Abstract
In periodontitis patients, furcation defects are crucial sites to regenerate due to their complex anatomy. Various modern surgical techniques and use of biomaterials have been suggested in the literature. Among all, platelet-rich fibrin (PRF) has potential in tissue regeneration thanks to its role in the release of growth factors. Therefore, the purpose of this study was to evaluate the beneficial effect of the addition of PRF to open flap debridement (OFD) or as an adjuvant to other biomaterials such as bone grafts in the treatment of grade 2 mandibular furcation defects. Systematic research was carried out on the databases Medline, Scopus, Embase, and Cochrane Library and registered on PROSPERO (CRD42020167662). According to the PICO guidelines by Cochrane, randomized trials and prospective non-randomized trials were evaluated, with a minimum follow-up period of 6 months. The inclusion criteria were the absence of systemic diseases, non-smoking patients, and a population aged from 18 to 65 years. Vertical pocket probing depth (PPD), vertical clinical attachment level (VCAL), and gingival recession (REC) were the primary outcomes. Vertical furcation depth (VFD), and the percentage of bone defect fill (%v-BDF) were considered as secondary outcomes. A meta-analysis of the primary and secondary outcomes was performed. Publication bias was assessed through a funnel plot. Eighty-four articles were initially extracted. Eight randomized clinical trials were analyzed according to the exclusion and inclusion criteria. The Quality assessment instrument (QAI) revealed four articles at low risk of bias, one at moderate, and three at high risk of bias. The metanalysis showed significant data regarding PPD, VCAL, VFD and %v-BDF in the comparison between PRF + OFD vs. OFD alone. The adjunct of PRF to a bone graft showed a significant difference for VCAL and a not statistically significant result for the other involved parameters. In conclusion, the adjunctive use of PRF to OFD seems to enhance the periodontal regeneration in the treatment of grade 2 furcation defects. The combination of PRF and bone graft did not show better clinical results, except for VCAL, although the amount of literature with low risk of bias is scarce. Further well-designed studies to evaluate the combination of these two materials are therefore needed.
Highlights
The clinical management of furcation defects is still a crucial issue due to the position of the furcation and the irregular anatomy of the roots, which makes the biofilm virtually inaccessible for oral hygiene measures
According to the formulated PICOS question, a framework developed to facilitate the literature search, this systematic review focused on all types of human studies, on young and adult periodontal patients with grade 2 furcation defects in first and second mandibular molars with a probing depth of minimum 5 mm and a horizontal depth of 3 mm that received the additional application of platelet-rich fibrin (PRF) to an open flap debridement (OFD) or a bone grafting (BG) treatment, evaluating the amount of soft and hard tissue regeneration, compared to subjects treated with OFD or BG alone
Seven abstracts were discarded due to the methodology not corresponding to the inclusion criteria; 15 full text papers were suitable for detailed examination; six articles were discarded according to the exclusion criteria after full text screening, and one article was excluded because some inconsistencies between the data reported in the tables and those reported in the text were found
Summary
The clinical management of furcation defects is still a crucial issue due to the position of the furcation and the irregular anatomy of the roots, which makes the biofilm virtually inaccessible for oral hygiene measures. The use of membranes requires specific considerations such as a more invasive flap, an additional surgery to remove the membrane (in case of non-resorbable membranes), and the possible exposure of the membrane that may compromise the results In light of these considerations, the actual tendency is to prefer minimally-invasive-surgical procedures and to look for highly performant materials to limit the use of synthetic membranes, especially when treating contentive defects. Even though these regenerative materials are still used today, the introduction of biomimetic agents, such as enamel matrix derivatives, bone morphogenetic proteins, and platelets concentrates, raises new opportunities for better outcomes in periodontal treatment [4,5,6,7]. Promising results from the use of endogenous materials seem to overcome the limits of exogenous-crafted materials and enhance the regenerative potential of bone graft materials (Table 1)
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