Accepted Article

Article Type : Systematic Review

Clinical performance of access flap in
the treatment of class II furcation
defects. A systematic review and metaanalysis of randomized clinical trials.
Filippo Graziani 1 , Stefano Gennai 1 , Dimitra Karapetsa 1 , Stefano Rosini 1 , Natalia Filice 1 ,
Mario Gabriele 1 , Maurizio Tonetti 2

1. DEPARTMENT OF SURGERY, UNIT OF DENTISTRY AND ORAL SURGERY, UNIVERSITY OF PISA

2. EUROPEAN RESEARCH GROUP ON PERIODONTOLOGY, GENOVA, ITALY

Running title:
Conservative surgical approach of furcation defects

Key words:
furcation defects, access flap, conservative surgery, meta-analysis

Abstract
Objectives: To systematically review the performance of access flap (OFD) in the treatment of class II
furcation-defects (FD).

Methods: RCTs evaluating surgical treatment of class II FD with OFD, minimum 6 months follow-up
were identified. Screening, data extraction and quality assessment were conducted independently

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/jcpe.12327
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Accepted Article

by 3 reviewers. The primary outcomes were tooth survival and change in horizontal clinical
attachment level (HCAL). Changes in vertical clinical attachment level (VCAL), reduction of pocket
probing depth (PPD), recession increase (REC), horizontal (HBL) and vertical bone level (VBL) were
also collected.

Results: The search identified 1571 studies out of which 11 articles met the inclusion criteria. Data
analysis was performed on 199 patients and 251 FD. Tooth survival was seldom reported. Altogether
with inflammatory amelioration, the weighted mean differences were for HCAL 0.96 mm (CI: [0.60,
1.32], p <0.001), 0.55 mm (CI: [0.00, 1.10], p= 0.05) for VCAL gain. PPD reduction over 6 months was
1.38 mm (CI: [0.91, 1.85], p < 0.01). Potential risk of bias was identified.

Conclusions: Teeth with mandibular class II furcation involvement treated with OFD show significant
clinical improvements 6 months after surgery. Nevertheless, in order to better understand the
magnitude of this changes and their clinical relevance, prospective long term trials are needed.

Conflict of Interest and Sources of Funding Statement

The authors report no conflict of interest for this study. The study was self-supported partly
by the Unit of Dentistry and Oral Surgery of the University of Pisa and partly by the Italian
Ministry Health and the Tuscan Region (Grant # GR-2009-1592229).

Clinical relevance
Scientific rationale for the study: To assess the clinical performance of access flap in the
treatment of class II furcation defects.

Principal findings: Access flap shows evident clinical improvements in the short term. Long
term trials and trials focusing on maxillary molars are lacking.

Practical implications: Clinicians should be aware that conservative surgery is capable of

certain clinical performance especially in mandibular class II furcation defects. Long term
trials are needed.

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Accepted Article

Results of individual studies and synthesis of results

Baseline characteristics of the included defects and subjects
Mean age of the included subjects was 45 years, ranging from 37 to 52. Smoking habit was reported
in only 4 studies, 3 of them consisted of a no smoking population (Bremm et al. 2004, Pradeep et al.
2009, Santana et al. 2009) and one of them reported a mixed smokers- no smokers population
(Lekovic et al. 2003). The total sample consisted of 199 subjects contributing with 251 teeth
presenting class II furcation defects. Seven studies reported only mandibular furcations (Lekovic et
al. 1989, 1991, 2003, Anderegg et al. 1999, Bremm et al. 2004, Pradeep et al. 2009, Santana et al.
2009). Three studies included both maxillary and mandibular molars presenting furcation defects
(Flanary et al. 1991, Yukna & Yukna 1996, Houser et al. 2001) whereas only one study analysed
exclusively maxillary furcations (Casarin et al. 2010).

Surgical technique
The surgical techniques employed were thoroughly described in all included studies. Four studies
reported a coronally advanced flap (Lekovic et al. 1989, Flanary et al. 1991, Bremm et al. 2004,
Santana et al. 2009) while six articles reported a flap in original position (Lekovic et al. 1991,
Anderegg et al. 1999, Houser et al. 2001, Lekovic et al. 2003, Pradeep et al. 2009, Casarin et al.
2010). Yukna et al. (Yukna & Yukna 1996) only referred to the surgical technique as full thickness
flap. Bremm et al. further reported that the molar root surface was treated with 10% tetracycline
solution for 3-5 minutes before performing a coronally advanced flap.

