- Email: [email protected]
Orthodontic treatment of periodontal defects. A systematic review
progress in orthodontics 1 1 ( 2 0 1 0 ) 41–44
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/pio
Review
Orthodontic treatment of periodontal defects. A systematic review Roberto Rotundo a,∗ , Michele Nieri a , Gloria Iachetti b , Jana Mervelt b , Francesco Cairo a , Tiziano Baccetti c , Lorenzo Franchi c , Giovanpaolo Pini Prato d a
Research fellow, Department of Periodontology, University of Florence, Italy Clinical Instructor, Department of Periodontology, University of Florence, Italy c Assistant Professor, Department of Orthodontics, University of Florence, Italy d Professor, Department of Periodontology, University of Florence, Italy b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Several studies have been published focusing on the possibility to treat patients affected by
Received 2 October 2009
periodontal defects by means of orthodontic treatment. The aim of this systematic review is
Accepted 20 April 2010
to evaluate the efficacy of the orthodontic treatment applied to the therapy of infraosseous defects, gingival recessions, and furcation lesions. To establish an appropriate search strat-
Keywords:
egy, the PICO assessment worksheet was used. Only Randomized Controlled Trials and
Furcation defect
Systematic Reviews were selected for this review. The electronic search (from January 1966
Gingival recession
to January 2008) and the hand search (from January 1988 to January 2008) were conducted
Infrabony/intrabony/angular defect
by three independent reviewers. There were no language restriction.
Orthodontics
No Randomized Controlled Trials and Systematic Reviews were identified during the inves-
Systematic review
tigated period and therefore it was not possible to perform meta-analysis. It appears important to encourage the researchers to produce Randomized Controlled clinical Trials aimed to investigate the efficacy of the orthodontic treatment, alone or in combination with the periodontal therapy, for the resolution of periodontal defects. © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
1.
Introduction
Periodontal infection is able to determine defects that involve alveolar bone and soft tissues, such as infrabony/suprabony defects and furcation lesions.1 Traumatic injuries, due to improper tooth-brushing habit, may also cause periodontal damage such as gingival recessions.2 Several non-surgical and surgical periodontal techniques have been developed to treat the infrabony defects and furcation lesions.3–5 Many surgical techniques have been proposed also to treat
∗
gingival recessions in order to improve aesthetics and dental hypersensitivity.6–8 All these therapeutic approaches per se demonstrate optimal clinical results showing the reconstruction of the infrabony defects, the stability of the surrounding treated area in correspondence of furcation defects, and the reconstruction of the mucogingival tissues around gingival recessions. During the last decades, several reports (oral communications and articles) have described the possibility to treat patients with periodontal defects by means of orthodontic therapy, alone or in combination with periodontal therapy.9–13
Corresponding author. via Ponte di Mezzo 26 - 50127 Firenze, Italy. E-mail address: roberto.rotundo@unifi.it (R. Rotundo). 1723-7785/$ – see front matter © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved. doi:10.1016/j.pio.2010.04.013
42
progress in orthodontics 1 1 ( 2 0 1 0 ) 41–44
It has been reported that orthodontic treatment might contribute to improve the healing of the infrabony defect, thus changing the anatomy of the defect area. Tooth up-righting and forced eruption (extrusion) may reduce pocket depth, while bodily movement of the tooth into the defect may reduce the entire volume of the lesion, creating a more suitable condition for periodontal surgical therapy. In his clinical and histological study, Brown14 reported the reduction of deep pockets and the related infrabony defects in teeth tilted mesially. Later, Ingber15 showed the favourable clinical and histological results of the treatment of 1- or 2-wall infrabony defects using extrusive tooth movement, based on the fact that the orthodontic tension created within the periodontal ligament stimulates the bone formation. In addition, damage at the periodontal attachment of the adjacent teeth was not observed. Little information is provided about the use of orthodontic treatment in cases with furcation lesions13 and gingival recessions.14 The purposes of this systematic review of the literature are: 1. to identify within the orthodontic and periodontal literature Randomized Controlled clinical Trials (RCTs) dealing with orthodontic therapy alone or in combination with periodontal techniques to treat periodontal defects (infraosseous defects, gingival recessions, and furcation lesions); 2. to perform a meta-analysis on this issue based on the available RCTs.
2.
Materials and methods
2.1.
