMA of randomized clinical trials (RCT) that compares all types of treatments for mandibular condylar process fractures (MCPFs). The aim of this NMA was to compare and rank all the available methods used in the treatment of MCPFs. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted in 3 major databases up to January 2023 to retrieve RCTs that compared various closed and open treatment methods for MCPFs. The predictor variable is treatment techniques: arch bars (ABs) + wire maxillomandibular fixation (MMF), rigid MMF with intermaxillary fixation screws, AB + functional therapy with elastic guidance (AB functional treatment), AB rigid MMF/functional treatment, single miniplate, double miniplate, lambda miniplate, rhomboid plate, and trapezoidal miniplate. Postoperative complications were the outcome variables and included occlusion, mobility, and pain, among other things. Risk ratio (RR) and standardized mean difference were calculated. Version 2 of the Cochrane risk-of-bias tool and Grading of Recommendations, Assessment, Development, and Evaluations system were used to determine the certainty of the results. RESULTS: The NMA included a total of 10,259 patients from 29 RCTs. At ≤6 months, the NMA revealed that the use of 2-miniplates significantly reduced malocclusion compared to rigid MMF (RR = 2.93; confidence interval [CI]: 1.79 to 4.81; very low quality) and functional treatment (RR = 2.36; CI: 1.07 to 5.23; low quality).Further, at ≥6 months, 2-miniplates resulted in significantly lower malocclusion compared to rigid MMF with functional treatment (RR = 3.67; CI: 1.93 to 6.99; very low quality).Trapezoidal plate and AB functional treatment were ranked as the best options in 3-dimensional (3D) plates and closed groups, respectively.3D-miniplates (very low-quality evidence) were ranked as the most effective treatment for reducing postoperative malocclusion and improving mandibular functions after MCPFs, followed closely by double miniplates (moderate quality evidence). CONCLUSIONS: This NMA found no substantial difference in functional outcomes between using 2-miniplates versus 3D-miniplates to treat MCPFs (low evidence).However, 2-miniplates led to better outcomes than closed treatment (moderate evidence).Additionally, 3D-miniplates produced better outcomes for lateral excursions, protrusive movements, and occlusion than closed treatment at ≤6 months (very low evidence).

Top 100 Most-Cited Articles on Mandibular Fractures: A Bibliometric Analysis.

PURPOSE: This study aimed to compile a list of the 100 most cited articles on mandibular fractures and to glean key insights from these articles via a bibliometric analysis. METHODS: This bibliometric analysis was performed using the Web of Science Core Collection database. The search was performed through January 2022. The bibliometric parameters extracted included title, number of citations, citation density (number of citations per year), first author's country, year of publication, study design, and subject. The software program VOSviewer was used to create graphical bibliometric maps. RESULTS: The articles were ranked by the total number of citations, which ranged from 64 to 374, with 32 articles being cited more than 100 times. The included articles were published from 1952 to 2015, mainly in maxillofacial surgery journals. The most frequent of these were the Journal of Oral and Maxillofacial Surgery (54%) and the International Journal of Oral and Maxillofacial Surgery (14%). The studies were from 29 different countries, with the United States of America (42%) contributing substantially more than others, with the next ranked nation being Germany (9%). The most frequently used keywords were osteosynthesis (25), open reduction (18), and fixation (16). CONCLUSIONS: The country that contributed most to mandibular fracture research was the United States of America. This conclusion was based on the number of published articles by nation of origin and the origin of the Journal of Oral and Maxillofacial Surgery, in which the majority were published. Osteosynthesis was the most cited field of research among the articles in the sample set.

Impact of relaxing incisions on maxillofacial growth following Sommerlad-Furlow modified technique in patients with isolated cleft palate: a preliminary comparative study.