Primary outcomes
Tooth loss
In seven studies (Flanary et al. 1991, Lekovic et al. 1991, Yukna & Yukna 1996, Anderegg et al. 1999,
Houser et al. 2001, Bremm et al. 2004, Pradeep et al. 2009) healing was reported as uneventful and
no complications were noted. No studies, however, reported tooth loss/ survival as primary
outcome and only in one out of eleven studies tooth survival was clearly reported in the result
section (Yukna & Yukna 1996).

HCAL gain
Five studies reported change in HCAL over a 6 months period (Flanary et al. 1991, Bremm et al. 2004,
Pradeep et al. 2009, Santana et al. 2009, Casarin et al. 2010). WMD was 0.96 mm (95% CI [0.60,
1.32], p< 0.001) at 6 months. Chi-square for heterogeneity was 16.66 (df=4), p=0.002 at 6 months.

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Accepted Article

Figure 2. Forest plot from fixed effects of meta-analysis evaluating the difference in HCAL gain (in
mm) 6 months and longer term.

Figure 3. Forest plot from fixed effects of meta-analysis evaluating the difference in VCAL gain (in
mm) 6 months and longer term.

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Accepted Article

Disease: (furc* [txt words] OR molar* [txt words] OR multi-rooted* [txt words] OR
radicular [txt words])

AND

Study design: (longitudinal study [mesh] OR randomized controlled study [mesh] OR

comparative study [mesh] OR clinical trial [mesh] OR controlled study OR prospective
study).

Hand searching was also performed on Journal of Periodontology, the Journal of Periodontal
Research and the Journal of Clinical Periodontology up to December 2013 and on bibliographies of
all retrieved papers and review articles.

Study selection and Data Collection

Eligibility assessment was performed through titles and abstract analysis and full text analysis. Titles
and abstracts of the search results were initially screened by the three reviewers (D.K., S.G., S.R.), for
possible inclusion in the review. Reviewers were calibrated for study screening against another
reviewer (F.G.) with experience in conducting systematic reviews. Each round of calibration
consisted of a duplicate, independent validity assessment of 20 titles and abstracts from the search.
After two rounds of calibration a consistent level of agreement was found (un-weighted k scores
from first to third exercise: 0.84, 0.90 and 0.98).

In order not to exclude potentially relevant articles, unclear abstracts were included in the full text
analysis. The full text of all studies of possible relevance was then obtained for independent
assessment by three reviewers (D.K., S.G., S.R.) against the stated inclusion criteria. Any
disagreement was resolved by discussion among the reviewers. The three reviewers conducted all
quality assessments independently and data of the included articles were extrapolated through an
ad hoc extraction sheet.

Data items
The primary outcome measures were tooth loss and horizontal clinical attachment level (HCAL) gain.
Secondary outcomes were change in vertical clinical attachment level (VCAL), reduction of pocket
probing depth (PPD), increase of recession (REC), horizontal and vertical bone level (HBL and VBL)
gain and change in bleeding on probing (BoP). Tooth survival was defined as the percentage of
retained teeth. When percentage was not provided, calculations were performed based on the raw
data reported in the paper.
HCAL and VCAL gain, PPD reduction, REC increase, HBL and VBL gain had to be expressed as the
average difference baseline/follow-up of the treated sites in millimetres. BoP was expressed as the
difference baseline/follow-up. VCAL was defined as the distance between the bottom of the pocket
and a fixed reference point (i.e. cement enamel junction), whereas HCAL was measured at the

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Accepted Article

furcation fornix with the root eminences of the mesial and distal roots as the fixed reference. The
VBL was evaluated using a PCP-15 periodontal probe and the HBL using a specific modified
periodontal probe, designed to evaluate the horizontal component of the defect (Suh et al. 2002).
The reviewers did not make any additional calculations on these parameters. Thus, studies not
reporting differences between baseline and follow-up examinations were excluded unless data of
each patient was provided. In the latter case average difference was calculated by the authors.

