Part I: 統合分析比較再生膜導合併骨移植物引牙周再生對大臼齒二級牙根分岔治療效果之系統性回顧 Part II: 系統性回顧比較單純清創手術, 牙釉質基衍生物及再生膜導引手術對動物大臼齒三級牙根分岔之治療效果

Part I: A systematic review of the treatment effect of guide tissue regeneration with or without bone grafting on the treatment of molar class II furcation involvement with meta-analysis. Part II: A systematic review of the outcome comparison between open flap debridement, enamel matrix derivatives, guided tissue regeneration and combination therapy on the treatment of animal molar class III furcation involvement

陳宗宏(Tsung-Hung Chen)

指導教授 ： 呂炫堃

臺北醫學大學/口腔醫學院/牙醫學系碩博士班/碩士(2012年)

https://doi.org/10.6831/TMU.2012.00073

摘要

研究目的：對於多根牙牙根分岔處的牙周病變破壞，很多學者提出各種不同的治療方式，包括單純的翻瓣清創手術、骨整形手術、引導牙周再生手術以及近十年相當熱門的生長因子等。本研究計畫的目的旨要透過系統性的文獻回顧，並利用統合分析的統計方式，來比較再生膜導引牙周再生技術、再生膜引導合併骨移植物、牙釉質基衍生物以及單純牙周翻辦清創手術之間的臨床效果，以提供臨床醫師實證醫學的根據。
研究方法：我們經由電子資料庫 (the Cochrane Oral Health Group specialist trials register and MEDLINE and PubMed up to and including March 2012)，以及徒手搜尋牙周相關期刊，收集超過六個月以上的追蹤時間的隨機臨床試驗，經過 “PICOS” 的過程，建立試驗的納入及排除條件，並將各個文獻之資料萃取出作統合分析計算，比較單純翻瓣清創手術、再生膜引導牙周再生手術、再生膜引導合併骨移植物之牙周再生手術的臨床治療效果：計算牙根分岔關閉比例之勝算比，水平附連程度改變、垂直附連程度改變、水平骨充填量以及垂直骨充填量計算各個組別的平均差，並呈現計算結果之異質性。第二部分中，我們同樣利用系統性回顧的方法，研究單純翻瓣清創手術、再生膜引導牙周再生手術、牙釉質基衍生物手術與合併再生膜及牙釉質基衍生物之引導牙周再生手術，於動物大臼齒牙根分岔三級破壞的治療效果：比較組織學上的新牙周附連與牙周骨生成之百分比。
實驗結果：第一部分經過統合分析之後的結果，再生膜引導牙周再生以及再生膜合併骨移植物之牙周再生手術，不論是在上顎或下顎大臼齒，在所有臨床效果上都優於單純翻瓣清創手術，除了比較再生膜引導牙周再生與單純翻瓣清創手術於上顎之水平骨骨充填的結果之外，其餘統計結果皆達統計學上之顯著差異 (P < 0.001)；而再生膜合併骨移植物的治療效果又比再生膜引導牙周再生手術得到更好的臨床效果，並達到統計學上之顯著差異 (P < 0.001)。第二部分經過系統性回顧，由於各篇文章之異質性過大，無法利用統合分析比較各種臨床治療技巧之優劣，。
結論： 臨床上二級根岔破壞可藉由再生膜引導牙周再生手術獲得改善，若合併骨移植物則可得到更好的臨床效果，而這些改善程度在下顎臼齒大於上顎臼齒，但不能預期會完全關閉；在三級根岔破壞的方面，動物實驗中不論是單純再生膜引導牙周再生或合併牙釉質基衍生物都無法達到理想的治療結果，對於牙根分岔之牙周破壞，需要有更進一步的研究，來達到更穩定更理想的結果。

關鍵字

牙根分叉的牙周破壞 ； 牙釉基質衍生物 ； 牙周再生手術 ； 統合分析 ； 牙周疾病/治療 ； 系統性回顧

並列摘要

Aim: In the last two decades, several techniques have been proposed to achieve the goal of improving the prognosis of furcation involved teeth, such as open flap debridement, resective/inductive osseous surgery, guided tissue regeneration and growth factors combined into the surgeries. This study aim to systemic review the efficacy of guided tissue regeneration with membrane technique (with/without osseous grafting), enamel matrix derivative and open flap debridement along with meta-analysis to establish the evidences and guidelines in clinical therapy of periodontal furcation defects.
Materials and methods: Randomized controlled clinical trials (RCTs) of at least 6 months’ follow up comparing open flap debridement (OFD), guided tissue regeneration with membrane technique (GTR), and combined approach of GTR and osseous grafting are searched from the data sources including electronic databases (the Cochrane Oral Health Group specialist trials register and MEDLINE and PubMed up to and including March 2012) and hand-searched journals. Through the question format “PICOS”, data from the including articles are extracted and processed for meta-analysis. The outcomes measure are furcation closure rate, vertical/ horizontal bone fill (re-entry) and vertical/horizontal attachment level gain. On the seconed part, animal studies were searched with regard to comparison of OFD, GTR, enamel matrix derivative (EMD), and GTR+EMD in treatment of class III furcation defects. After the PICOS procedure, the data were extract for meta-analysis. The outcomes measure are new bone formation and new cementum formation in percentage.
Results: The meta-analysis showed that the GTR and GTR+OG groups achieved better clinical results than OFD group in all the outcome measurement (P < 0.001). The GTR+OG group obtained greater clinical benefits than GTR group (P < 0.001). The outcomes of animal studies systemic review showed that the heterogeneities among the included studies are too high to conduct a meta-analysis.
Conclusion: According to this systemic review of RCTs, the GTR technique seemed to be more effective than OFD for resolving class II periodontal furcation defects, and the GTR+OG technique showed even better clinical results. The outcomes were better for mandibles molars than for maxillary molars. However, the data indicated that complete resolution of mandible furcation still did not occur consistently. In the second part, there were great heterogeneities among animal studies and meta-analysis was not possible. The outcomes of each study couldn’t show any successful resolution of furcation defects. Further comprehensive studies should be made to establish a more predictable therapy of class III furcation defects.

並列關鍵字

furcation defects ； enamel matrix derivatives ； guided tissue regeneration ； meta-analysis ； periodontal diseases/ therapy ； systematic review

參考文獻

Anderegg, C. R., Martin, S. J., Gray, J. L., Mellonig, J. T. & Gher, M. E. (1991) Clinical evaluation of the use of decalcified freeze-dried bone allograft with guided tissue regeneration in the treatment of molar furcation invasions. J Periodontol 62, 264-268.

Andersson, B., Bratthall, G., Kullendorff, B., Grondahl, K., Rohlin, M. & Attstrom, R. (1994) Treatment of furcation defects. Guided tissue regeneration versus coronally positioned flap in mandibular molars; a pilot study. J Clin Periodontol 21, 211-216.

Araujo, M. G. & Lindhe, J. (1998) GTR treatment of degree III furcation defects following application of enamel matrix proteins. An experimental study in dogs. J Clin Periodontol 25, 524-530.

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Aukhil I, Pettersson E, Suggs C. Guided tissue regeneration. An experimental procedure in beagle dogs. J Periodontol 1986B;57:727-734.