OBJECTIVE: To estimate the impact of relaxing incisions on maxillofacial growth following Sommerlad-Furlow modified technique in patients with isolated cleft palate. STUDY DESIGN: A Retrospective Cohort Study. METHODS: A total of 90 participants, 60 patients with non-syndromic isolated soft and hard cleft palate underwent primary palatoplasty (30 patients received the Sommerlad-Furlow modified technique without relaxing incision (S.F-RI group), and 30 received Sommerlad-Furlow modified technique with relaxing (S.F+RI group) with no significant difference found between them regarding the cleft type, cleft width, and age at repair. While the other 30 were healthy noncleft participants with skeletal class I pattern as a Control group. The control group (C group) was matched with the patient groups in number, age, and sex. All participants had lateral cephalometric radiographs at least 5 years old age. The lateral cephalometric radiographs were taken with the same equipment by the same experienced radiologist while the participants were in centric occlusion and a standardized upright position, with the transporionic axis and Frankfort horizontal plane parallel to the surface of the floor. A well-trained assessor (S. Elayah) used DOLPHIN Imaging Software to trace twice to eliminate measurement errors. All the study variables were measured using stable landmarks, including 12 linear and 10 angular variants. RESULTS: The mean age at collection of cephalograms was 6.03 ± 0.80 in the S.F+RI group, 5.96 ± 0.76 in the S.F-RI group, and 5.91 ± 0.87 in the C group. Regarding cranial base, the results showed no statistically significant differences between the three groups in S-N and S-N-Ba. While the S.F+R.I group had a significantly shortest S-Ba than the S.F-R.I & C groups (P = 0.01 & P < 0.01), but there was no statistically significant difference between S.F-R.I & C groups (P = 0.71). Regarding the skeletal maxilla, there was no significant difference between the S.F+R.I and S.F-R.I groups in all linear measurements (N-ANS and S-PM) except Co-A, the S.F+R.I group had significantly shorter Co-A than the S.F-R.I & C groups (P = < 0.01). While the angular measurement, S.F+R.I group had significantly less SNA angle than the S.F-R.I & C groups (P = < 0.01). Regarding mandibular bone, there were no statistically significant differences in all linear and angular mandibular measurements between the S.F+R.I and S.F-R.I.groups. Regarding intermaxillary relation, the S.F+R.I group had significant differences in Co-Gn-Co-A and ANB compared to the S.F-R.I & C groups (P = < 0.01). While there was no statistically significant difference in PP-MP between the three groups. CONCLUSION: As a preliminary report, the Sommerlad-Furlow modified technique without relaxing incisions was found to have a good maxillary positioning in the face and a satisfactory intermaxillary relationship compared to the Sommerlad-Furlow modified technique with relaxing incisions.

Erich arch bars vs intermaxillary fixation screws for mandibular fracture reduction during ORIF: a randomized clinical trial.

OBJECTIVE: This randomized clinical trial aimed to compare the efficacy of Erich arch bars (EAB) and intermaxillary fixation (IMF) screws in reducing mandibular fractures during open reduction and internal fixation (ORIF). METHODS: A total of 28 patients with mandibular fractures were randomly allocated to either the EAB group or the IMF screws group. The study evaluated various parameters including occlusal stability, complications, duration of application, oral hygiene status, quality of life, and patient characteristics. RESULTS: The study found no significant differences in occlusal stability between the EAB and IMF screw groups. However, the application and removal times were longer for EAB compared to IMF screws. The EAB group showed a higher presence of biofilm on teeth, indicating poorer oral hygiene status compared to the IMF screws group. In terms of quality of life, patients in the EAB group reported worse results in the "handicap" domain at the 15th postoperative day. No significant differences were observed in other quality-of-life parameters. Patient characteristics were well distributed between the two groups, enhancing the reliability of the results. CONCLUSION: Both EAB and IMF screws demonstrated comparable occlusal stability for minimally displaced mandibular fractures. However, IMF screws offered advantages such as shorter application and removal times, better oral hygiene maintenance, and potentially improved quality of life in the "handicap" domain. Further studies with larger sample sizes are necessary to validate these findings and explore the stability of IMF methods in cases requiring postoperative malocclusion correction or prolonged IMF.

Are acupuncture and dry needling effective in the management of masticatory muscle pain: A network meta-analysis of randomised clinical trials.