Risk of bias in individual studies

Risk of bias was evaluated through a process of quality analysis performed by two reviewers (S.G.
and D.K.).
Quality analysis of Randomized Clinical Trial (RCT) according to the Cochrane Reviewers Handbook
(Higgins & Green 2011) implied the assessment of six RCT issues: (i) random sequence generation,
(ii) allocation concealment, (iii) blinding of participants, personnel and outcome assessors (iv),
handling of incomplete outcome data, v) selective outcome reporting and vi) other sources of bias.
All the six included issues were finally deemed as adequate, inadequate or unclear (Higgins et al.
2009). In order to properly assess other source of bias the CONSORT guidelines for nonpharmacological treatments (NPT) were used such as information concerning the study design, the
source of funding, the setting of the study, the therapists expertise, the definition of level analysis,
the calibration, the statistical methods, the definition of the furcation defect, the participants
smoking habits, the initial oral hygiene conditions and the supportive periodontal treatment were
considered (Boutron et al. 2008).
Risk of bias across studies
Heterogeneity between the studies was tested and evaluated through Q and I2 test. A p value of Q
statistic <0.1 was defined as an indicator of heterogeneity. The I2 statistic was used to describe
variations across studies due to heterogeneity rather than chance, with I2 over 75% being considered
to indicate substantial heterogeneity (Higgins & Thompson 2002). A fixed-effects model was used
when the heterogeneity among studies was statistically significant, whereas a random-effects was
chosen otherwise.

Summary measures and synthesis of the results

Clinical performance in terms of VCAL gain, HCAL gain, PPD reduction, REC increase, HBL gain and
VBL gain was calculated as a weighted treatment effect (preoperative-postoperative) and the results
were expressed as WMD and 95% CI for continuous outcomes using both fixed and random models.
Mean differences and standard errors were entered for each study in order to combine parallel
group and intra-individual (split-mouth) studies (Needleman et al. 2005). The patient was the unit of
the analysis. Analyses were performed with OpenMeta[Analyst]
(http://www.cebm.brown.edu/open_meta/open_meta/open_meta). Data were collected in
evidence tables and results of the meta-analysis were summarized with forest plots.

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Accepted Article

Additional analysis
A subgroup analysis, was conducted to explore heterogeneity among studies when study design
presented similarities among different trials. Parameters analysed were: position of the furcation
defects (mandibular or maxillary), location of the furcation (buccal/distal/mesial for the upper jaw
and buccal/lingual for the lower jaw), type of maintenance, smoking habits. The results were
summarized in a table reporting the difference in PPD reduction, VCAL gain, HCAL gain, REC increase,
HBL gain and VBL gain at 6 months.

Results
Study selection
A total of 1571 studies were identified for inclusion in the review. The electronic search determined
a total of 1559 articles. Hand searching identified a further 12 articles for the full text analysis (Fig.
1). Screening of titles and abstracts led to rejection of 1526 articles and thus the full text of the
remaining 45 articles was obtained. After full-text analysis and the exclusion of further 34 articles
(reasons for exclusion and list of excluded articles are reported in Appendix 1), the remaining 11
articles were analysed for methodological quality and availability of data for meta-analysis. These 11
manuscripts, representing 11 trials, met the criteria for inclusion in this meta-analysis (Lekovic et al.
1989, 1991, 2003, Flanary et al. 1991, Yukna & Yukna 1996, Anderegg et al. 1999, Houser et al. 2001,
Bremm et al. 2004, Pradeep et al. 2009, Santana et al. 2009, Casarin et al. 2010). Characteristics of
the included studies are reported in Table 1. One trial was of parallel group design (Santana et al.
2009), 9 were split mouth (Lekovic et al. 1989, 1991, 2003, Flanary et al. 1991, Yukna & Yukna 1996,
Anderegg et al. 1999, Bremm et al. 2004, Pradeep et al. 2009, Casarin et al. 2010) and one presented
a mixed parallel-split mouth design (Houser et al. 2001). Of the included articles, one reported 24
months follow-up (Casarin et al. 2010), 2 reported 12 months follow-up (Yukna & Yukna 1996,
Santana et al. 2009) and the remaining 8 reported 6 months follow-up (Lekovic et al. 1989, 2003,
Anderegg et al. 1999, Houser et al. 2001, Bremm et al. 2004, Pradeep et al. 2009).

