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HERRERA ET AL .
Effect sizes and their clinical relevance 1. The included study reported that fixed appliances have benefits over aligners for PPD (1 study; MD = 1.64 mm; 95% CI [ 2.50 to 0.78]; p < .001), but not for RBL (1 study; MD = 0.01; 95% CI [ 1.01 to 1.03; p = .99). 2. Adjunctive use of fiberotomy was associated with benefits in CAL (1 study; MD = 0.63 mm; 95% CI [ 1.10 to 0.16]; p = .009) and RBL (2 studies; MD = 0.98 mm; 95% CI [ 1.87 to 0.10]; p = .03), but not PPD (1 study; MD = 0.03 mm; 95% CI [ 0.48 to 0.42]; p = .90). 3. In terms of different anchorage systems, there is no evidence of added benefits on periodontal parameters from using a specific type of anchorage system during OT. In terms of orthodontic outcomes, the use of osseointegrated implants as anchorage (one study), TADs (three studies) and conventional anchorage resulted in different tooth movements (such as intrusion) ranging between 1 and 7 mm, without a clear advantage among the different systems. Root resorption after OT in periodontitis patients was reported in stud- ies using different anchorage systems, with similar levels of reported resorption (between 0.2 and 3.0 mm) with either conventional anchor- age or skeletal anchorage. Root resorption was also reported in similar ranges in studies with OT in healthy periodontal patients. Consistency In relation to the type of orthodontic appliance, since only one study was available, the consistency could not be assessed. For the adjunc- tive use of fiberotomy, the results were not consistent for the peri- odontal outcomes. The results using different anchorage systems reported the same tendency. Balance of benefit and harm There are no considerable harms for the periodontal tissues and other dental tissues and structures, with the use of conventional fixed appli- ances (braces), other than the increased microbial burden, related to the difficulties in oral hygiene practices, which can however be man- aged appropriately. Similarly, there is no evidence of significant harms associated with the different anchorage systems. Although fiberotomy is a surgical procedure, the possible side effects have not been adequately reported.
currently more aesthetic alternatives in fixed appliances (ceramic/ lingual appliances). 2. Fiberotomy is a surgical intervention, albeit minimally invasive, what might be less acceptable by some patients. 3. Some patients might experience discomfort when receiving TADs, although this fact has not been evaluated in the reported studies. Feasibility 1. The use of fixed appliances requires specific knowledge of applied biomechanics, what is usually rendered by orthodontic specialists, while aligners treatment is mostly facilitated through third parties (companies or external laboratories) producing the aligners and enabling both specialists and general dentists to provide this kind of treatment. However, extensive knowledge of tooth biology and applied biomechanics is still a pre-requisite for treatment planning and monitoring. 2. Fiberotomy requires specific surgical experience from the operator. 3. In cases of using skeletal anchorage systems, knowledge of surgical anatomy and surgical skills are needed. Ethical and economic considerations Fiberotomy, as an additional surgical insult to the periodontal tissues, must be further evaluated in terms of its long-term effectiveness and since it is an additional surgical intervention, it might be associated with further costs.
Legal considerations There are no specific legal considerations.
R7.7. How should we manage stage IV periodontitis patients during and after the completion of OT to prevent recurrence of periodontitis?
Additional question addressed by the WG
R7.7: Expert consensus-based recommendation We recommend that during OT the patient's periodontal status is closely monitored and managed , ideally at each orthodontic appointment . If signs of periodontitis recurrence are detected , active OT should be interrupted , and the affected teeth should be maintained passively , while rendering proper periodontal treatment and oral hygiene reinforcement . Once periodontal health/stability has been re- established , OT can be re-instituted . We recommend that after completion of OT , life-long supportive periodontal care and life-long orthodontic retention are provided tailored to the individual needs/risk profile of the patient . Supporting literature (Arn et al., 2020; Jiang et al., 2021) and Expert opinion Quality of evidence Low (expert opinion) Grade of recommendation GradeA — "" Strength of consensus Unanimous consensus (0% of the group abstained due to potential CoI)
Overall certainty of the evidence Low.
From evidence to recommendation — additional considerations
Acceptability 1. Some patients might prefer aligners over fixed appliances, due to their enhanced aesthetics and easiness for oral hygiene. However, braces have been historically well accepted by adults and there are
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