BACKGROUND: Several studies have shown that both acupuncture and dry needling are effective in the treatment of musculoskeletal pains. Therefore, the aim of this network meta-analysis (NMA) was to investigate the treatment outcome of acupuncture and dry-needling for masticatory muscle pain (TMD-M) and to compare with active and inactive placebo. MATERIAL AND METHOD: An electronic search was performed to identify randomised controlled trials (RCTs) published until September 2019, comparing dry-needling, acupuncture, and inactive as well as active placebo in patients with TMD-M. Outcome variables were post-treatment pain intensity, pressure pain threshold (PPT), and maximum mouth opening (MMO). The quality of evidence was rated according to Cochrane's tool for assessing the risk of bias. Mean difference was used to analyse via frequentist NMA using STATA-software. RESULTS: Both NMA and direct pairwise meta-analysis have shown that there was no difference between active treatment with either acupuncture or dry-needling when compared to active and inactive placebo in patients with TMD-M with respect to pain intensity, and PPT (p > .05). However, there was a significant increase in MMO following dry-needling when compared to the placebo (very low-quality evidence). CONCLUSION: Despite the short-term positive effect of MMO by dry-needling, this NMA could not show any pain-reducing effect in patients with TMD-M by acupuncture or dry-needling when compared to an active or inactive placebo. Taken together, this NMA indicates that it is the placebo effect that accounts for the majority of the treatment effect of TMD-M, rather than a real therapeutic effect of acupuncture/dry-needling.

Publication performance and trends in bruxism research: A bibliometric analysis.

BACKGROUND: Bruxism is an umbrella term that encompass a multidimensional spectrum of masticatory muscle activities. OBJECTIVE: The purpose of this study was to do a bibliometric analysis including citation performance in the research topic of bruxism, by using an innovative method including details of article title, author keyword, KeyWords Plus and abstracts. METHODS: The data were retrieved 2022-12-19 from the Clarivate Analytics Web of Science Core Collection, and the online version of the Science Citation Index Expanded (SCI-EXPANDED) for studies published 1992 to 2021. To evaluate research trends, the distribution of keywords in the article title and author-selected keywords were used. RESULTS: The search yielded 3233 documents in SCI-EXPANDED, of which 2598 were of the document-type 'articles' published in 676 journals. The analysis of the articles revealed that "bruxism/sleep bruxism," "electromyography," "temporomandibular disorders" and "masticatory muscles" are the most used keywords by the authors. Further, the most frequently cited study was published 9 years ago and handles the present definition of bruxism. CONCLUSION: The most productive authors and those with the highest performance have some common features; they have several national and international collaborations; and they have published articles about the definition, aetiology/pathophysiology and prevalence of bruxism, all senior researchers in the field of TMD. Hopefully, based on this study, researchers and clinicians will have information to be stimulated to outline future research projects on bruxism-related aspects, and to initiate new international or multinational collaborations.

Influence of inflammation on bleeding and wound healing following surgical extraction of impacted lower third molars.

OBJECTIVE: This study aimed to investigate the effect of inflammatory states following impacted lower third molar (ILTM) surgery regarding postoperative bleeding and wound healing. METHODS: The study included patients who underwent extraction of ILTMs associated with or without inflammatory conditions. Post-extraction bleeding and wound healing were assessed. In addition, mean grey values (MGVs) of alveolar bone and bone height using an orthopantomography radiograph were analyzed. RESULTS: A total of 376 patients were enrolled; 171 pericoronitis, 51 pulpitis, 44 chronic periapical periodontitis, 36 chronic periodontitis, and 74 control. The bleeding score in the control group was significantly lower than in the periapical periodontitis and periodontitis groups. Excellent wound healing for control, pericoronitis, pulpitis, periapical periodontitis, and periodontitis groups was (78.38%, 35.67%, 70.59%, 70.45%, and 33.33%, respectively). Patients with pericoronitis and periodontitis had significantly poorer wound healing (P < 0.01). The MGV in periapical periodontitis and periodontitis was considerably lower than in the control group. CONCLUSIONS: The inflammatory conditions associated with ILTMs increase the risk of bleeding. So suturing with the placement of local hemostatic agents over a pressure pack alone is recommended. The poorest wound healing was in localized gingival inflammation. Furthermore, MGV was affected by age and was lower with periapical periodontitis.