Risk of Bias in individual studies

Analysis of the risk of bias in individual studies showed adequate methods of randomization (coin
tossing) in 7 out of 11 studies (Flanary et al. 1991, Houser et al. 2001, Lekovic et al. 2003, Pradeep et
al. 2009, Santana et al. 2009, Casarin et al. 2010) whereas two studies did not report any information
concerning the sequence generation (Yukna & Yukna 1996, Bremm et al. 2004) (Table 2). Allocation
concealment was only reported in one of the studies (Casarin et al. 2010). Examiner blinding was
evident in five out of eleven studies (Casarin et al. 2010, Santana et al. 2009, Pradeep et al. 2009,
Bremm et al. 2004, Lekovic et al. 2003). None of the studies reported losses to follow-up and all the
outcomes stated in the material & method section were analysed and presented. Other sources of
bias are thoroughly documented in table 2. Thus, a gradient of risk of bias may be noted among the
included studies indicating that Casarin and co-workers (Casarin et al. 2010) showed the lowest risk
of bias and Yukna & Yukna (Yukna et al. 1996) the higher.

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Results of individual studies and synthesis of results

Baseline characteristics of the included defects and subjects
Mean age of the included subjects was 45 years, ranging from 37 to 52. Smoking habit was reported
in only 4 studies, 3 of them consisted of a no smoking population (Bremm et al. 2004, Pradeep et al.
2009, Santana et al. 2009) and one of them reported a mixed smokers- no smokers population
(Lekovic et al. 2003). The total sample consisted of 199 subjects contributing with 251 teeth
presenting class II furcation defects. Seven studies reported only mandibular furcations (Lekovic et
al. 1989, 1991, 2003, Anderegg et al. 1999, Bremm et al. 2004, Pradeep et al. 2009, Santana et al.
2009). Three studies included both maxillary and mandibular molars presenting furcation defects
(Flanary et al. 1991, Yukna & Yukna 1996, Houser et al. 2001) whereas only one study analysed
exclusively maxillary furcations (Casarin et al. 2010).

Surgical technique
The surgical techniques employed were thoroughly described in all included studies. Four studies
reported a coronally advanced flap (Lekovic et al. 1989, Flanary et al. 1991, Bremm et al. 2004,
Santana et al. 2009) while six articles reported a flap in original position (Lekovic et al. 1991,
Anderegg et al. 1999, Houser et al. 2001, Lekovic et al. 2003, Pradeep et al. 2009, Casarin et al.
2010). Yukna et al. (Yukna & Yukna 1996) only referred to the surgical technique as full thickness
flap. Bremm et al. further reported that the molar root surface was treated with 10% tetracycline
solution for 3-5 minutes before performing a coronally advanced flap.

Primary outcomes
Tooth loss
In seven studies (Flanary et al. 1991, Lekovic et al. 1991, Yukna & Yukna 1996, Anderegg et al. 1999,
Houser et al. 2001, Bremm et al. 2004, Pradeep et al. 2009) healing was reported as uneventful and
no complications were noted. No studies, however, reported tooth loss/ survival as primary
outcome and only in one out of eleven studies tooth survival was clearly reported in the result
section (Yukna & Yukna 1996).

HCAL gain
Five studies reported change in HCAL over a 6 months period (Flanary et al. 1991, Bremm et al. 2004,
Pradeep et al. 2009, Santana et al. 2009, Casarin et al. 2010). WMD was 0.96 mm (95% CI [0.60,
1.32], p< 0.001) at 6 months. Chi-square for heterogeneity was 16.66 (df=4), p=0.002 at 6 months.

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Forest plot of the HCAL gain after surgical intervention is reported in Fig. 2. Casarin and co-workers
also reported data 24 months after OFD showing a mean HCAL difference of 0.7 1.3 mm (Casarin et
al. 2010).

Secondary outcomes
VCAL gain
Ten out of 11 studies reported VCAL gain calculation over 6 months (Casarin et al. 2010, Santana et
al. 2009, Pradeep et al. 2009, Bremm et al. 2004, Lekovic et al. 2003, Houser et al. 2001, Yukna &
Yukna 1996, Lekovic et al. 1991, Flanary et al. 1991, Lekovic et al. 1989). VCAL gain at 6 months was
0.55 mm (95% CI [0.00, 1.10], p= 0.048). Chi-square for heterogeneity was 199.49 (df=9), p< 0.001.
Forest plot of the VCAL gain after surgical intervention is presented in Fig. 3.

PPD reduction
PPD reduction over 6 months was reported in 9 studies (Flanary et al. 1991, Lekovic et al. 1991,
Yukna & Yukna 1996, Anderegg et al. 1999, Houser et al. 2001, Bremm et al. 2004, Pradeep et al.
2009, Santana et al. 2009, Casarin et al. 2010) and it was 1.38 mm (95% CI [0.91, 1.85], p< 0.001)
(Appendix 2). Chi-square for heterogeneity was 59.38 (df=8), p< 0.01.

