Clinical efficacy of different biomaterials for the regenerative treatment of periodontal intrabony defects: a systematic review and Bayesian network meta-analysis

To systematically compare the clinical efficacy of various biomaterial-based regenerative strategies for periodontal intrabony defects and to provide clinically meaningful evidence for optimizing treatment selection. This study followed the PRISMA-NMA guidelines. PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, and VIP databases were systematically searched from January 2010 to February 2026. Randomized controlled trials (RCTs) involving regenerative treatment of periodontal intrabony defects were included. Interventions consisted of different biomaterial-based regenerative therapies. The primary outcomes were changes from baseline in probing depth (PD), clinical attachment level (CAL), bone gain (mm), and gingival recession (REC). Two reviewers independently performed study selection and data extraction, and the risk of bias was assessed using the Cochrane RoB 2.0 tool. Bayesian network meta-analysis was conducted using STATA 16, Review Manager 5.4, and R 4.4.2 with the BUGSnet and gemtc packages. Effect sizes were expressed as weighted mean differences (WMD) with 95% credible intervals (CrI). Treatment rankings were estimated using the surface under the cumulative ranking curve (SUCRA). A total of 32 RCTs and 14 treatment strategies were included. According to SUCRA rankings, bone graft combined with platelet-rich fibrin (BoneGraft + PRF) showed the highest probability of achieving PD reduction (93.6%) and bone gain (94.9%). FGF-2 combined with bone graft (FGF2 + BoneGraft) ranked first for CAL gain (91.9%), followed by BoneGraft + PRF (82.6%) and FGF-2 alone (82.4%). For bone gain, FGF2 + BoneGraft (91.2%) and stem cell therapy (82.8%) also showed favorable rankings. For gingival recession reduction (REC), where lower values indicate better outcomes, PRF combined with ascorbic acid (PRF_AA) demonstrated the best ranking (4.3%), followed by FGF2 + BoneGraft (9.6%) and PRF (19.6%). Selected pairwise estimates showed that, compared with OFD, BoneGraft + PRF produced greater PD reduction (MD = 2.09 mm, 95% CrI: 0.45 to 3.75) and bone gain (MD = 2.76 mm, 95% CrI: 0.94 to 4.59), whereas FGF2 + BoneGraft produced greater CAL gain (MD = 1.88 mm, 95% CrI: 0.32 to 3.45). For REC, PRF_AA showed a lower recession estimate than OFD (MD = -2.57 mm, 95% CrI: -6.62 to 1.47), although the CrI crossed zero. This study provides a comprehensive comparative evaluation of multiple biomaterial-based regenerative strategies using a network meta-analytic approach. The findings suggest that combined regenerative approaches integrating structural scaffolds and bioactive factors may provide greater clinical benefit, although the certainty of evidence should be interpreted cautiously in periodontal regeneration compared with single-material therapies. These results highlight the importance of synergistic treatment strategies and may assist clinicians in selecting more effective, evidence-based regenerative protocols tailored to specific clinical outcomes. However, given the limited evidence for certain interventions, further high-quality multicenter RCTs are required to confirm these findings.