Volumetric reduction in large cystic jaw lesions postoperative enucleation: a longitudinal clinical study.

BACKGROUND: Enucleation, a surgical procedure, is commonly used to treat large jaw cysts, unicystic ameloblastomas and keratocysts. However, it remains unclear to what extent the jaw bone regenerates after enucleation. We aimed to evaluate the percentage and the survival analysis of jaw bone regeneration, in terms of cavity volume residual (CVR), in patients who underwent enucleation of large jaw cysts, unicystic ameloblastomas and keratocysts. METHODS: We collected data longitudinally from 75 patients who underwent jaw cystic lesions enucleation at the Stomatological Hospital of Xi'an Jiaotong University, between January 2015 and June 2021. All patients had both preoperative and postoperative cone-beam computed tomography (CBCT) imaging data. CBCT images were analyzed using Image J. Changes in the CVR were assessed at various follow-up time points, and the Kaplan-Meier method was utilized to evaluate the CVR over time. RESULTS: The patients had a mean age of 31.7 years (range: 5.5-72 years) with 58.66% of them being male. The postoperative CVR was 32.20% at three months, 21.10% at six months, 15.90% at 12 months, and 5.60% at 24 months. The percentage of CVR during follow-up periods for the initial size Quartile (Q)1 (212.54-1569.60 mm3) was substantially lower than those of Q2 and Q3 at and after seven months of follow-up and became statistically significant at the 12-month mark. CONCLUSION: This study demonstrates that spontaneous bone regeneration can occur after enucleation of large jaw cysts, unicystic ameloblastomas and keratocysts, even without the use of filler materials. The initial size of the lesion had a significant impact on the outcome of cystic lesion enucleation over time. To minimize the risks associated with radiation exposure and expenses, we recommend reducing the frequency of CT imaging follow-ups for patients with small initial cavity sizes (ranging from 212.54 to 1569.60 mm3).

Treatment of Frontal Sinus Fractures: A Systematic Review and Meta-analysis.

PURPOSE: There is still no consensus about the best treatment for frontal sinus fractures (FSFs). Thus, the aims of this study were to answer the following questions: 1) what treatment of FSFs has the lowest rate of postoperative complications? 2) does sinus preservation using observation produce a lower complication rate? 3) are FSFs with nasofrontal outflow tract (NFOT) injury associated with greater complication rates following different treatment options when compared to those patients without NFOT involvement? METHODS: A systematic review and meta-analysis were performed based on PRISMA that included several databases with specific keywords, a reference search, and a manual search for suitable articles. Randomized clinical trials, controlled clinical studies, retrospective studies and case series that estimated complications rate after different treatments options for FSFs were included. The predictor variable was treatment groups, including observation, ORIF, cranialization and obliteration. The outcome variable was complication rate and correlation between complication rate and presence/absence of NFOT. A weighted complication rate/proportion using a random effect model, or risk ratio (RR) with a 95% confidence interval (CI), was performed to construct forest plots. Data analysis was done using a comprehensive meta-analysis. RESULTS: A total of 2,911 patients with FSFs enrolled in 23 studies were included in this study. The weighted complication rate for different treatment was as follows: observation (7%), ORIF (9.4%), obliteration (10.6%), and cranialization (11%). Nonsurgical treatment decreased the complication rate by 2.1 times (low quality evidence, RR = 2.1, CI: 1.13 to 3.9, P = .000) when compared to surgical treatments for FSFs. CR for fractures with NFOT was 8 % (55/619) compared to a complication rate of 5% (18/353) for fractures without NFOT with insignificant difference (very low quality evidence, RR = 1.7, CI: 0.75 to 4.1, P = .158). CONCLUSIONS: FSFs vary in their severity and treatments. The more severe fractures, the higher the complication rate, no matter how they were treated.

Do length and gauge of dental needle affect success in performing an inferior alveolar nerve block during extraction of adult mandibular molars? A prospective, randomized observer-blind, clinical trial.

