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HERRERA ET AL .
Background
outcomes with significantly reduced overall treatment time) seem to outweigh the potential risks.
Intervention
From evidence to recommendation — additional considerations
1. Orthodontic tooth movements can be carried out either by fixed (braces) or removable (able to be inserted/removed by the patients, such as removable plates, thermoplastic aligners, etc.) orthodontic appliances. 2. Circumferential fiberotomy of the supracrestal periodontal fibres has been suggested as an adjunct surgical procedure to improve the post-treatment stability after correction of severely rotated teeth or as an intervention aimed to improve attachment levels during orthodontic tooth intrusion. 3. In stage IV periodontitis patients with a healthy but reduced per- iodontium, the use of skeletal anchorage devices, compared with conventional anchorage systems, may improve the efficacy of OT and its effect on periodontal outcomes.
Acceptability Although there is no evidence from PROMs, the combination of periodontal and orthodontic therapies was well accepted by the patients. Feasibility The combination of complex periodontal and orthodontic therapies requires the coordinated efforts of different oral care providers (spe- cialists or dentists with advanced training and skills in periodontal and orthodontic therapies) and these special settings may not be encoun- tered in every oral health care environment.
Available evidence
Ethical considerations There is no evidence for ethical considerations.
Number and design of included studies 1. One non-randomized retrospective comparative study comparing fixed appliances (braces) with aligners, reporting results from before peri- odontal to after OT, in terms of CAL/RBL/PPD/root length outcomes. 2. The use of fiberotomy as an adjunct to combined periodontal – orthodontic therapy was assessed in two within-individual RCTs. 3. Anchorage systems: In 4 studies, skeletal anchorage (temporary anchorage devices, TADs, or implants) was used in all patients. In 12 studies, different types of conventional anchorage were used. 2 studies presented results of patients treated with TADs mixed with patients without TADs. Risk of bias 1. Type of orthodontic appliance The only included study was judged as serious risk of bias using the ROBINS-I tool. 2. Use of fiberotomy Both randomized trials were judged as high risk of bias using the RoB 2.0 tool for at least two domains each. 3. Anchorage systems The overall quality of the included studies was judged as “ low ” . Considering the 12 pre – post intervention studies assessed, 2 were rated as “ good ” , 4 of them were rated as “ fair ” (moder- ate risk of bias) and 6 were rated as “ poor ” . The study rated according to ROBINS-I tool received an overall assessment of “ serious ” risk of bias. Considering the five RCTs assessed using RoB 2.0 tool, the overall bias assessment was “ high ” for two RCTs; one RCTs was rated as “ low risk of bias ” and another two were rated with “ some concerns ” .
Economic considerations There is no evidence from cost-effectiveness studies, although the combined periodontal – orthodontic therapy of these patients is complex, requires multiple care providers and it is usually costly.
Legal considerations There are no specific legal considerations.
R7.6. How should we implement OT in stage IV periodontitis patients to maintain/improve periodontal outcomes ?
PICOS question addressed by a SR
R7.6: Evidence-based recommendation In patients with severe periodontitis (stage IV or equivalent) with indication of OT to maintain/improve periodontal stability : 1. we suggest using fixed rather than removable appliances ; 2. use of fiberotomy as an adjunct to orthodontic tooth movement may be considered to improve periodontal outcomes ; 3. use of skeletal anchorage devices (implants or temporary anchorage devices — micro-screws or mini-plates) may be considered to enhance orthodontic tooth movement . Supporting literature (Martín et al., 2021; Papageorgiou et al., 2021) Quality of evidence Low Grade of recommendation GradeB — " (1), Grade O — $ (2, 3) Strength of consensus Consensus (1.7% of the group abstained due to potential CoI)
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