Clinical Performance of Access Flap in the Treatment of Class II Furcation Defects. a Systematic Review and Meta-Analysis o

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     A  c  c  e  p   t  e   d   A  r   t   i  c   l  e This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/jcpe.12327 This article is protected by copyright. All rights reserved. Article Type : Systematic Review Clinical performance of access flap in the treatment of class II furcation defects. A systematic review and meta-analysis of randomized clinical trials. Filippo Graziani 1 , Stefano Gennai 1 , Dimitra Karapetsa 1 , Stefano Rosini 1 , Natalia Filice 1 , Mario Gabriele 1 , Maurizio Tonetti 2 1.   D EPARTMENT OF S URGERY ,   U NIT OF D ENTISTRY AND O RAL S URGERY ,   U NIVERSITY OF P ISA  2.   E UROPEAN R ESEARCH G ROUP ON P ERIODONTOLOGY ,   G ENOVA ,   I TALY   Running title: Conservative surgical approach of furcation defects Key words: furcation defects, access flap, conservative surgery, meta-analysis Abstract Objectives : To systematically review the performance of access flap (OFD) in the treatment of class II furcation-defects (FD). Methods : RCTs evaluating surgical treatment of class II FD with OFD, minimum 6 months follow-up were identified. Screening, data extraction and quality assessment were conducted independently     A  c  c  e  p   t  e   d   A  r   t   i  c   l  e This article is protected by copyright. All rights reserved. by 3 reviewers. The primary outcomes were tooth survival and change in horizontal clinical attachment level (HCAL). Changes in vertical clinical attachment level (VCAL), reduction of pocket probing depth (PPD), recession increase (REC), horizontal (HBL) and vertical bone level (VBL) were also collected. Results : The search identified 1571 studies out of which 11 articles met the inclusion criteria. Data analysis was performed on 199 patients and 251 FD. Tooth survival was seldom reported. Altogether with inflammatory amelioration, the weighted mean differences were for HCAL 0.96 mm (CI: [0.60, 1.32], p <0.001), 0.55 mm (CI: [0.00, 1.10], p= 0.05) for VCAL gain. PPD reduction over 6 months was 1.38 mm (CI: [0.91, 1.85], p < 0.01). Potential risk of bias was identified. Conclusions : Teeth with mandibular class II furcation involvement treated with OFD show significant clinical improvements 6 months after surgery. Nevertheless, in order to better understand the magnitude of this changes and their clinical relevance, prospective long term trials are needed. Conflict of Interest and Sources of Funding Statement The authors report no conflict of interest for this study. The study was self-supported partly by the Unit of Dentistry and Oral Surgery of the University of Pisa and partly by the Italian Ministry Health and the Tuscan Region (Grant # GR-2009-1592229). Clinical relevance Scientific rationale for the study:  To assess the clinical performance of access flap in the treatment of class II furcation defects. Principal findings:  Access flap shows evident clinical improvements in the short term. Long term trials and trials focusing on maxillary molars are lacking. Practical implications:  Clinicians should be aware that conservative surgery is capable of certain clinical performance especially in mandibular class II furcation defects. Long term trials are needed.     A  c  c  e  p   t  e   d   A  r   t   i  c   l  e This article is protected by copyright. All rights reserved. Introduction Multi-rooted teeth represent a clinical challenge for the daily practice because of their unique anatomical features and their posterior location in the mouth. The anatomy of the furcation is complex with the presence of a number of small ridges, peaks and depressions forming a mixture of convexities and concavities (Svärdström & Wennström 1988). These anatomical features in combination with the limited furcation entrance dimension render a thorough cleaning, performed with routine instruments, quite difficult (Bower 1979). Furthermore, the distal position of the molars i) impede adequate self-performed hygiene (Lang et al. 1973) and ii) implicate a relatively difficult access to professional debridement (Fleischer et al. 1989). In untreated periodontitis the presence of furcation determines a greater amount of periodontal breakdown (Harris 2003) and highest tooth mortality (Papapanou et al. 1989), especially in the maxilla (Buckley & Crowley 1984). This is most probably related to the