OBJECTIVE: Association between length and gauge of dental needle and success rate and pain perception during an inferior alveolar nerve block (IANB) has not been investigated using a randomized clinical trial (RCT). This RCT aimed to compare the success rate of IANB and perceived pain using 27- or 30-gauge needles for the extraction of adult mandibular molars. MATERIAL AND METHOD: A prospective RCT was conducted on two hundred and twelve adult patients requiring extraction of mandibular molars using standard methods as described by Malamed with 1.8 ml of 2% lidocaine with 1:80,000 adrenaline. One hundred six patients received IANB using 27-gauge needles (32 mm × 0.2 mm) and one hundred six patients received IANB using 30-gauge needles (25 mm × 0.15 mm). Predictor variables were 27-gauge and short and 30-gauge. Outcome variables were the success rate of IANB and pain perception during injection using a visual analogue scale. RESULTS: There was a highly significantly increase in the success of IANB using 27-gauge needle (95.28%) versus 30-gauge needle (41.51%) (P = 0.001). There was a significant increase in pain perception for patients who received IANB by shorter and thinner needle (30-gauge) when compared to the long and thicker needle (27-gauge). CONCLUSION: This RCT demonstrated that 27-gauge needle seems to be associated with a higher success rate of IANB and lower pain perception during injection when compared to 30-gauge needle in the extraction of adult mandibular molars when compared to 30-gauge needles. CLINICAL RELEVANCE: For adult patients, when thickness of soft tissue to be penetrated is essential to achieve bony contact, long or large gauge dental needle is preferred to get a higher success rate of IANB with less pain perception during injection.

Is the therapeutic effect of occlusal stabilization appliances more than just placebo effect in the management of painful temporomandibular disorders? A network meta-analysis of randomized clinical trials.

STATEMENT OF PROBLEM: Occlusal devices, particularly the stabilization appliances, have been commonly used as treatment for painful temporomandibular disorders (TMDs). However, the mechanisms of action of these devices are still unclear, including the role of the placebo effect in the pain management. PURPOSE: The purpose of this network meta-analysis was to identify to what extent the degree of efficacy of stabilization appliances in the management of painful TMDs arises from the placebo effect only or whether it arises chiefly from an actual effect. MATERIAL AND METHODS: An electronic search was undertaken to identify randomized clinical trials (RCTs) published up to April 2020, comparing the efficacy of the stabilization appliances in patients with painful temporomandibular disorders, with nonoccluding appliances (active placebo), and untreated controls (passive placebo). Outcome variables were pain intensity at follow-ups, the proportion of participants reporting pain improvement, and the number needed to treat. The quality of evidence was rated as per the Cochrane tool for assessing risk of bias. Mean difference was used to analyze via frequentist network meta-analysis by using the STATA software program. RESULTS: Treatment with stabilization appliances showed a significant reduction in pain intensity when compared with the other groups; but, the lower pain intensity at follow-ups in favor of stabilization appliances when compared with nonoccluding appliances was not statistically significant. However, a significantly higher number of participants reported pain improvement after treatment with stabilization appliances when compared with those treated with nonoccluding appliances or untreated participants. CONCLUSIONS: This network meta-analysis showed no significant difference in reported pain intensity at follow-ups between the treatment of painful TMDs with stabilization appliances or nonoccluding appliances (active placebo). However, a significant difference in participants reporting treatment satisfaction with reduced pain, and a significantly lower number needed to treat in favor of stabilization appliances were found. Patient-reported treatment satisfaction probably included more domains than just pain intensity, such as improvements in physical functioning and psychosocial factors, and deserves further investigation. The authors concluded that stabilization appliances treatment efficacy is beyond the placebo effect.

Needling therapies in the management of myofascial pain of the masticatory muscles: A network meta-analysis of randomised clinical trials.