REC increase
REC increase over 6 months was 0.73 mm (95% CI [0.37, 1.09], p< 0.01 as reported in 10 studies
(Lekovic et al. 1989, 1991, 2003, Flanary et al. 1991, Yukna & Yukna 1996, Houser et al. 2001, Bremm
et al. 2004, Pradeep et al. 2009, Santana et al. 2009, Casarin et al. 2010) (Appendix 2). Chi-square
for heterogeneity was 148.60 (df=9), p< 0.01.

HBL gain
Five studies presented data for HBL gain calculation over 6 months (Lekovic et al. 1989, 1991, 2003,
Yukna & Yukna 1996, Casarin et al. 2010). HBL gain at 6 months was 0.09 mm (95% CI [-0.16, 0.34],
p=0.461. Chi-square for heterogeneity was 19.750 (df=4), p< 0.001.

VBL gain
Eight studies contributed to VBL gain calculation over 6 months (Lekovic et al. 1989, 1991, 2003,
Flanary et al. 1991, Yukna & Yukna 1996, Pradeep et al. 2009, Santana et al. 2009, Casarin et al.
2010). VBL gain at 6 months was -0.17 mm (95% CI [-0.21, -0.13], p< 0.001. Chi-square for
heterogeneity was 68.92 (df=7), p< 0.01.

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BoP
Six studies presented data concerning the BoP at baseline and after the follow-up period (Lekovic et
al. 1989, 1991, 2003, Pradeep et al. 2009, Santana et al. 2009, Casarin et al. 2010) (Table 4). All six
studies reported amelioration of the inflammatory clinical condition.

Results of the subgroup analysis

The first subgroup analysis consisted of two groups stratifying for maxillary (Casarin et al. 2010) or
only mandibular (Lekovic et al. 1989, 1991, 2003, Anderegg et al. 1999, Bremm et al. 2004, Pradeep
et al. 2009, Santana et al. 2009) furcation defects. Findings from subgroup analysis revealed a
statistically significant PPD reduction, REC increase (p < 0.01) and HCAL gain (p < 0.001) for the
mandibular defects 6 months after conservative surgical treatment. The subgroup analysis on the
location of the furcation defect showed a statistically significant (p < 0.01) PPD reduction, REC
increase, HCAL gain and VBL gain in the treatment of mandibular buccal furcation (Appendix 3).

No other subgroup analysis was possible due to heterogeneity of the included manuscripts.

Discussion
This systematic review reports the clinical performance of access flap in the treatment of furcation
defects. Our data indicated that six months after surgery surrogate periodontal parameters showed
a significant improvement. Aim of this review was also to evaluate tooth survival that was rarely
directly reported. Indeed, most of the articles indicated that no adverse events or complications
occurred, and only one (Yukna & Yukna 1996) of them clearly stated that no tooth loss occurred.

The magnitude of the improvements of the clinical periodontal parameters was small. Horizontal
clinical attachment level gain (HCAL) is of importance as it testifies the capability of one treatment to
change the class of the furcation. Ideally, a treatment should be able to close the furcation or,
pragmatically, to reduce the furcation involvement to class I determining a better tooth prognosis as
the broader is the furcation involvement the higher is the chance of tooth loss (Hirschfeld
&Wasserman 1978). Such a transition may be of relevance as class I furcation lesions can be
successfully treated with non-surgical treatment and supportive periodontal treatment (SPT)
guaranteeing a long-term clinical success (Huynh-Ba et al. 2009). Our data indicated that
approximately 1 mm of HCAL change was noted 6 months after conservative surgery, an
improvement that most probably would not change the class of furcation or determine a furcation
closure. Indeed, furcation closure was reported in 7 out of the 11 included studies never indicating
furcation closure 6 months after OFD (Flanary et al. 1991, Yukna & Yukna 1996, Houser et al. 2001,
Bremm et al. 2004, Pradeep et al. 2009, Santana et al. 2009, Casarin et al. 2010).

