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中华口腔医学研究杂志(电子版)

中华口腔医学研究杂志(电子版) ›› 2022, Vol. 16 ›› Issue (06) : 370 -377. doi: 10.3877/cma.j.issn.1674-1366.2022.06.006

Meta分析

翻瓣与不翻瓣种植手术疗效对比的Meta分析
余晓宁1,†(), 蔡洁琛1, 陈小红2   
  1. 1. 惠州市第一人民医院口腔科，惠州　516003
    2. 东莞东华医院口腔科，东莞　523110
  • 收稿日期:2022-06-20 出版日期:2022-12-01
  • 通信作者: 余晓宁

The effect of flap and flapless surgery on the outcomes of implant treatment: A Meta analysis

Xiaoning Yu1,†(), Jiechen Cai1, Xiaohong Chen2   

  1. 1. Department of Stomatology, Huizhou First Peoples Hospital, Huizhou 516003, China
    2. Department of Stomatology, Dongguan Tungwah Hospital, Dongguan 523110, China
  • Received:2022-06-20 Published:2022-12-01
  • Corresponding author: Xiaoning Yu
  • Supported by:
    Science and Technology Planning Project of Huizhou(2020Y059)
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引用本文：

余晓宁, 蔡洁琛, 陈小红. 翻瓣与不翻瓣种植手术疗效对比的Meta分析[J]. 中华口腔医学研究杂志(电子版), 2022, 16(06): 370-377.

Xiaoning Yu, Jiechen Cai, Xiaohong Chen. The effect of flap and flapless surgery on the outcomes of implant treatment: A Meta analysis[J]. Chinese Journal of Stomatological Research(Electronic Edition), 2022, 16(06): 370-377.

目的

分析翻瓣与不翻瓣种植手术的疗效对比，为临床合理选择种植手术方式提供依据。

方法

分别检索PubMed、Cochrane Library、Web of Science和Embase等数据库，时间为数据库建库至2021年9月1日，以Dental impalnts、Surgical flaps、Surgery等主题词及其下位词，查找关于翻瓣与不翻瓣种植手术的相关文献，严格按照纳入、排除标准进行筛选，对纳入的文献进行质量评估，提取关于翻瓣与不翻瓣种植手术疗效相关的数据，包括共提取失败例数、手术时间、炎症、肿胀、改良菌斑指数（MPI）、牙龈出血指数（MSBI）、牙周袋深度（PD）、语言模拟疼痛评估量表（VAS）、种植体稳定性商数值（ISQ）、骨吸收、近中骨吸收、远中骨吸收、即刻负重近中骨吸收和即刻负重远中骨吸收等。采用RevMan 5.3软件计算疗效指标的比值比（OR）或均数差（MD）和95%置信区间（CI），采用StataSE 12.0软件对存在异质性的研究进行敏感性分析和发表偏倚检验。

结果

共纳入24篇相关研究，报道含翻瓣种植手术1 124例，不翻瓣种植手术1 184例。研究结果显示，不翻瓣种植术后MSBI[OR = -0.12，95% CI（-0.22，-0.01），P = 0.03]、PD[OR = -0.21，95% CI（-0.25，-0.17），P<0.001]、VAS[OR = -0.39，95% CI（-0.60，-0.19），P = 0.000 2]、骨吸收[OR = -0.11，95% CI（-0.18，-0.03），P = 0.007]明显低于翻瓣种植手术，差异有统计学意义；失败例数、MPI、ISQ、即刻负重近中骨吸收、即刻负重远中骨吸收在翻瓣与不翻瓣种植手术均无明显差异（P>0.05）。

结论

不翻瓣种植术后疼痛的发生明显低于翻瓣种植手术，负荷后牙龈出血、牙周袋深度和骨吸收明显低于翻瓣种植手术。临床工作中，应根据病例的软硬组织条件选择适当的种植手术方式，不翻瓣种植手术具有更大优势。

关键词: 口腔种植, 手术翻瓣, 不翻瓣, Meta分析
Objective

To analyze and compare the curative effect of flap and flapless surgery on the outcomes implant treatment, and to provide the basis for clinical rational selection of implant surgery.