OBJECTIVE: A network meta-analysis (NMA) of randomised clinical trials (RCTs) was performed aiming to compare the treatment outcome of dry needling, acupuncture or wet needling using different substances in managing myofascial pain of the masticatory muscles (TMD-M). METHOD: An electronic search was undertaken to identify RCTs published until September 2019, comparing dry needling, acupuncture or wet needling using local anaesthesia (LA), botulinum toxin-A (BTX-A), granisetron, platelet-rich plasma (PRP) or passive placebo versus real active placebo in patients with TMD-M. RCTs meeting the inclusion criteria were stratified according to the follow-up time: immediate post-treatment to 3 weeks, and 1 to 6 months post-treatment. Outcome variables were post-treatment pain intensity, increased mouth opening (MMO) and pressure threshold pain (PPT). The quality of evidence was rated according to Cochrane's tool for assessing risk of bias. Mean difference (MD) was used to analysed via frequentist NMA using Stata software. RESULTS: Twenty-one RCTs involving 959 patients were included. The quality of evidence of the included studies was low or very low. There was significant pain decrease after PRP when compared to an active/passive placebo and acupuncture. There was a significant improvement of MMO after LA (MD = 3.65; CI: 1.18-6.1) and dry needling therapy (MD = 2.37; CI: 0.66-4) versus placebo. The three highest ranked treatments for short-term post-treatment pain reduction in TMD-M (1-20 days) were PRP (95.8%), followed by LA (62.5%) and dry needling (57.1%), whereas the three highest ranked treatments at intermediate-term follow-up (1-6 months) were LA (90.2%), dry needling (66.1%) and BTX-A (52.1%) (all very low-quality evidence). LA (96.4%) was the most effective treatment regarding the increase in MMO followed by dry needling (72.4%). CONCLUSION: Based on this NMA, one can conclude that the effectiveness of needling therapy did not depend on needling type (dry or wet) or needling substance. The outcome of this NMA suggests that LA, BTX-A, granisetron and PRP hold some promise as injection therapies, but no definite conclusions can be drawn due to the low quality of evidence of the included studies. This NMA did not provide enough support for any of the needling therapies for TMD-M.

What Is the Most Effective Rehabilitation Method for Posterior Maxillas With 4 to 8 mm of Residual Alveolar Bone Height Below the Maxillary Sinus With Implant-Supported Prostheses? A Frequentist Network Meta-Analysis.

PURPOSE: The most effective rehabilitation method for patients with edentulous posterior maxillas with an intermediate (4 to 8 mm) residual bone height (RBH) below the maxillary sinus is unclear. Evidence derived from conventional meta-analysis is limited because of the lack of head-to-head studies. This network meta-analysis (NMA) was performed to identify the most effective method to treat patients with intermediate posterior RBH. MATERIALS AND METHODS: An NMA of randomized controlled clinical trials (RCTs) was conducted to assess various rehabilitation methods using implant-supported prostheses for patients with intermediate posterior maxillary RBH (4 to 8 mm). Publications from 1970 through March 2018 in 3 major databases were searched. Parallel and split-mouth RCTs that reported the outcomes of interest with follow-up of at least 6 months from initial loading were included. Predictor variables were short implants (SIs; ≤8 mm) alone, SIs in conjunction with osteotome sinus floor elevation (OSFE) with or without bone grafting, long implants (LIs) in conjunction with OSFE with and without bone grafting, and LIs combined with lateral sinus floor elevation (LSFE) with bone grafting. Outcome variables were implant and prosthesis failure rates, marginal bone loss, and complications. Frequentist NMA was performed using STATA software. RESULTS: Twenty RCTs involving 770 patients with intermediate posterior maxillary RBH and 837 concerned maxillary sinuses who received 1,486 implants using any of the 4 rehabilitation methods were included. There were no statistically significant differences among the 4 groups for implant and prosthesis failure rates and marginal bone loss at follow-up (range, 6 months to 5 years after loading). There was a marked decrease in complications for SIs alone compared with LIs combined with LSFE. For implant and prosthesis survival rates, SIs in conjunction with OSFE with or without bone grafting ranked first as the most effective option (77.1%) followed by LIs plus OSFE with or without bone grafting (62%), LIs plus LSFE with bone grafting (43.9%), and SIs alone (24.8%). CONCLUSION: There is moderate-quality evidence derived from this NMA showing that OSFE combined with SI or LI placement with or without bone grafting or SI placement alone is superior to LI placement combined with LSFE and bone grafting when used for patients with intermediate maxillary RBH (4 to 8 mm). Furthermore, the results of this study show that LSFE for patients with intermediate RBH is not a suitable treatment option because of unjustified high cost and rate of complications.

