臺灣博碩士論文加值系統

Background:
Managing impacted mandibular third molar (MTM), whether it’s asymptomatic or with periodontal defect, may be quite vexing for periodontists. There have been countless studies on treatment guidelines and procedures, particularly with asymptomatic and second molar periodontal osseous defect (POD); however most results still remain to be controversial. To date there have not been a robust concept and instructions on such circumstance. As of current discussion, it is still a challenge in making the decision on whether to receive MTM extractions, more specifically as to when and how the procedure should be done.

Purpose:
The aim of this study is to briefly review the latest research on the management of POD after extraction of impacted MTM and find a new clinical decision tree.

Materials and Methods:
This current study was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Literatures concerning the treatment of POD after third molar extraction were searched electronically and manually from The Medline, Embase and Cochrane databases up to December 2017. Over this review, we intent to answer the following focused questions: (1) Are asymptomatic site of MTM free from disease in a long term follow up? (2) Can age be an independent factor in evaluating third molar extraction? (3) Will ridge preservation enhance postoperative extraction prognosis? (4) Is different type of flap design as the main contributing factor in treatment outcome over long term follow up? The clinical outcomes included patient ages, probing depth (PD), ridge preservation, flap design with a follow up > 6 months.

Results:
With a total of 11 studies included for meta-analysis, there was no adequate evidence for discussion in regards to asymptomatic vs disease site of third molar in long term follow up. Postoperative PD over second molar distal site of participants with mean age below 25 would still remain lesser than 5 mm, while residual pockets remain around 5 mm after 6 months at the age of 25 and above with cases of initial PD > 7 mm. For ridge preservation over MTM extraction site, significant positive effect can be seen in the reduction of second molar distal site PD, regardless of the different biomaterials being placed during more than 6 months follow up period (z = 4.69, p < 0.00001). Regarding flap design, when comparing to triangular flap, both the Szmyd flap (z = 1.05, p = 0.29, I2 = 53%) and envelope flap (z = 1.88, p = 0.06, I2 = 94%) failed to show significant difference over PD reduction.

Conclusion:
Age is of utmost importance in preoperative evaluation during extraction of impacted MTM. The timing for ridge preservation is another essential determinant in order to achieve optimal treatment outcome and prognosis. All these circumstances should be considered carefully before deciding on a treatment plan. The clinical decision tree that we proposed could serve as guidance for clinicians on how to deal with POD after extraction of impacted MTM.

Clinical relevance:
As treatment strategy progresses every day to surpass, clinicians still strive for further understanding of various contributing factors in impacted MTM removal. Through our clinical decision tree, clinical relevance in research is translated for a refinement in clinical practice.

ABSTRACT

Background:
Managing impacted mandibular third molar (MTM), whether it’s asymptomatic or with periodontal defect, may be quite vexing for periodontists. There have been countless studies on treatment guidelines and procedures, particularly with asymptomatic and second molar periodontal osseous defect (POD); however most results still remain to be controversial. To date there have not been a robust concept and instructions on such circumstance. As of current discussion, it is still a challenge in making the decision on whether to receive MTM extractions, more specifically as to when and how the procedure should be done.

Purpose:
The aim of this study is to briefly review the latest research on the management of POD after extraction of impacted MTM and find a new clinical decision tree.

Materials and Methods:
This current study was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Literatures concerning the treatment of POD after third molar extraction were searched electronically and manually from The Medline, Embase and Cochrane databases up to December 2017. Over this review, we intent to answer the following focused questions: (1) Are asymptomatic site of MTM free from disease in a long term follow up? (2) Can age be an independent factor in evaluating third molar extraction? (3) Will ridge preservation enhance postoperative extraction prognosis? (4) Is different type of flap design as the main contributing factor in treatment outcome over long term follow up? The clinical outcomes included patient ages, probing depth (PD), ridge preservation, flap design with a follow up > 6 months.

Results:
With a total of 11 studies included for meta-analysis, there was no adequate evidence for discussion in regards to asymptomatic vs disease site of third molar in long term follow up. Postoperative PD over second molar distal site of participants with mean age below 25 would still remain lesser than 5 mm, while residual pockets remain around 5 mm after 6 months at the age of 25 and above with cases of initial PD > 7 mm. For ridge preservation over MTM extraction site, significant positive effect can be seen in the reduction of second molar distal site PD, regardless of the different biomaterials being placed during more than 6 months follow up period (z = 4.69, p < 0.00001). Regarding flap design, when comparing to triangular flap, both the Szmyd flap (z = 1.05, p = 0.29, I2 = 53%) and envelope flap (z = 1.88, p = 0.06, I2 = 94%) failed to show significant difference over PD reduction.

Conclusion:
Age is of utmost importance in preoperative evaluation during extraction of impacted MTM. The timing for ridge preservation is another essential determinant in order to achieve optimal treatment outcome and prognosis. All these circumstances should be considered carefully before deciding on a treatment plan. The clinical decision tree that we proposed could serve as guidance for clinicians on how to deal with POD after extraction of impacted MTM.