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With regards to the other variables a clinical improvement trend may be noticed. In the first place a
resolution of the inflammation, clinically manifested as a BoP reduction, was remarked (Table 4).
Furthermore, PPD showed a consistent reduction of approximately 1.5 mm along with less than 1
mm recession. The clinical entity of these results underlines the stabilization of the periodontal
attachment of furcation defects after conservative surgery, while the added benefit in terms of PPD
reduction and VCAL gain may be of great clinical significance for the maintainability and the survival
of the involved elements. Interestingly, HBL gain at 6 months was almost imperceptible (0.09 mm).
However, this might be due to the fact that bone fill may require more time. Therefore, studies with
longer follow-up are needed to properly assess the clinical relevance of these modest improvements
in surrogate outcomes that point towards better resolution of inflammation and stabilization of the
disease process in furcation sites.

When interpreting these clinical changes the regular and rigorous SPT reported in all included
studies must be kept in mind. Patients were having gentle debridement for the whole study followup period and despite the different techniques and recall intervals observed in the included studies,
the incorporation of strict supervised maintenance care appears to be a fundamental determinant of
the clinical enhancement and therefore of the tooth survival (Renvert & Persson 2004, Axelsson et
al. 2004). This concept was further highlighted in a recent study reporting smoking and lack of
compliance with regular SPT as risk factors of tooth loss for multi-rooted teeth presenting with class
II and III furcation defects (Salvi et al. 2014). Unfortunately in the present meta-analysis, the
heterogeneity of the included studies, the design and the information provided for SPT and smoking
did not permit us to perform further analyses to better investigate the effect of these two variables
on the clinical parameters after surgery.

A subgroup analysis, for a subset of studies based on the location of the furcation defects, was
conducted to explore the considerable heterogeneity observed between studies. The analysis
involved two groups, studies reporting only maxillary or only mandibular furcation defects (Appendix
2). Interestingly, despite the clinical frequency of the maxillary furcation defects only one study
reported such data. Stratification showed that mandibular furcation defects, most probably due to
the anatomy of the defect interfering with the wound healing process, appear to better respond to
treatment.

Nowadays it is well established that severe furcation involvement (class II or III) is suboptimally
treated with non-surgical therapy (Cattabriga et al. 2000, Dannewitz et al. 2006, Huynh-Ba et al.
2009). Various surgical approaches have been advanced with the ultimate goal of completely
removing all supra- and sub-gingival plaque deposits or completely closing the furcation defects. In
the present study, all test groups underwent various regenerative treatments. These ranged from
the application of non-resorbable membranes to enamel matrix derivatives or platelet rich plasma
application or mixed techniques. Despite the analysis of the regenerative performance was not the
focus of the present manuscript, in eight out of eleven studies HCAL and PPD reduction were
statistically significantly higher in the test group in comparison to the control group (Flanary et al.

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Accepted Article

1991, Lekovic et al. 1991, 2003, Houser et al. 2001, Bremm et al. 2004, Pradeep et al. 2009, Santana
et al. 2009, Casarin et al. 2010). The usage of membranes and biological agents showed a higher
potential than OFD (Kinaia et al. 2011, Koop et al. 2012). Regenerative surgery is apparently
providing the best clinical results and it is superior to a simple OFD approach, but its application is
limited by prerequisites of anatomical (Al-Shammari et al. 2001) and behavioural order. Indeed, the
benefit of regenerative surgery is clinically significant only when applied to systemically healthy nonsmoking subjects capable of performing an adequate plaque control (Sanz & Giovannoli 2000) and to
certain classes of furcation-involved lesions, deep probing depth at baseline (Horwitz et al. 2004),
low furcation and osseous defect values (i.e. low distance of CEJ/furcation fornix to bone defect
margin) (Casarin et al. 2009). Moreover, another important feature of the regenerative procedures
that has to be taken into consideration when considering them in a treatment plan is their elevated
cost.
While these data are interesting, the substantial heterogeneity observed among studies represents
the major limitation of this study. The approach used in the present review to assess the risk of bias
addressed six specific domains as suggested by the Cochrane bias methods group (Higgins et al.
2009). The heterogeneity was due to differences between studies in terms of methodological
factors, such as use of blinding, sequence generation and concealment of allocation. The quality
analysis of the single studies showed a moderately low level (Table 2). This may be due to the fact
that half of the included trials were carried out in the last decades of the previous century when
design of the protocols and reporting of the data were less rigorous than nowadays. HCAL is an
important outcome, nevertheless one should bear in mind that horizontal probing may be taken
with different methods with little possibility of calibration unless stents are used. Moreover, this
methodological heterogeneity is responsible of preventing an in depth analysis of the various factors
which may affect healing such as smoking, type of surgery, adherence to maintenance programme,
etc. Subgroup analysis was in fact possible only on location of the furcation defects.