Inclusion criteria and outcome measures
At the beginning of this study, the PICO assessment worksheet was used in order to define the topic and to plan the search strategy.16 The question addressed by the present systematic review was: “What is the clinical efficacy of the orthodontic treatment applied to the therapy of infraosseous defects, gingival recessions, and furcation lesions?”. The population selected for this study consisted of adult patients, aged 18 years and over. All the selected studies should present a minimum follow-up of 6 months and they had to be performed on human beings (animal and laboratorial studies were not considered eligible for the review). The types of study included in this systematic review were Randomized Controlled Trials (RCTs) and Systematic Reviews (SR). The comparative interventions considered eligible for this review were Orthodontic Treatment (every type) versus Periodontal Therapy (every type); Orthodontic Treatment (every type) plus Periodontal Therapy (every type) versus Periodontal Therapy (every type) alone; Orthodontic Treatment (every type) versus Orthodontic Treatment (every type). Studies presenting any of the following outcome measures were evaluated: 1. Outcomes for the periodontist: Missing Teeth during the follow-up period (MT); Clinical Level Gain (CAL Gain); Probing Depth Gain (PD Gain); Gingival Recession Reduction (RecRed); Biological Complications (Complic).
2. Outcomes for the patients: Pain during and after treatment (Pain); Esthetic Satisfaction (Esthetic); Treatment time satisfaction (Time); Cost of treatment (Cost).
2.2.
Search strategy
For the identification of the studies included or considered for this review, a search strategy was conducted referring to the period January 1st , 1966 – January 31st , 2008. The search strategy used a combination of controlled vocabulary (MeSH) and free text terms based on the following: orthodontic treatment / therapy; infraosseous / intraosseous / intrabony / infrabony / angular defects; gingival recession; furcation defects. There was no language restriction. Two searching strategies were adopted for this review: electronic search and hand-search. The electronic search utilized was Medline (Pubmed) and the period investigated was from January 1966 to January 2008. The following terms were searched: – “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Gingival Recession”[MeSH] – “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Furcation Defects”[MeSH] – “Orthodontics”[MeSH] AND “therapy”[Subheading] AND (“Periodontal Pocket”[MeSH] OR “Periodontal Diseases”[MeSH]) AND “Intrabony Defect” “[All Fields] – “Orthodontics“[MeSH] AND “therapy“[Subheading] AND (“Periodontal Pocket“[MeSH] OR “Periodontal Diseases”[MeSH]) AND “Infrabony Defect” “[All Fields] – “Orthodontics”[MeSH] AND “therapy”[Subheading] AND (“Periodontal Pocket”[MeSH] OR “Periodontal Diseases”[MeSH]) AND “Infraosseous Defect” “[All Fields] – “Orthodontics”[MeSH] AND “therapy”[Subheading] AND (“Periodontal Pocket”[MeSH] OR “Periodontal Diseases”[MeSH]) AND “Intraosseous Defect” “[All Fields] – “Orthodontics”[MeSH] AND “therapy”[Subheading] AND (“Periodontal Pocket”[MeSH] OR “Periodontal Diseases“[MeSH]) AND “Angular Defect” “[All Fields] A similar electronic search was performed in The Cochrane Oral Health Group’s Trials Register and The Cochrane Central Register of Controlled Trials (CENTRAL). For the investigative period from January 1988 to January 2008, the following journals were manually searched: Journal of Periodontology, Journal of Clinical Periodontology, International Journal of Periodontics and Restorative Dentistry, American Journal of Orthodontics and Dentofacial Orthopedics, The Angle Orthodontist, European Journal of Orthodontics.
2.3.
Methods of the review
The titles and abstracts (when available) of articles searched manually were scanned independently by two blinded examiners (G.I. and J.M.) by means of a cross-over method. The titles and abstracts (when available) of articles searched electronically were scanned independently by a third examiner (R.R.). For studies that met the inclusion criteria the full article was obtained. In case of disagreement about the inclusion of the study, this was resolved by discussion. Where resolution was not possible, a third review author was consulted. All studies meeting the inclusion criteria underwent quality assessment and data extraction.
progress in orthodontics 1 1 ( 2 0 1 0 ) 41–44
2.3.1.
Quality Assessment
The quality assessment of the included studies was evaluated by 2 examiners independently (R.R., M.N.). Three main quality criteria were considered: 1) Allocation concealment (A: adequate; B: unclear; C: inadequate) as described by Higgins and Green;17 2) Blind outcomes assessment (A: Yes; B: No; C: Unclear); and 3) Completeness of follow-up (quality of explanation for withdrawals and drop-outs in each treatment group. A: Yes; B: No). Based on these previous assessments, the studies were grouped into 2 categories: A) Low risk of bias, if all 3 quality criteria were met. B) High risk of bias, if one or more of the 3 quality criteria were not met. In addition, other characteristics of the studies were taken into consideration, such as sample-size calculations, definition of exclusion/inclusion criteria, and comparability of test and control groups at entry.
2.3.2.