Methods

PubMed, Cochrane Library, Web of Science and Embase database were searched to find the related literature about the effect of flap and flapless surgery on the outcomes of implant treatment. The searching time was from the establishment of the databases to September 1st, 2021. The literature was retrieved by Medical Subject Headings of Dental implants, Surgical flaps, Surgery, and their hyponyms. The literature was screened strictly according to the inclusion and exclusion criteria, and evaluated for their quality. The effects of flap and flapless surgery on the outcomes of implant treatment were extracted as available data, including the number of failed cases, operation time, inflammation, swelling, modified plaque index (MPI) , modified sulcus bleeding index (MSBI) , probing depth (PD) , verbal analogue scale (VAS) , implant stability quotient (ISQ) , crestal bone loss, mesial bone loss, distal bone loss, mesial and distal bone loss after immediate loading. Odds ratio (OR) or mean difference (MD) and 95% confidence interval (CI) for efficacy indicators were calculated by RevMan (v.5.3) . Sensitivity analysis and publication bias test were performed for studies with heterogeneity using StataSE (v.12.0) .

Results

A total of 24 studies were included in this study, including 1 124 cases of flap and 1 184 cases of flapless surgeries. The results showed that MSBI[OR = -0.12, 95% CI (-0.22, -0.01) , P = 0.03], PD[OR = -0.21, 95% CI (-0.25, -0.17) , P<0.001], VAS[OR = -0.39, 95% CI (-0.60, -0.19) , P = 0.000 2], crestal bone loss[OR = -0.11, 95% CI (-0.18, -0.03) , P = 0.007] after flapless implant surgery were significantly lower than those of flap surgery (P<0.05) . The number of failed cases, MPI, ISQ, mesial and distal bone loss after immediate loading were not significantly different between the flap and flapless implant surgery (P>0.05) .

Conclusions

The incidence of pain after flapless implant surgery was significantly lower than that after flap surgery, and the gingival bleeding, periodontal pocket depth and crestal bone loss after loading were significantly less than those after flap surgery. In clinical work, appropriate implantation method should be selected according to the soft and hard tissue conditions of the case, and flapless implant surgery has more advantages than flap surgery.

