CRITICAL APPRAISAL FOR SYSTEMATIC REVIEW

1. CRITICAL APPRAISAL for

3. By using prisma “PRISMA 2009 Checklist”
• Checklist items:
1. Title
2. Abstract
3. Introduction
4. Methods
5. Results
6. Discussion
7. funding

4. PRISMA 2009 Checklist

5. 1. Title
• Mentioned from the title it was a systematic
review but we didn't mention if there meta-
analysis.
– P (participants): Localized Bony Defects.
– I (Intervention) : Barrier Membranes.
– (Comparator) : Not specified.
– O (Outcome) : Specified.

6. 2. Abstract
• Clear
– Background: Not specified
– Objectives: the aim was clear
– Data sources: specified.
– Comparator: clear.
– Intervention: clear.
– Outcome: clear.

7. 2. Abstract
–Eligibility criteria: clear.
• Controlled animal and human studies,
• follow up more than 4 weeks,
• No studies of periodontal lesions, extraction
sockets, and maxillary sinus grafts.
recombinant growth factor, or assessments of
membranes on implant.

8. 3. INTRODUCTION
• Rational: Specified.
– Highlighted the gap of knowledge “large number of
studies and systematic reviews have been published,
However, they didn’t discussed whether bone
regeneration was vertical or horizontal”. Also unclear
follow-up periods1 and animal-based results.
– Sculean.etal. 2008

9. 3. INTRODUCTION
• Objectives:
– clear statement clarify the items, participants,
interventions, outcome (PICO).
– Primary outcome and secondary outcome:
1. Vertical and horizontal bone regeneration.
clinical, histologic, and radiographic measurements
2. Improper tissue healing.

10. 4. METHODS
• Protocol and registration: Not specified “didn’t
mention any protocol registration”.
• Information sources:
– Databases clear
• Electronic search: specified.
• Hand search: specified
• Unpublished or gray literature: not specified.
• dates of coverage: from January 1988 up to May 2011.
• Updating his search in 2012: Not specified.
• contact with authors: Not specified.
– Search strategy clear for one database “Pubmed”

11. 4. METHODS
– Eligibility criteria:
1. Study characteristics;
1. Intervention and comparator : Specified
2. follow up period : Specified . “studies that
included more than one follow-up period, the
longest period was chosen”?????
2. Report characteristics;
1. Publication in English,
2. A controlled study design,
 Clear inclusion and exclusion criteria.

12. 4. METHODS
• Study selection:
• Process for selecting studies: Not specified.
• Data collection process:
• Used Data extraction form.
– Data extraction forms were designed to collect the data as:
1. type of membrane,
2. bone graft substitute material,
3. number of subjects,
4. species for animal studies,
5. method of analyzing data,
6. duration of follow up,
7. Results.
Descriptive results of all selected studies were extracted and
gathered in tables.

13. – Subgrouping has been done according to:
I. study subject (humans or animals) and,
II. membrane type (resorbable versus
nonresorbable).

14. 4. METHODS
– Risk of bias in individual studies:
• Two reviewers independently assessed the risk of bias in
included studies. Selection bias, performance bias,
detection bias, attrition bias, and reporting bias.
• categorized as “low risk,” “high risk,” or “unclear risk.”
• Done at study or outcome level.
• Methods used to assess risk of bias: Not specified .

15. 4. METHODS
– Synthesis of results and Summary measures:
• A fixed-effect method was used for meta-analysis.????
• Heterogeneity was assessed by I2 statistic test
I2 = (Q – df)/Q × 100%.
• A generic inverse-variance approach was used for meta-analysis of
primary outcomes, and the overall estimate of effect was sought
for each study and the mean difference were used for summary
statistics.
• While the Mantel-Haenszel method was the chosen statistical
approach for secondary outcome , and odds ratios were used for
summary statistics.

16. 4. METHODS
– Risk of bias across studies:
» publication bias, selective reporting within studies: Not specified.
– Additional analyses:
» sensitivity analysis or, meta-regression: Not specified.

17. 5. RESULTS
– Study selection:
• Not specified how many article extract from each database.
• Not specified how many reviewers did it and if done
independently or in duplicate.
• Numbers of studies screened, assessed for eligibility, and
included in the review, with reasons for exclusions : Clear
• Flow diagram: Specified.

18. 5. RESULTS
– Study characteristics:
– Characteristics “No. of patients, defect location,
Materials used, Method of data analysis, duration
of follow-up” and results of the selected articles
are shown in Tables.

21. 5. RESULTS
• Risk of Bias of Included Studies:
– Selection bias a lot of missing data.
– The performance and detection biases higher
• the performers and detectors knew which defects served
as control and test groups.
– Low attrition bias a limited number of
samples were missed at the end of the study in the
selected articles.
– Low reporting bias, since most authors tried to
report all their observations.
– No scores.

22. 5. RESULTS
• Synthesis of results:
– Some studies didn’t report quantitative results.
– Great heterogeneity observed made it
impossible to make a meta-analysis all studies.
– Used fixed effect, not random effect.???

23. 5. RESULTS
–Used A generic inverse-variance approach to
built meta-analysis of mean difference results.
–And Mantel-Hanszel statistical method used
with odd-ratios.

24. 5. RESULTS
– Table-7 used Mantel-Hanszel but in the note they
mentioned using inverse-variance approach.

25. – Meta-analysis could not be performed for the
outcome of horizontal bone augmentation.
– the included human clinical trials in the vertical
bone augmentation group didn’t provided usable
information for meta-analysis.

26. 5. RESULTS
– Meta-analysis of vertical bone augmentation done on
only four qualified animal studies.
– Meta-analysis done on Improper Soft Tissue Healing in
Animal Studies.
– Meta-analysis done on Improper Soft Tissue Healing
(According to Controlled Clinical Trials)

28. 5. RESULTS

29. 6. DISCUSSION
–Summary of evidence : Specified
• Lack of human studies and quantitative results, also the great
heterogenity, made their meta-analysis confirm paucity of
available studies. Means needs more human research.
• For care provider and users he mentioned that there
statistictical significance in vertical bone gain bet test and
control grp, but the clinical importance of this amount of
augmentation is not clear.
• Also found that animal results different from human ,the
reason was 1. biologic variance 2. high healing potential and
vascularity favoring animal model. Also 3. bacterial
contamination, poor oral hygiene) are controllable in animal
models.

30. 6. DISCUSSION
– Limitations : not fully specified
• Didn’t mention the study settings.
• Types of defects “supra/intra bony – 2,3,or 1 wall -furcation
defects - fenestration”.
• Not mention the tools used for assessment risk of bias.

31. 6. DISCUSSION
– Conclusions: Specified
»difficult to draw clinical relevant conclusions due to
different surgical techniques, defect morphology,
maintenance protocols, and follow-up periods.
»Barrier membranes may have a benefit in the treatment of
vertical bone deficiencies.
»RCTs are needed to measure the efficacy of membranes in
bone augmentation to answer the question of whether
barrier membranes have an advantage over traditional
bone repair methods.

32. 7. FUNDING
–Sources of funding :
• Not specified.
• Authors mentioned no conflicts of interest related to this
study.