Extraction and Synthesis
Only in presence of studies with similar comparisons reporting the same outcome measures, a meta-analysis was performed. For dichotomous outcomes, the estimates of the effect of an intervention are expressed as risk ratios (RR) together with 95% confidence intervals (CI) using a random-effect model. For continuous outcomes, weighted mean differences (WMD) were combined using a random-effect model. For this systematic review, the considered statistical unit is the patient. The significance of any discrepancies in the estimates of the treatment effects from the different trials is assessed by means of Cochran’s test for heterogeneity and the I2 statistic.
3.
Results
The manual and electronic search retrieved initially a total of 160 articles: 16 articles for infrabony defects (12 electronic and 4 manual), 126 articles for gingival recessions (118 electronic and 0 manual), and 18 articles for furcation defects (18 electronic and 0 manual). However, once entry criteria were applied, no RCTs or Systematic Reviews were identified. Due to this lack of studies, no meta-analysis was able to be performed.
4.
43
complete root coverage.6–8 Therefore, periodontal therapy per se is able to obtain optimal clinical results. On the other hand, orthodontic therapy has demonstrated in animal studies that periodontal defects such as infrabony defects, may be treated by means of bodily tooth movement after a thorough elimination of infection.19,20 Furthermore, some reports have been published showing the possibility to treat periodontal defects by means of orthodontic treatment.9–13 In order to focus on this issue, the aim of this systematic review was to evaluate the efficacy of the orthodontic treatment, alone or in combination with periodontal therapy in the treatment of infraosseous defects, gingival recessions and furcation defects. In particular, the first step of this study was to find RCTs dealing with orthodontic therapy alone or in combination with periodontal techniques to treat the abovementioned periodontal defects. The search was addressed to identify RCTs and SR which compare Orthodontic Treatment vs Periodontal Therapy, or Orthodontic Treatment plus Periodontal Therapy vs Periodontal Therapy alone; or Orthodontic Treatment vs Orthodontic Treatment in the orthodontic and periodontal literature published in the last 40 years. Only RCTs and SR were selected because other studies such as case reports, case series and not randomized controlled trials do not provide useful information about the efficacy of the therapy. The second aim was to perform a meta-analysis on this issue based on the available RCTs if possible. However, the result of this systematic review showed a complete lack of randomized controlled clinical trials and systematic reviews on this topic. Therefore, it was impossible to perform a subsequent meta-analysis. As a consequence, up to now, the efficacy of the orthodontic therapy alone or in combination with periodontal techniques is not clearly proved, and it is yet based on a low level of evidence. Therefore, the clinicians should perform these therapies with adequate criticism and particular attention for each clinical case. It is also of paramount importance before treatment to appropriately inform patients about the unclear efficacy of the orthodontic therapy applied to treat periodontal defects. For this reason, it appears important to encourage the researchers to produce randomized controlled clinical trials on the efficacy of the orthodontic treatment as a single approach or in combination with the periodontal therapy in the treatment of the infrabony defects, gingival recessions or furcation lesions.
Discussion
In Periodontology, the ideal treatment of periodontal defects would be the reconstruction of lost periodontal tissues. Several surgical techniques have been proposed thus including guided tissue regeneration (GTR), bone grafting (BG) and the use of enamel matrix derivative (EMD). All these treatments have been shown to be effective in particular to regenerate infrabony defects.5 In case of defects affecting multi-rooted teeth, regenerative procedures may not be effective to treat furcation defects. In these cases, resection therapies including root resection remain important procedures in periodontal therapy.18 In case of gingival recessions caused by traumatic injuries (i.e., toothbrushing trauma), it has been reported that several mucogingival techniques result effective in obtaining a
Conflict of interest The authors have reported no conflicts of interest.
Riassunto Numerosi studi hanno riportato la possibilità di trattare ortodonticamente pazienti che presentavano difetti parodontali. Scopo di questa revisione sistematica è quello di valutare l’efficacia del trattamento ortodontico per la terapia di difetti infraossei, recessioni gengivali e lesioni delle forcazioni. Al fine di stabilire un’appropriata strategia di ricerca è stato messo a punto un foglio di lavoro PICO. Solo studi di tipo controllato randomizzato (RCT) e revisioni sistematiche (SR) sono stati selezionati. Una ricerca elettronica, dal gennaio 1966 al
44
progress in orthodontics 1 1 ( 2 0 1 0 ) 41–44
gennaio 2008, e una ricerca cartacea, dal gennaio 1988 al gennaio 2008, sono state condotte da tre revisori indipendenti, senza porre alcun limite alla lingua in cui sono stati scritti gli articoli. I risultati della ricerca hanno riportato un’assenza di studi del tipo RCT e SR, motivo per cui non è stato possibile eseguire una metanalisi. Sulla base dei suddetti risultati è importante incoraggiare i clinici e i ricercatori a produrre pubblicazioni scientifiche del tipo RCT al fine di investigare la reale efficacia del trattamento ortodontico, da solo o in combinazione con la terapia parodontale, per la risoluzone dei più comuni difetti che affliggono le strutture di supporto dentali e cioè difetti infraossei, recessioni gengivali e lesioni delle forcazioni.
