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Dimensional and histomorphometric evaluation of biomaterials used for alveolar ridge preservation: a systematic review and network meta-analysis

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Abstract

Objectives

This systematic review and network meta-analysis aimed to answer to the following questions: (a) In patients undergoing alveolar ridge preservation after tooth extraction, which grafting material best attenuates horizontal and vertical ridge resorption, as compared to spontaneous healing?, and (b) which material(s) promotes bone formation in the extraction socket?

Materials and methods

The MEDLINE, SCOPUS, CENTRAL, and EMBASE databases were screened in duplicate for RCTs up to March 2021. Two independent authors extracted the data and assessed the risk of bias of the included studies. Primary outcomes were ridge horizontal and vertical dimension changes and new bone formation into the socket. Both pairwise and network meta-analysis (NMA) were undertaken to obtain estimates for primary outcomes and compare different grafting materials.

Results

Eighty-eight RCTs were included, with a total of 2805 patients and 3073 sockets. Overall, a total of 1740 sockets underwent alveolar ridge preservation with different materials (1432 were covered by a membrane). Pairwise meta-analysis showed that, as compared to spontaneous healing, all materials statistically significantly reduced horizontal and vertical shrinkage. According to the multidimensional scale ranking of the NMA, xenografts (XG) and allografts (AG), alone or combined with bioactive agents (Bio + AG), were the most predictable materials for horizontal and vertical ridge dimension preservation, while platelet concentrates performed best in the percentage of new bone formation.

Conclusions

Alveolar ridge preservation is effective in reducing both horizontal and vertical shrinkage, as compared to untreated sockets. NMA confirmed the consistency of XG for ridge dimension preservation, but several other materials and combinations like AG, Bio + AG, and AG + alloplasts, produced even better results than XG in clinical comparisons. Further evidence is needed to confirm the value of such alternatives to XG for alveolar ridge preservation. Bio + AG performed better than the other materials in preserving ridge dimension and platelet concentrates in new bone formation. However, alloplasts, xenografts, and AG + AP performed consistently good in majority of the clinical comparisons.

Clinical relevance

XG and Bio + AG demonstrated significantly better performance in minimizing post-extraction horizontal and vertical ridge dimension changes as compared with other grafting materials or with spontaneous healing, even if they presented the worst histological outcomes. Allografts and other materials or combinations (AG + AP) presented similar performances while spontaneous healing ranked last.

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Author notes

  1. L. Canullo and M. Del Fabbro contributed equally to this work.

Authors and Affiliations

  1. Department of Periodontology, University of Bern, Bern, Switzerland

    L. Canullo & A. Sculean

  2. Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Milan, Italy

    M. Del Fabbro, S. Khijmatgar & S. Panda

  3. IRCCS Orthopedic Institute Galeazzi, Milan, Italy

    M. Del Fabbro & G. Tommasato

  4. Department of Periodontics and Oral Implantology, Siksha ‘O’ Anusandhan University, Bhubaneswar, India

    S. Panda

  5. Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, MI, USA

    A. Ravidà

  6. Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy

    P. Pesce

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Supplementary information

Supplemental Fig. 1.

Risk of Bias table (JPG 563 kb)

Supplemental Fig. 2

A-B-C. Spontaneous healing vs xenografts dimensional data 2a horizontal 2b vertical 2c histological data. (JPEG 4675 kb)

Supplemental Fig. 2

D. Subgroup analysis for SH Vs XG. The forest plot displays the study labels, the number of studies within each group ( K), the plot of effect sizes and their CIs ( plot), the values of effect sizes (Hedge’s g) and their CIs, and the p-values (p-value) of the corresponding significance tests. The test investigates whether the overall effect sizes corresponding to two groups are different or not. (PDF 970 kb)

Supplemental Fig. 3

A-B Spontaneous healing vs allografts dimensional data 3a horizontal 3b vertical 3c histological data. (JPEG 3072 kb)

Supplemental Fig. 3

D Subgroup analysis for SH Vs AG. The forest plot displays the study labels, the number of studies within each group ( K), the plot of effect sizes and their CIs ( plot), the values of effect sizes and their CIs (esci), and the p-values (pvalue) of the corresponding significance tests. The test investigates whether the overall effect sizes corresponding to two groups are the same. (PDF 904 kb)

Supplemental Fig. 4

A-B Spontaneous healing vs alloplasts dimensional data 4a horizontal 4b vertical 4c histological data (JPEG 3484 kb)

Supplemental Fig. 5

A-B Spontaneous healing vs platelet concentrates dimensional data 5a horizontal 5b vertical 5c histological data (JPEG 2009 kb)

Supplemental Fig. 6

A Network Geometry Plot for horizontal outcome in preserving alveolar socket for 3–4 months’ follow-up. Supplemental Fig. 6B. Predictive Interval and Confidence Interval Plot in preserving alveolar socket for 3–4 months’ follow-up. Supplemental Fig. 6C. Multidimensional Scale Ranking for 3–4 months’ follow-up for horizontal dimension. (JPEG 2363 kb)

Supplemental Fig. 7

A Network Geometry Plot for Horizontal Outcome in preserving alveolar socket for ≥ 6 months’ follow-up. Supplemental Fig. 7B. Predictive Interval and Confidence Interval Plot in preserving alveolar socket for ≥ 6 months’ follow-up for Horizontal Dimension. Supplemental Fig. 7C. Multidimensional Scale Ranking for ≥6 months’ follow-up for horizontal dimension. (JPEG 2228 kb)

Supplemental Fig. 8

A Network Geometry Plot for vertical dimension outcome in preserving alveolar socket for 3–4 months’ follow-up. Supplemental Fig. 8B. Predictive Interval and Confidence Interval Plot in preserving alveolar socket for ≥ 3–4 months’ follow-up for vertical dimension outcome. Supplemental Fig. 8C. Multidimensional Scale Ranking for 3–4 months’ follow-up for vertical dimension. (JPEG 2489 kb)

Supplemental Fig. 9

A Network Geometry Plot for vertical dimension outcome in preserving alveolar socket for ≥6 months’ follow-up. Supplemental Fig. 9B. Predictive Interval and Confidence Interval Plot in preserving alveolar socket for ≥ 6 months’ follow-up for vertical dimension. Supplemental Fig. 9C. Multidimensional Scale Ranking for 6 months’ follow-up for vertical dimension. (JPEG 2069 kb)

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Canullo, L., Del Fabbro, M., Khijmatgar, S. et al. Dimensional and histomorphometric evaluation of biomaterials used for alveolar ridge preservation: a systematic review and network meta-analysis. Clin Oral Invest 26, 141–158 (2022). https://doi.org/10.1007/s00784-021-04248-1

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