Rehabilitation of patients with maxillary defects: A network meta-analysis

Statement of problem

Different treatments for maxillary defects have been described, but a meta-analysis of these treatments to provide clinical guidance is lacking.

Purpose

The purpose of this systematic review and network meta-analysis was to evaluate the effect of tissue-supported obturator prostheses and other rehabilitation treatments for patients with maxillary defects on patient-reported outcome measures (PROMs) assessed through quality of life (QoL) questionnaires.

Material and methods

Inclusion criteria were parallel-arm randomized controlled trials (RCTs) and nonrandomized studies of intervention (NRSIs) with a tissue-supported obturator as one of the treatments. Nine databases and nonpeer-reviewed literature were searched. Independent reviewers selected studies, extracted data, and assessed the risk of bias. Seven outcomes were analyzed separately for RCTs and NRSIs: appearance, mastication, pain, social contact, speech, swallowing, and QoL. A Bayesian random-effect network meta-analysis (NMA) calculated mean differences (MD) and 95% credible interval (Crl) for each treatment comparison. Data interpretation followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and the magnitude of the effect was calculated as the minimal important difference (MID) – the minimal clinical benefit for the patient - for each outcome.

Results

The review included 4 RCTs and 9 NRSIs. Most studies had a high and critical risk of bias. There were 7 treatments: no reconstructive or rehabilitative treatment, surgical obturator, interim obturator, tissue-supported obturator, implant-supported obturator, magnet obturator, and flap, totaling 120 treatment comparisons (56 among RCTs and 64 among NRSIs). Some treatments reached the minimum clinical benefit (MID). However, the 95%Crl crossed the null effect line for all treatment comparisons, indicating that any treatment can be efficient. The certainty of the evidence was very low for all comparisons, mainly because of the risk of bias, indirectness, intransitivity, and imprecision.

Conclusions

No treatment was better than another for any outcome. More RCTs comparing treatments for the rehabilitation of maxillary defects are encouraged to improve the evidence.