The clinical effect of bone perforations in periodontal regeneration and alveolar socket preservation: a systematic review with meta-analysis

OBJECTIVES: The present systematic review aimed to evaluate if cortical bone perforation is effective in enhancing periodontal surgery and guided bone regeneration (GBR) in humans. MATERIALS AND METHODS: Electronic search was performed in PubMed, Scopus and Cochrane CENTRAL up to October 31st, 2023. Grey literature was also searched. Prospective controlled studies were included. Two PICO questions were created; one focusing on the effect of bone perforation in the treatment of peridodontal intrabony defects (primary outcome probing depth (PD)) and one focusing on the effect of bone perforation in guided bone regeneration (primary outcome: histologic and histomorphometric data). The risk of bias of the included studies was assessed using the Cochrane tool for randomized controlled studies (RCTs) and the Joanna Briggs Institute Critical Appraisal tool for cohort studies. Pairwise meta-analysis was undertaken when possible, to estimate the overall effect for the outcomes investigated. RESULTS: The search on databases yielded a total of 653 articles. After screening, five RCTs and one non-randomized study were included. A meta-analysis was performed for the first PICO. PD was evaluated in 4 articles and no significant difference was found between the perforation vs. no perforation groups (0.11 mm (95% CI [-0.14 to 0.37 mm], P = 0.38). Additionally, radiographic defect depth (mean difference 0.77 mm, 95% CI [0.24 to 1.30 mm], P = 0.004) and distance between cemento-enamel junction and bone defect (standardized mean difference 0.98 mm, 95% CI [0.47 to 1.50 mm], P = 0.0002) resulted improved in the cortical bone perforation group. CONCLUSION: The evidence supporting a positive effect of using cortical perforations is very poor. Further studies with larger sample sizes are needed to determine whether decortication brings meaningful advantages. CLINICAL RELEVANCE: This study is focused on clinical studies and, using a rigorous study selection and a meta-analytic approach suggests that the apparent positive effect of bone decortication on the regeneration process still requires to be confirmed by more solid evidence.