Does Temporomandibular Joint Pathology With or Without Surgical Management Affect the Stability of Counterclockwise Rotation of the Maxillomandibular Complex in Orthognathic Surgery? A Systematic Review and Meta-Analysis.

PURPOSE: This study was designed to determine the stability of counterclockwise rotation (CCWR) of the maxillomandibular complex (MMC) in orthognathic surgery with or without surgical correction of coexisting temporomandibular joint (TMJ) pathology. MATERIALS AND METHODS: The authors implemented a systematic review and meta-analysis. A search of major databases through PubMed, EMBASE, and Cochrane CENTRAL was performed. Inclusion criteria were studies that analyzed CCWR of the MMC in regard to skeletal stability after orthognathic surgery in patients with or without pre-existing TMJ pathology that was or was not surgically corrected concomitantly. The predictor variables were patients who underwent CCWR of the MMC in the following subgroups: 1) healthy TMJs (presumed healthy based on history, clinical evaluation, and radiographic analysis but without magnetic resonance imaging [MRI] confirmation), 2) no TMJ assessment, 3) untreated TMJ disc displacement (confirmed by MRI), 4) TMJ disc displacement (confirmed by MRI) repositioned using Mitek anchors, and 5) reconstruction with TMJ total joint prosthesis. Outcome variables were surgical relapse for angular and linear measurements. Postsurgical mean changes for the occlusal plane (OP) and linear measurements using a fixed-effects model with a 95% confidence interval were analyzed. RESULTS: A total of 345 patients enrolled in 12 studies were included in this study. There was significant OP relapse and horizontal relapse at the B point and menton for studies with untreated TMJ disc displacement and studies without TMJ assessment (P < .005). There was significant horizontal relapse at the A point for studies with healthy TMJs, without assessment of the TMJs, and with TMJ reconstruction with total joint prostheses (P < .005). There was no significant vertical relapse at the B and A points for all subgroup analyses (P < .005). CONCLUSION: The result of the meta-analysis suggests that CCWR of the MMC is a stable procedure for patients with healthy TMJs, patients undergoing concomitant TMJ disc repositioning with Mitek anchors, and patients with TMJ patient-fitted total joint prostheses but unstable in the presence of untreated TMJ disc displacements and when TMJ status is not assessed.

Does Orthognathic Surgery Cause or Cure Temporomandibular Disorders? A Systematic Review and Meta-Analysis.

PURPOSE: There is still controversy about whether orthognathic surgery negatively or positively affects temporomandibular disorders (TMDs). The purpose of this study was to determine whether orthognathic surgery has a beneficial or deleterious effect on pre-existing TMDs. MATERIALS AND METHODS: A systematic review and meta-analysis were conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched 3 major databases to locate all pertinent articles published from 1980 to March 2016. All subjects in the various studies were stratified a priori into 9 categories based on subdiagnoses of TMDs. The predictor variables were those patients with pre-existing TMDs who underwent orthognathic surgery in various subgroups. The outcome variables were maximal mouth opening and signs and symptoms of a TMD before and after orthognathic surgery based on the type of osteotomy. The meta-analysis was performed using Comprehensive Meta-Analysis software (Biostat, Englewood, NJ). RESULTS: A total of 5,029 patients enrolled in 29 studies were included in this meta-analysis. There was a significant reduction in TMDs in patients with a retrognathic mandible after bilateral sagittal split osteotomy (BSSO) (P = .014), but no significant difference after bimaxillary surgery (BSSO and Le Fort I osteotomy) (P = .336). There was a significant difference in patients with prognathism after isolated BSSO or intraoral vertical ramus osteotomy and after combined BSSO and Le Fort I osteotomy (P = .001), but no significant difference after BSSO (P = .424) or bimaxillary surgery (intraoral vertical ramus osteotomy and Le Fort I osteotomy) (P = .728). CONCLUSIONS: Orthognathic surgery caused a decrease in TMD symptoms for many patients who had symptoms before surgery, but it created symptoms in a smaller group of patients who were asymptomatic before surgery. The presence of presurgical TMD symptoms or the type of jaw deformity did not identify which patients' TMDs would improve, remain the same, or worsen after surgery.