Key words: Dental implants, Surgical flaps, Flapless, Meta-analysis
图1 翻瓣与不翻瓣种植手术疗效对比的文献检索流程图
表1 纳入翻瓣与不翻瓣种植手术24篇研究文献的一般特征
纳入文献 FL/F（例） 研究设计 质量评估 即刻负重 种植牙位 疗效指标
Al-Juboori 2015[6] 11/11 RCT 5 否 上下颌后牙 ISQ
Cannizzaro 2011[7] 76/67 RCT 6 是 上下颌后牙 手术时间、失败例数、VAS、ISQ、肿胀、炎症、骨吸收
de Bruyn 2011[8] 28/25 CCT 8 否 上下颌后牙 骨吸收
Divakar 2020[9] 10/10 RCT 6 否 下颌后牙 VAS、肿胀、骨吸收
Froum 2017[10] 14/14 CT 8 是 上下颌后牙 失败例数、PD、骨吸收
Heba 2020[11] 26/24 RCT 6 否 上下颌后牙 ISQ
Jané-Salas 2018[12] 24/24 RCT 6 否 上下颌后牙 失败例数、VAS、手术时间
Karaky 2018[13] 376/295 CT 8 否 全口牙位 失败例数、VAS
Kaur 2019[2] 20/20 RCT 6 是 下颌第一磨牙 近中骨吸收、远中骨吸收、即刻负重近中骨吸收、即刻负重远中骨吸收
Kumar 2018[14] 9/9 RCT 5 否 下颌后牙 VAS、近中骨吸收、远中骨吸收
Lindeboom 2010[15] 48/48 RCT 6 否 上颌无牙颌 手术时间
Maier 2016[16] 95/100 CT 9 否 上下颌后牙 失败例数、骨吸收
Maló 2008[17] 32/40 CT 8 是 全口牙位 失败例数、骨吸收
Maló 2016[18] 32/40 CT 8 是 全口牙位 失败例数、MPI、骨吸收、即刻负重近中骨吸收、即刻负重远中骨吸收
Naeini 2018[19] 22/15 RCT 5 否 全口牙位 骨吸收
Parmigiani-Izquierdo 2013[20] 19/19 RCT 6 否 上下颌后牙 VAS、炎症
Pisoni 2016[21] 39/30 RCT 5 否 上下颌后牙 骨吸收
Rousseau 2010[22] 174/203 CCT 8 否 上下颌后牙 失败例数、近中骨吸收、远中骨吸收
Singh 2021[23] 50/48 RCT 6 是 下颌第一磨牙 失败例数、骨吸收、MPI、MSBI、PD
Singla 2018[24] 10/10 RCT 6 是 全口牙位 即刻负重近中骨吸收、即刻负重远中骨吸收
Tsoukaki 2013[25] 15/15 RCT 6 否 全口牙位 VAS、骨吸收、MPI、PD
Stoupel 2016[26] 18/21 RCT 6 是 上颌前牙 失败例数、MSBI、骨吸收、即刻负重近中骨吸收、即刻负重远中骨吸收
Wadhwa 2015[27] 16/16 RCT 6 否 下颌第一磨牙 近中骨吸收、远中骨吸收
Wang 2017[28] 20/20 RCT 6 否 下颌第一磨牙 VAS、骨吸收、MPI、MSBI、PD
表2 翻瓣与不翻瓣种植手术疗效指标的Meta分析结果
因素 文献数（篇） FL/F（例） 统计学方法 OR或MD[95% CI] 异质性I2 P值
失败例数 10 891/852 M-H.fixed 1.53[0.90，2.58] 0 0.11
手术时间 3 139/130 M-H.random -8.14[-23.04，6.76] 99 0.28
炎症 3 127/126 M-H.random 0.21[0.01，7.88] 84 0.40
肿胀 2 25/39 M-H.random -0.23[-0.95，0.49] 89 0.53
MPI 4 117/123 M-H.fixed -0.04[-0.12，0.04] 39 0.31
MSBI 3 88/89 M-H.fixed -0.12[-0.22，-0.01] 46 0.03
PD 4 99/97 M-H.random -0.39[-0.59，-0.19] 98 <0.001
VAS 8 540/450 M-H.random -8.60[-11.66，-5.53] 100 <0.001
ISQ 3 113/102 M-H.random -1.21[-3，82，1.40] 64 0.36
骨吸收 13 437/435 M-H.random -0.07[-0.21，0.07] 85 0.32
近中骨吸收 4 219/248 M-H.random -0.40[-1.35，0.54] 100 0.41
远中骨吸收 4 219/248 M-H.random -0.38[-1.30，0.54] 100 0.41
即刻负重近中骨吸收 4 66/81 M-H.random -0.01[-0.09，0.08] 3 0.91
即刻负重远中骨吸收 4 65/80 M-H.random 0.08[-0.40，0.56] 67 0.74
表3 存在异质性疗效指标经敏感性分析及Egger检验的结果
因素 Galbraithe图提示存在异质性的研究 排除异质性研究后统计合并效应 P值 Egger检验
OR或MD[95% CI] 异质性I2（%）
手术时间 Cannizzaro 2011[7] - - - -
  Lindeboom 2010[15]        
炎症 Maló 2016[18] - - - -
  Parmigiani-Izquierdo 2013[20]        
PD Singh 2021[23] -0.21[-0.25，-0.17] 31 <0.001 0.143
  Tsoukaki 2013[25]        
VAS Divakar 2020[9] -0.39[-0.60，-0.19] 14 0.0002 0.348
  Karaky 2018[13]        
  Parmigiani-Izquierdo 2013[20]        
  Tsoukaki 2013[25]        
  Wang 2017[28]        
ISQ Cannizzaro 2011[7] -2.66[-5.80，0.48] 22 0.10 0.683
骨吸收 Divakar 2020[9] -0.11[-0.18，-0.03] 0 0.007 0.937
  Froum 2017[10]        
  Maier 2016[16]        
  Maló 2008[17]        
  Maló 2016[18]        
  Wang 2017[28]        
近中骨吸收 Kumar 2018[14] - - - -
  Rousseau 2010[22]        
  Wadhwa 2015[27]        
远中骨吸收 Kaur 2019[2] - - - -
  Kumar 2018[14]        
  Wadhwa 2015[27]        
即刻负重远中骨吸收 Maló 2016[18] -0.07[-0.59，0.45] 65 0.79 0.689
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