Résumé Plusieurs études ont été édité sur la possibilité de soigner des patients affectés par des défauts périodontales au moyen de traitement orthodontique. Le but de cette revue systématique est d’évaluer l’efficacité du traitement orthodontique appliqué à la thérapie des défauts infraosseous, des récessions gingivales, et des lésions de furcation. Pour établir une stratégie de recherche appropriée on a employée la feuille de travail d’évaluation de PICO. Seulement des Randomized Controlled Trials and Systematic Reviews ont été choisies pour cette revue. La recherche électronique (de janvier 1966 à janvier 2008) et la recherche à la main (de janvier 1988 à janvier 2008) ont été conduites par 3 critiques indépendants. Il n’y avait aucune restriction de langue. Aucune Randomized Controlled Trials and Systematic Reviews ont été identifiées au cours de la période étudiée et donc il n’était pas possible d’effectuer la méta-analyse. Il semble important d’encourager les chercheurs à produire des tests cliniques commandés randomisés visant à étudier l’efficacité du traitement orthodontique, seulement ou en combination avec la thérapie périodontale, pour la résolution des défauts périodontiques.
Resumen Se publicaron diferentes estudios que se centran en la posibilidad de tratar a pacientes afectados por defectos periodontales por medio de un tratamiento ortodóntico. El objetivo de esta revisión sistemática es valorar la eficacia del tratamiento ortodóntico aplicado a la terapia de lo defectos intraóseos, recesiones gingivales y lesiones de furcación. Con vistas a establecer una adecuada estrategia de investigación se utilizó la hoja de valoración y trabajo PICO. Para esta revisión se utilizaron sólo Ensayos Controlados Aleatorizados y Revisiones Sistemáticas. La búsqueda electrónica (de enero de1966 a enero de 2008) y la búsqueda manual (de enero de 1988 a enero de 2008) fueron llevadas a cabo por tres revisores independientes. No hubo restricción lingüística. Los Ensayos Controlados Aleatorizados y las Revisiones Sistemáticas fueron identificados durante el periodo investigado y por lo tanto no es posible realizar meta-análisis. Es menester instar a los investigadores a producir Ensayos clínicos Controlados Aleatorizados que apunten a profundizar en la eficacia del tratamiento ortodóntico, por sí solo o en combinación con el tratamiento periodontal para remediar a los defectos periodontales.
references
1. Papapanou PN, Tonetti MS. Diagnosis and epidemiology of periodontal osseous lesions. Periodontology 2000;22:8–21.
2. Wennstrom J, Pini Prato G. Mucogingival therapy – Periodontal plastic surgery. In: Lindhe J, Karring T, Lang NP, editors. Clinical Periodontology and Implant Dentistry. 4th Ed. Oxford: Blackwell Publishing Company; 2003. p. 576–631. 3. Heitz-Mayfield LJ, Trombelli L, Heitz F, Needleman I, Moles D. A systematic review of the effect of surgical debridement vs non-surgical debridement for the treatment of chronic periodontitis. J Clin Periodontol 2002;29(Suppl):92–102. 4. Needleman IG, Worthington HV, Tucker RJ, Giedrys-Leeper E. Guided tissue regeneration for periodontal infra-bony defects. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.:CD001724. DOI:10.1002/14651858.CD001724, pub2. 5. Esposito M, Grusovin MG, Coulthard P, Worthington HV. Enamel matrix derivative (Emdogain®) for periodontal tissue regeneration in intrabony defects (Review). Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003875. pub2. DOI:10.1002/14651858.CD003875, pub2. 6. Oates TW, Robinson M, Gunsolley JC. Surgical therapies for the treatment of gingival recession. A systematic review. Ann Periodontol 2003;8:303–20. 7. Clauser C, Nieri M, Franceschi D, Pagliaro U. Evidence-based mucogingival therapy. Part 2: ordinary and individual patient data meta-analyses of surgical treatment of recession using complete root coverage as the outcome variable. J Periodontol 2003;74:741–56. 8. Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures. A systematic review. J Clin Periodontol 2008;35(Suppl):141–67. 9. Melsen B, Agerbaek N, Markenstam. G Intrusion of incisors in adult patients with marginal bone loss. Am J Orthod Dentofacial Orthop 1989;96:232–41. 10. Nevins M, Wise RJ. Use of orthodontic therapy to alter infrabony pockets. 2. Int J Periodontics Restorative Dent 1990;10:198–207. 11. Re S, Corrente G, Abundo R, Cardaropoli D. Orthodontic treatment in periodontally compromised patients: 12-year report. Int J Periodontics Restorative Dent 2000;20:31–9. 12. Re S, Cardaropoli D, Abundo R, Corrente G. Reduction of gingival recession following orthodontic intrusion in periodontally compromised patients. Orthod Craniofac Res 2004;7:35–9. 13. Sam K, Rabie AB, King NM. Orthodontic intrusion of periodontally involved teeth. J Clin Orthod 2001;35:325–30. 14. Brown IS. The effect of orthodontic therapy on certain types of periodontal defects. I. Clinical findings. J Periodontol 1973;44:742–56. 15. Ingber JS. Forced eruption. I. A method of treating isolated one and two wall infrabony osseous defects-rationale and case report. J Periodontol 1974;45:199–206. 16. Miller SA, Forrest JL. Enhancing your practice through evidence-based decision making: PICO, learning how to ask good questions. J Evid Based Dent Pract 2001;1:136–41. 17. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions 4.2.6. 2006 Available at: http://www.cochrane.org/resources/handbook/hbook.htm. Updated September 2006. 18. De Sanctis M, Murphy KG. The role of resective periodontal surgery in the treatment of furcation defects. Periodontoloy 2000;22:154–68. 19. Polson A, Caton J, Polson AP, Nyman S, Novak J, Reed B. Periodontal response after tooth movement into intrabony defects. J Periodontol 1984;55:197–202. 20. Wennström JL, Stokland BL, Nyman S, Thilander B. Periodontal tissue response to orthodontic movement of teeth with infrabony pockets. Am J Orthod Dentofacial Orthop 1993;103:313–9.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/pio
Review
Orthodontic treatment of periodontal defects. A systematic review Roberto Rotundo a,∗ , Michele Nieri a , Gloria Iachetti b , Jana Mervelt b , Francesco Cairo a , Tiziano Baccetti c , Lorenzo Franchi c , Giovanpaolo Pini Prato d a
Research fellow, Department of Periodontology, University of Florence, Italy Clinical Instructor, Department of Periodontology, University of Florence, Italy c Assistant Professor, Department of Orthodontics, University of Florence, Italy d Professor, Department of Periodontology, University of Florence, Italy b
a r t i c l e
i n f o
a b s t r a c t
Article history:
Several studies have been published focusing on the possibility to treat patients affected by
Received 2 October 2009
periodontal defects by means of orthodontic treatment. The aim of this systematic review is
Accepted 20 April 2010
to evaluate the efficacy of the orthodontic treatment applied to the therapy of infraosseous defects, gingival recessions, and furcation lesions. To establish an appropriate search strat-
Keywords:
egy, the PICO assessment worksheet was used. Only Randomized Controlled Trials and
Furcation defect
Systematic Reviews were selected for this review. The electronic search (from January 1966
Gingival recession
to January 2008) and the hand search (from January 1988 to January 2008) were conducted
Infrabony/intrabony/angular defect
by three independent reviewers. There were no language restriction.
Orthodontics
No Randomized Controlled Trials and Systematic Reviews were identified during the inves-
Systematic review
tigated period and therefore it was not possible to perform meta-analysis. It appears important to encourage the researchers to produce Randomized Controlled clinical Trials aimed to investigate the efficacy of the orthodontic treatment, alone or in combination with the periodontal therapy, for the resolution of periodontal defects. © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved.
1.