To conclude, the clinical performance of conservative surgery in the treatment of furcation defects
may represent a valid cost-effective treatment solution for the class II, in particular mandibular,
defects mainly when other therapeutic options are not applicable either for anatomical or patient
related factors. Interestingly, very little information is available on a common defect such as the
maxillary furcation. Additional studies with sound methodological design and long follow-up are
needed to elucidate the clinical potentials of the conservative surgical approach in the treatment of
furcation defects. Important factors which may have a significant impact on healing such as smoking,
maintenance and surgical technique should be further investigated.

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Table 1. Characteristics of the included studies

Study

Methods

Control Group
Participants
12 individuals
(9 females)
51.6 8.8 years

Control group
Defects
12 teeth
II furcation class
Average PPD 6.4
1.2 mm
Average
HCAL
10.5 1.4 mm

Interventions

Outcomes

Tooth
loss
NR

Site and
funding
University,
Industry

Casarin et al .2010

Split mouth
24 months

1. OFD
2. EMD

PPD,REC,
HCAL,
VCAL, HBL,
VBL

Santana et al. 2009

Parallel
group
12 months

30 individuals
48.3 years

30 teeth
II furcation class
Average PPD 5.9
1.3 mm
Average HCAL 6.1
1.4 mm

1. OFD
2. GTR+graft

PPD, REC,
HCAL,
VCAL, HBL,
VBL

NR

University,
Self-funded

Pradeep et al. 2009

Split mouth
6 months

20 individuals
(10 females)
42.8 years

20 teeth
II furcation class
Average PPD 5.10
1.20
Average HCAL
8.70 1.64

1. OFD
2. Autologous
PRP

PPD, REC,
HCAL,
VCAL, VBL

University,
Self-funded

Bremm et al. 2004

Split mouth
6 months

10 individuals
(6 females)
44 years

10 teeth
II furcation class

1. OFD
2. GTR

PPD, REC,
HCAL,VCAL

University,
Industry

Lekovic et al. 2003

Split mouth
6 months

26 individuals
(14 females)
38 11 years

26 teeth
II furcation class

1. OFD
2. PRP+GTR+graft

REC, VCAL,
HBL, VBL

NR

University,
Self-funded

Houser et al. 2001

Split mouth/
Parallel
6 months

13 individuals
46 years

13 teeth
II furcation class

1.OFD
2. GTR+graft

PPD, REC,
VCAL

University,
Industry

Anderegg et al. 1999

Split mouth
6months

15 individuals
55 years

15 teeth
II furcation class
Average PPD 6.47
0.92

1. OFD
2. GTR+graft

PPD

Private,
Self-funded

Yukna & Yukna 1996

Split mouth
12 months

27 individuals
46.8 years

59 teeth
II furcation class
Average PPD 5.50
1.6 mm

1. OFD
2. GTR

PPD, REC,
VCAL, HBL,
VBL

University,
Industry

Lekovic et al. 1991

Split mouth
6 months

15 individuals
(7 females)
39.67 years

30 teeth
II furcation class
Average PPD 6.27
0.88

1.OFD
2.Graft

PPD, REC,
VCAL, HBL,
VBL

University,
Self-funded

Flanary et al. 1991

Split mouth
6 months

19 individuals
(7 females)
47 years

19 teeth
II furcation class
Average PPD 3.4
1.1

1.OFD
2.GTR

PPD, REC,
HCAL,
VCAL, VBL

University,
Self-funded

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Accepted Article

Lekovic et al. 1989

Split mouth
6 months

12 individuals
(8 females)
37.2 years

12 teeth
II furcation class
Average PPD 5.96
0.8

1.OFD
2.GTR

REC, HBL,
VBL, VCAL

NR

University,
Industry

OFD, open flap debridement; EMD, enamel matrix derivatives; GTR, guided tissue regeneration; PRP, platelet-rich plasma;
NR, not reported; PPD, pocket probing depth; REC, recession; VCAL, vertical clinical attachment level; HCAL, horizontal
clinical attachment level; HBL, horizontal bone level; VBL, vertical bone level; , difference