Clinical relevance:
As treatment strategy progresses every day to surpass, clinicians still strive for further understanding of various contributing factors in impacted MTM removal. Through our clinical decision tree, clinical relevance in research is translated for a refinement in clinical practice.

Table of Contents

ABSTRACT 5
CHAPTER 1: INTRODUCTION 8
1.1 General Background Information 8
1.2 Clinical decision tree for the management of treating impacted third molar 10
CHAPTER 2: LITERATURE REVIEW 11
2.1 Preoperative Evaluation: Asymptomatic versus Disease Site 11
2.2 Age: An independent factor for third molar extraction 12
2.3 Postoperative Evaluation: Ridge preservation 13
2.4 Is Surgical skill not the main contributing factor on treatment outcome over long term follow up? 16
CHAPTER 3: MATERIALS AND METHODS 17
3.1 Research Design 17
3.1.1 Type of studies 17
3.1.2 Focused question 17
3.1.3 Search strategy 17
3.2 Subjects/ Participants 19
3.2.1 Types of participant 19
3.2.2 Types of intervention 19
3.3 Selection criteria 20
3.3.1 Inclusion criteria 20
3.3.2 Exclusion criteria 20
3.4 Data Collection Procedure 21
3.4.1 Section of studies 21
3.4.2 Data extraction 21
3.4.3 Outcome measures 21
3.5 Assessment of Risk of Bias 22
3.6 Statistical analysis 23
CHAPTER 4: RESULTS 24
4.1 Search strategy and screening process 24
4.2 Risk of bias assessment 24
4.3 Qualitative review and meta-analysis of studies 25
4.3.1 Asymptomatic versus disease site of third molar 25
4.3.2 Age 25
4.3.3 Ridge Preservation 26
4.3.4 Flap Design 27
4.4 Clinical decision making dealing with impacted third molar 27
CHAPTER 5: DISCUSSION 28
5.1 Asymptomatic versus disease site of third molar 28
5.2 Age was an independent factor for third molar extraction 30
5.3 Ridge preservation as a main role for postoperative outcome 32
5.4 Flap design won’t influence the prognosis of second molar distal PD 34
CHAPTER 6: CONCLUSION 35
REFERENCES 36
FIGURES 43
Figure 1. Important aspects should be deliberated when facing impacted third molar extraction. 43
Figure 2. Flowchart of search strategy and screening process. 44
Figure 3: Risk of bias of the included studies 45
Figure 4a. The postoperative PD over second molar distal site of patients with mean age of < 25 years. 46
Figure 4b. The postoperative PD over second molar distal site of patients with mean age of < 25 years: Preoperative PD < 5 mm 47
Figure 4c. The postoperative PD over second molar distal site of patients with mean age of < 25 years: Preoperative PD > 5 mm 47
Figure 5a. The postoperative PD over second molar distal site of patients with mean age of > 25 years. 48
Figure 5b. The postoperative PD over second molar distal site of patients with mean age of > 25 years: Preoperative PD < 5 mm 49
Figure 5c. The postoperative PD over second molar distal site of patients with mean age of > 25 years: Preoperative PD > 5 mm 49
Figure 5d. The postoperative PD over second molar distal site of patients with mean age of > 25 years: Preoperative PD > 7 mm 50
Figure 6a. Weighted mean difference of PD over second molar distal site after > 6 months follow up 51
Figure 6b. Weighted mean difference of PD over second molar distal site with mean age > 25 years and more than 12 months follow up: Membrane used 51
Figure 6c. Weighted mean difference of PD over second molar distal site with mean age > 25 years and more than 12 months follow up: Preoperative PD < 5 mm 51
Figure 6d. Weighted mean difference of PD over second molar distal site with mean age > 25 years and more than 12 months follow up: Preoperative PD > 5-7 mm 52
Figure 6e. Weighted mean difference of PD over second molar distal site with mean age > 25 years and more than 12 months follow up: Preoperative PD > 7 mm 52
Figure 7a. Postoperative PD over second molar distal site with different type of flap design after > 6 months follow up 53
Figure 7b. Weighted mean difference of PD over second molar distal site after > 6 months follow up: Szmyd and Envelope flap versus Triangular flap 54
Figure 7c. Weighted mean difference of PD over second molar distal site after > 6 months follow up: Szmyd flap versus Triangular flap 54
Figure 7d. Weighted mean difference of PD over second molar distal site after > 6 months follow up: Envelope flap versus Triangular flap 54
Figure 8. Clinical decision making dealing with impacted third molar 55
TABLES 56
Table 1. Criteria for Studies Selected to Be Included in the Meta-analysis. 56
Table 2: The Cochrane Collaboration’s tool for assessing risk of bias. 57
Table 3: Assessment the quality of selected clinical studies. 58
Table 4: Summary of included studies 59
Table 5: Brief overview of the excluded studies 63

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