Introduction
Periodontal infection is able to determine defects that involve alveolar bone and soft tissues, such as infrabony/suprabony defects and furcation lesions.1 Traumatic injuries, due to improper tooth-brushing habit, may also cause periodontal damage such as gingival recessions.2 Several non-surgical and surgical periodontal techniques have been developed to treat the infrabony defects and furcation lesions.3–5 Many surgical techniques have been proposed also to treat
∗
gingival recessions in order to improve aesthetics and dental hypersensitivity.6–8 All these therapeutic approaches per se demonstrate optimal clinical results showing the reconstruction of the infrabony defects, the stability of the surrounding treated area in correspondence of furcation defects, and the reconstruction of the mucogingival tissues around gingival recessions. During the last decades, several reports (oral communications and articles) have described the possibility to treat patients with periodontal defects by means of orthodontic therapy, alone or in combination with periodontal therapy.9–13
Corresponding author. via Ponte di Mezzo 26 - 50127 Firenze, Italy. E-mail address: roberto.rotundo@unifi.it (R. Rotundo). 1723-7785/$ – see front matter © 2010 Società Italiana di Ortodonzia SIDO. Published by Elsevier Srl. All rights reserved. doi:10.1016/j.pio.2010.04.013
42
progress in orthodontics 1 1 ( 2 0 1 0 ) 41–44
It has been reported that orthodontic treatment might contribute to improve the healing of the infrabony defect, thus changing the anatomy of the defect area. Tooth up-righting and forced eruption (extrusion) may reduce pocket depth, while bodily movement of the tooth into the defect may reduce the entire volume of the lesion, creating a more suitable condition for periodontal surgical therapy. In his clinical and histological study, Brown14 reported the reduction of deep pockets and the related infrabony defects in teeth tilted mesially. Later, Ingber15 showed the favourable clinical and histological results of the treatment of 1- or 2-wall infrabony defects using extrusive tooth movement, based on the fact that the orthodontic tension created within the periodontal ligament stimulates the bone formation. In addition, damage at the periodontal attachment of the adjacent teeth was not observed. Little information is provided about the use of orthodontic treatment in cases with furcation lesions13 and gingival recessions.14 The purposes of this systematic review of the literature are: 1. to identify within the orthodontic and periodontal literature Randomized Controlled clinical Trials (RCTs) dealing with orthodontic therapy alone or in combination with periodontal techniques to treat periodontal defects (infraosseous defects, gingival recessions, and furcation lesions); 2. to perform a meta-analysis on this issue based on the available RCTs.
2.
Materials and methods
2.1.
Inclusion criteria and outcome measures
At the beginning of this study, the PICO assessment worksheet was used in order to define the topic and to plan the search strategy.16 The question addressed by the present systematic review was: “What is the clinical efficacy of the orthodontic treatment applied to the therapy of infraosseous defects, gingival recessions, and furcation lesions?”. The population selected for this study consisted of adult patients, aged 18 years and over. All the selected studies should present a minimum follow-up of 6 months and they had to be performed on human beings (animal and laboratorial studies were not considered eligible for the review). The types of study included in this systematic review were Randomized Controlled Trials (RCTs) and Systematic Reviews (SR). The comparative interventions considered eligible for this review were Orthodontic Treatment (every type) versus Periodontal Therapy (every type); Orthodontic Treatment (every type) plus Periodontal Therapy (every type) versus Periodontal Therapy (every type) alone; Orthodontic Treatment (every type) versus Orthodontic Treatment (every type). Studies presenting any of the following outcome measures were evaluated: 1. Outcomes for the periodontist: Missing Teeth during the follow-up period (MT); Clinical Level Gain (CAL Gain); Probing Depth Gain (PD Gain); Gingival Recession Reduction (RecRed); Biological Complications (Complic).
2. Outcomes for the patients: Pain during and after treatment (Pain); Esthetic Satisfaction (Esthetic); Treatment time satisfaction (Time); Cost of treatment (Cost).
2.2.
Search strategy
For the identification of the studies included or considered for this review, a search strategy was conducted referring to the period January 1st , 1966 – January 31st , 2008. The search strategy used a combination of controlled vocabulary (MeSH) and free text terms based on the following: orthodontic treatment / therapy; infraosseous / intraosseous / intrabony / infrabony / angular defects; gingival recession; furcation defects. There was no language restriction. Two searching strategies were adopted for this review: electronic search and hand-search. The electronic search utilized was Medline (Pubmed) and the period investigated was from January 1966 to January 2008. The following terms were searched: – “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Gingival Recession”[MeSH] – “Orthodontics”[MeSH] AND “therapy”[Subheading] AND “Furcation Defects”[MeSH] – “Orthodontics”[MeSH] AND “therapy”[Subheading] AND (“Periodontal Pocket”[MeSH] OR “Periodontal Diseases”[MeSH]) AND “Intrabony Defect” “[All Fields] – “Orthodontics“[MeSH] AND “therapy“[Subheading] AND (“Periodontal Pocket“[MeSH] OR “Periodontal Diseases”[MeSH]) AND “Infrabony Defect” “[All Fields] – “Orthodontics”[MeSH] AND “therapy”[Subheading] AND (“Periodontal Pocket”[MeSH] OR “Periodontal Diseases”[MeSH]) AND “Infraosseous Defect” “[All Fields] – “Orthodontics”[MeSH] AND “therapy”[Subheading] AND (“Periodontal Pocket”[MeSH] OR “Periodontal Diseases”[MeSH]) AND “Intraosseous Defect” “[All Fields] – “Orthodontics”[MeSH] AND “therapy”[Subheading] AND (“Periodontal Pocket”[MeSH] OR “Periodontal Diseases“[MeSH]) AND “Angular Defect” “[All Fields] A similar electronic search was performed in The Cochrane Oral Health Group’s Trials Register and The Cochrane Central Register of Controlled Trials (CENTRAL). For the investigative period from January 1988 to January 2008, the following journals were manually searched: Journal of Periodontology, Journal of Clinical Periodontology, International Journal of Periodontics and Restorative Dentistry, American Journal of Orthodontics and Dentofacial Orthopedics, The Angle Orthodontist, European Journal of Orthodontics.