Is Counterclockwise Rotation of the Maxillomandibular Complex Stable Compared With Clockwise Rotation in the Correction of Dentofacial Deformities? A Systematic Review and Meta-Analysis.

PURPOSE: To compare postsurgical skeletal stability between counterclockwise rotation (CCWR) of the maxillomandibular complex (MMC) and clockwise rotation (CWR) of the MMC for the correction of dentofacial deformities. MATERIALS AND METHODS: To address the study purpose, we designed and implemented a systematic review with meta-analysis based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search strategy was developed, and a search of major databases-PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL)-was conducted to find all pertinent articles published from inception through March 2016. The inclusion criteria were randomized controlled trials, controlled clinical trials, retrospective studies, and case series with the aim of comparing postsurgical stability of CCWR and CWR of the MMC. The analysis was performed using lateral cephalometric analysis of postsurgical mean values and correlation between the surgical and postsurgical changes of the occlusal plane angle and linear changes at A point and B point. A weighted mean difference analysis using a random-effects model with 95% confidence intervals was performed. RESULTS: A total of 133 patients were enrolled from 3 studies (CCWR, n = 83; CWR, n = 50). All included studies were at moderate risk of bias. There was a statistically significant difference between CCWR and CWR of the MMC in the postsurgical changes of the occlusal plane angle (P = .034), but no statistically significant difference was found in the correlation between the surgical and postsurgical changes of the occlusal plane angle in the 2 groups. There was no statistically significant difference between CCWR and CWR of the MMC for stability between assessments immediately after surgery and at longest follow-up relative to the vertical and horizontal positions at A point and B point (P > .05). CONCLUSIONS: CCWR compared with CWR for the correction of dentofacial deformities in the absence of pre-existing temporomandibular joint pathology is skeletally stable relative to the postsurgical changes of the occlusal plane, as well as the vertical and horizontal changes of the maxilla and mandible.

Does the Excision of Overlying Oral Mucosa Reduce the Recurrence Rate in the Treatment of the Keratocystic Odontogenic Tumor? A Systematic Review and Meta-Analysis.

PURPOSE: The purpose of this study was to identify whether there is scientific evidence to support excision of the overlying mucosa (EOM) in conjunction with cyst enucleation to decrease the recurrence rate (RR) of keratocystic odontogenic tumors (KOTs). MATERIALS AND METHODS: A systematic review with meta-analysis conforming to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines was performed. A comprehensive search of 3 major databases through PubMed, EMBASE, and Cochrane CENTRAL was conducted to identify all relevant articles published without date or language restrictions from inception to December 2015. Eligible articles were selected based on the following inclusion criteria: randomized, prospective, or retrospective studies comparing enucleation with EOM to enucleation without EOM for patients with KOTs. The predictor variable was treatment group (enucleation with EOM vs enucleation without EOM). The outcome variables were RR of KOTs, presence of epithelial islands and microcysts in the excised overlying mucosa, and correlation between recurrent cortically perforated KOTs. A weighted RR and odds ratio (OR; using a random- or fixed-effect model) and the Mantel-Haenszel test with 95% confidence interval (CI) were performed using comprehensive meta-analysis software. RESULTS: Eleven studies were included in this review. There was no significant difference between enucleation with and without EOM (random; OR = 3.259; 95%, 0.975-10.901, P = 0.055). The weighted event rates for enucleation with Carnoy's solution plus EOM and enucleation without EOM in cortically perforated lesions were 6.2% (random; 95% CI, 2.6-14) and 9.1% (random; 95% CI, 1.6-38.2), respectively. The weighted event rate for the presence of epithelial islands and microcysts in overlying mucosa of KOTs was 68.8% (random; 95% CI, 27.2-92.9). CONCLUSION: The results of this study suggest that enucleation of KOTs plus the use of Carnoy's solution or liquid nitrogen (when indicated) should be combined with EOM to obtain the lowest RR, specifically for retromandibular trigone, posterior maxillary, and cortically perforated lesions. However, the results from this study do not provide sufficient scientific evidence for EOM in combination with enucleation of KOTs.