larger area exposed to bacterial/endotoxin burden (Waerhaug 1980). Periodontal treatment is hampered in the presence of furcation due to the negative prognosis in terms of tooth survival (Goldman 1986). This is confirmed by several long-term retrospective studies. Hirschfeld and Wasserman followed-up 600 patients for 15-53 years (Hirschfeld & Wasserman 1978). Subjects received various types of periodontal treatment but root amputation or furcation closure procedures were rarely attempted. After supportive periodontal care rendered on a 4-6 months basis, furcated molars were the teeth more likely to be lost. Mc Fall (McFall 1982) confirmed these findings in a sample of 100 periodontally treated patients maintained for 15-29 years: he reported 57% tooth loss for furcation involved teeth and 7% for single-rooted teeth. In particular, a recent study by Salvi and co-workers indicated that smokers and poor compliance with supportive periodontal treatment are risk factors for loss of multi-rooted teeth (Salvi et al 2014).   Improvement in the prognosis of furcated molars represents therefore one of the true goals of periodontal treatment. Numerous treatment strategies, including non-surgical and surgical debridement, resective and regenerative procedures, have been presented. Among these, conservative surgical treatment such as surgical open flap debridement has been suggested to determine some clinical improvements which may be sufficient in preserving the majority of furcation-affected molars. Svärdström and Wennström retrospectively reported that 8-12 years after scaling and root planing with or without modified Widman flap approach, 96% of the furcated molars in 160 subjects were still in function (Svärdström & Wennström 2000). Dannewitz and co-workers noticed the loss of 9 furcated molars on a sample of 227 treated molars with flap procedures and at least 5 years of supportive treatment (Dannewitz et al. 2006). However, the vast majority of the studies are retrospective in nature and thus at higher risk of bias. In fact, evidence based approaches on furcation treatment have been mainly used to evaluate reconstructive procedures such as guided tissue regeneration (Jepsen et al. 2002), enamel matrix     A  c  c  e  p   t  e   d   A  r   t   i  c   l  e This article is protected by copyright. All rights reserved. derivative (Koop et al. 2012) and bone replacement grafts (Sohrabi et al. 2012). Systematic evidence on open flap debridement (OFD), i.e. surgical debridement of the furcation with no anatomical modification of the tooth/ bony structure, is not available. In order to minimize the risk of biases and to increase the applicability of the findings a useful source of prospective, high-quality data is provided by the prospective data of the control groups of randomized clinical trials (RCT). Therefore, aim of this systematic review was to investigate the clinical performance of conservative surgery, as reported in control groups of RCTs, in the treatment of furcation defects caused by periodontal disease. Materials and Methods Protocol development and eligibility criteria A detailed protocol was designed according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement (Liberati et al. 2009, Moher et al. 2009). The systematic review was designed to answer the following focused question: “What is the performance of OFD, in terms of horizontal attachment gain and other periodontal parameters of teeth affected by periodontitis-related furcation defects, 6 months after surgery”? Only RCTs showing a group of patients undergoing OFD of furcation defects were included in the meta-analysis. Selected studies should have the following characteristics: a minimum of 6 months of post-surgical follow-up and a population of at least 10 subjects. No time and language limitations were applied. Information sources and Search Search on electronic databases up to and including March 2014. The search was applied to the Cochrane Oral Health Group specialist trials, MEDLINE via Pubmed and EMBASE via Ovid. The strategy used was a combination of MeSH terms and free text words (Limits: Humans; Clinical Trial, Randomized Controlled Trial, up to the 28 th  of March 2014): ã   Intervention: (“surgical flaps” [mesh] OR “periodontal pocket surgery” [mesh] OR “access” [txt words] OR “open” [txt words] OR “widman” [txt words] OR “regener*” [txt words] OR “perio” [txt words]) AND
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