2.3.
Methods of the review
The titles and abstracts (when available) of articles searched manually were scanned independently by two blinded examiners (G.I. and J.M.) by means of a cross-over method. The titles and abstracts (when available) of articles searched electronically were scanned independently by a third examiner (R.R.). For studies that met the inclusion criteria the full article was obtained. In case of disagreement about the inclusion of the study, this was resolved by discussion. Where resolution was not possible, a third review author was consulted. All studies meeting the inclusion criteria underwent quality assessment and data extraction.
progress in orthodontics 1 1 ( 2 0 1 0 ) 41–44
2.3.1.
Quality Assessment
The quality assessment of the included studies was evaluated by 2 examiners independently (R.R., M.N.). Three main quality criteria were considered: 1) Allocation concealment (A: adequate; B: unclear; C: inadequate) as described by Higgins and Green;17 2) Blind outcomes assessment (A: Yes; B: No; C: Unclear); and 3) Completeness of follow-up (quality of explanation for withdrawals and drop-outs in each treatment group. A: Yes; B: No). Based on these previous assessments, the studies were grouped into 2 categories: A) Low risk of bias, if all 3 quality criteria were met. B) High risk of bias, if one or more of the 3 quality criteria were not met. In addition, other characteristics of the studies were taken into consideration, such as sample-size calculations, definition of exclusion/inclusion criteria, and comparability of test and control groups at entry.
2.3.2.
Extraction and Synthesis
Only in presence of studies with similar comparisons reporting the same outcome measures, a meta-analysis was performed. For dichotomous outcomes, the estimates of the effect of an intervention are expressed as risk ratios (RR) together with 95% confidence intervals (CI) using a random-effect model. For continuous outcomes, weighted mean differences (WMD) were combined using a random-effect model. For this systematic review, the considered statistical unit is the patient. The significance of any discrepancies in the estimates of the treatment effects from the different trials is assessed by means of Cochran’s test for heterogeneity and the I2 statistic.
3.
Results
The manual and electronic search retrieved initially a total of 160 articles: 16 articles for infrabony defects (12 electronic and 4 manual), 126 articles for gingival recessions (118 electronic and 0 manual), and 18 articles for furcation defects (18 electronic and 0 manual). However, once entry criteria were applied, no RCTs or Systematic Reviews were identified. Due to this lack of studies, no meta-analysis was able to be performed.
4.
43
complete root coverage.6–8 Therefore, periodontal therapy per se is able to obtain optimal clinical results. On the other hand, orthodontic therapy has demonstrated in animal studies that periodontal defects such as infrabony defects, may be treated by means of bodily tooth movement after a thorough elimination of infection.19,20 Furthermore, some reports have been published showing the possibility to treat periodontal defects by means of orthodontic treatment.9–13 In order to focus on this issue, the aim of this systematic review was to evaluate the efficacy of the orthodontic treatment, alone or in combination with periodontal therapy in the treatment of infraosseous defects, gingival recessions and furcation defects. In particular, the first step of this study was to find RCTs dealing with orthodontic therapy alone or in combination with periodontal techniques to treat the abovementioned periodontal defects. The search was addressed to identify RCTs and SR which compare Orthodontic Treatment vs Periodontal Therapy, or Orthodontic Treatment plus Periodontal Therapy vs Periodontal Therapy alone; or Orthodontic Treatment vs Orthodontic Treatment in the orthodontic and periodontal literature published in the last 40 years. Only RCTs and SR were selected because other studies such as case reports, case series and not randomized controlled trials do not provide useful information about the efficacy of the therapy. The second aim was to perform a meta-analysis on this issue based on the available RCTs if possible. However, the result of this systematic review showed a complete lack of randomized controlled clinical trials and systematic reviews on this topic. Therefore, it was impossible to perform a subsequent meta-analysis. As a consequence, up to now, the efficacy of the orthodontic therapy alone or in combination with periodontal techniques is not clearly proved, and it is yet based on a low level of evidence. Therefore, the clinicians should perform these therapies with adequate criticism and particular attention for each clinical case. It is also of paramount importance before treatment to appropriately inform patients about the unclear efficacy of the orthodontic therapy applied to treat periodontal defects. For this reason, it appears important to encourage the researchers to produce randomized controlled clinical trials on the efficacy of the orthodontic treatment as a single approach or in combination with the periodontal therapy in the treatment of the infrabony defects, gingival recessions or furcation lesions.