Table 2. Summary of risk of bias in individual studies

Study

Sequence
Generation

Allocation
Concealment

Examiner
blinding

Missing
outcome
balanced
among groups
NLFU

Casarin et al. 2010

Coin tossing

Opaque
envelopes

Examiner
masked

DTD, SFD, DLA, C, SMD, DFD, OHLR, ISPT

Santana et al. 2009

Coin tossing

Unclear

Examiner
masked

NLFU

DTD, SFD, US, DLA, SMD, DFD, SR, OHLR, ISPT

Pradeep et al. 2009

Coin tossing

Inadequate

Examiner
masked

NLFU

DTD, SFD, US, DLA, SMD, DFD, SR, OHLR, ISPT

Bremm et al. 2004

Unclear

Unclear

Examiner
masked

NLFU

DTD, SFD, US, DLA, SMD, DFD, SR, OHLR, ISPT

Lekovic et al. 2003

Coin tossing

Unclear

Examiner
masked

NLFU

DTD, SFD, US, DLA, C, SMD, DFD, SR, OHLR,

ISPT

Houser et al. 2001

Coin tossing

Unclear

NR

NLFU

DTD, SFD, US, DLA, SMD, DFD, OHLR

Anderegg et al. 1999 Unclear

Unclear

NR

NLFU

DTD, SFD, PPS, DLA, SMS, DFD, OHLR, ISPT

Yukna & Yukna 1996 Unclear

Unclear

NR

NLFU

SFD, US, DLA, SMD, DFD, ISPT

Lekovic et al. 1991

Unclear

NR

NLFU

DTD, SFD, US, DLA, SM, DFD, OHLR, ISPT

Unclear

Selective Other sources of bias

outcome
reporting

Flanary et al. 1991

Coin tossing

Unclear

NR

NLFU

DTD, SFD, US, DLA, C, SMD, DFD, OHLR, ISPT

Lekovic et al. 1989

Unclear

Unclear

NR

NLFU

DTD, SFD, US, DLA, SMD, DFD, OHLR, ISPT

DTD, definition of trial design; SFD, source of funding disclosed; US, university setting; DLA, definition of level analysis; C, calibration; SMD,
statistical methods definition; DFD, definition of furcation defect; OHLR, oral hygiene level reporting; ISPT, info on supportive therapy
provided; SR, smoking reporting; NR, not reported; NLFU, No losses to follow-up;*All outcomes stated in the material & method section
were analyzed and presented.

Table 3. Summary of meta-analysis

Outcome

PPD
reduction
VCAL gain
HCAL gain
REC increase
HBL gain
VBL gain

No. of
studies

No. of
patients

Weighted
mean
difference
(mm)

95% CI

P-value

Heterogeneity

174

1.38

[0.91, 1.85]

<0.01

Chi-square
value
59.38

10
5
10
5
8

147
94
159
75
155

0.55
0.96
0.73
0.09
-0.17

[0.00, 1.10]
[0.60, 1.32]
[0.37, 1.09]
[-0.16, 0.34]
[-0.21, -0.13]

0.05
<0.001
<0.01
0.461
<0.01

199.490
16.669
148.60
19.750
68.92

CI, confidence interval; Df, degrees of freedom

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P-value

I2

Df

<0.01

87%

<0.001
0.002
<0.01
<0.001
<0.01

95%
76%
94%
80%
90%

9
4
9
4
7

Accepted Article

Table 4. Summary of Bleeding on Probing (BoP)

Authors
Casarin et al. 2010
Santana et al. 2009
Pradeep et al. 2009*

BoP at baseline
100%
11.60 3.6
8% (score 0.1-1)
12% (score 1.1-1.5)
Bremm et al. 2004
NR
Lekovic et al. 2003
0.68 0.26
Houser et al. 2001
NR
Anderegg et al. 1999
15
Yukna & Yukna 1996
NR
Lekovic et al. 1991
1.00 0.00
Flanary et al. 1991
NR
Lekovic et al. 1989
1.48 0.24
*Sulcus bleeding Index (Muhleman- Son 1971)

BoP at the end of the study

67%
NR
16% (score 0-0.5)
4% (score 0.6-1)
NR
0.51 0.22
NR
4
NR
0.73 0.46
NR
1.42 0.58

Figure 1. Flowchart of the meta-analysis.

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Mean difference
NR
2.87 4.1
NR
NR
NR
NR
NR
NR
0.13 0.27
NR
NR

Accepted Article

Figure 2. Forest plot from fixed effects of meta-analysis evaluating the difference in HCAL gain (in
mm) 6 months and longer term.

Figure 3. Forest plot from fixed effects of meta-analysis evaluating the difference in VCAL gain (in
mm) 6 months and longer term.

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