Discussion
In Periodontology, the ideal treatment of periodontal defects would be the reconstruction of lost periodontal tissues. Several surgical techniques have been proposed thus including guided tissue regeneration (GTR), bone grafting (BG) and the use of enamel matrix derivative (EMD). All these treatments have been shown to be effective in particular to regenerate infrabony defects.5 In case of defects affecting multi-rooted teeth, regenerative procedures may not be effective to treat furcation defects. In these cases, resection therapies including root resection remain important procedures in periodontal therapy.18 In case of gingival recessions caused by traumatic injuries (i.e., toothbrushing trauma), it has been reported that several mucogingival techniques result effective in obtaining a
Conflict of interest The authors have reported no conflicts of interest.
Riassunto Numerosi studi hanno riportato la possibilità di trattare ortodonticamente pazienti che presentavano difetti parodontali. Scopo di questa revisione sistematica è quello di valutare l’efficacia del trattamento ortodontico per la terapia di difetti infraossei, recessioni gengivali e lesioni delle forcazioni. Al fine di stabilire un’appropriata strategia di ricerca è stato messo a punto un foglio di lavoro PICO. Solo studi di tipo controllato randomizzato (RCT) e revisioni sistematiche (SR) sono stati selezionati. Una ricerca elettronica, dal gennaio 1966 al
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progress in orthodontics 1 1 ( 2 0 1 0 ) 41–44
gennaio 2008, e una ricerca cartacea, dal gennaio 1988 al gennaio 2008, sono state condotte da tre revisori indipendenti, senza porre alcun limite alla lingua in cui sono stati scritti gli articoli. I risultati della ricerca hanno riportato un’assenza di studi del tipo RCT e SR, motivo per cui non è stato possibile eseguire una metanalisi. Sulla base dei suddetti risultati è importante incoraggiare i clinici e i ricercatori a produrre pubblicazioni scientifiche del tipo RCT al fine di investigare la reale efficacia del trattamento ortodontico, da solo o in combinazione con la terapia parodontale, per la risoluzone dei più comuni difetti che affliggono le strutture di supporto dentali e cioè difetti infraossei, recessioni gengivali e lesioni delle forcazioni.
Résumé Plusieurs études ont été édité sur la possibilité de soigner des patients affectés par des défauts périodontales au moyen de traitement orthodontique. Le but de cette revue systématique est d’évaluer l’efficacité du traitement orthodontique appliqué à la thérapie des défauts infraosseous, des récessions gingivales, et des lésions de furcation. Pour établir une stratégie de recherche appropriée on a employée la feuille de travail d’évaluation de PICO. Seulement des Randomized Controlled Trials and Systematic Reviews ont été choisies pour cette revue. La recherche électronique (de janvier 1966 à janvier 2008) et la recherche à la main (de janvier 1988 à janvier 2008) ont été conduites par 3 critiques indépendants. Il n’y avait aucune restriction de langue. Aucune Randomized Controlled Trials and Systematic Reviews ont été identifiées au cours de la période étudiée et donc il n’était pas possible d’effectuer la méta-analyse. Il semble important d’encourager les chercheurs à produire des tests cliniques commandés randomisés visant à étudier l’efficacité du traitement orthodontique, seulement ou en combination avec la thérapie périodontale, pour la résolution des défauts périodontiques.
Resumen Se publicaron diferentes estudios que se centran en la posibilidad de tratar a pacientes afectados por defectos periodontales por medio de un tratamiento ortodóntico. El objetivo de esta revisión sistemática es valorar la eficacia del tratamiento ortodóntico aplicado a la terapia de lo defectos intraóseos, recesiones gingivales y lesiones de furcación. Con vistas a establecer una adecuada estrategia de investigación se utilizó la hoja de valoración y trabajo PICO. Para esta revisión se utilizaron sólo Ensayos Controlados Aleatorizados y Revisiones Sistemáticas. La búsqueda electrónica (de enero de1966 a enero de 2008) y la búsqueda manual (de enero de 1988 a enero de 2008) fueron llevadas a cabo por tres revisores independientes. No hubo restricción lingüística. Los Ensayos Controlados Aleatorizados y las Revisiones Sistemáticas fueron identificados durante el periodo investigado y por lo tanto no es posible realizar meta-análisis. Es menester instar a los investigadores a producir Ensayos clínicos Controlados Aleatorizados que apunten a profundizar en la eficacia del tratamiento ortodóntico, por sí solo o en combinación con el tratamiento periodontal para remediar a los defectos periodontales.
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